Finding the perfect PA
Our troubleshooter Jane Braithwaite gives advice on recruiting and employing a personal assistant P18
How we can stop the rise of superbugs
Dr John Burke of Bupa on how to prevent antimicrobial resistance increasing P20
Don’t get crushed by staff litigation
Solicitor Julia Gray advises on how to deal with employment tribunals P34
By Robin Stride
Private doctors’ representatives are looking forward to ‘a res toration of confidence in the professional integrity of doctors throughout the sector’ in the wake of the Government’s support for recommendations arising from the Paterson inquiry.
and another is being kept under review (see pages four and five)
The Federation of Independent Practitioner Organisations (FIPO) said rogue surgeon Ian Paterson betrayed the basic principles of medicine and had a devastating impact not only on the patients whose lives he ruined but also ‘on the medical profession as a whole’. Its comments were backed by the London Consultants’ Association, which said private specialists would be pleased to only practice with providers who have the correct assurances and governance in place.
Welcoming the Government’s long-awaited response to the remaining recommendations of the former Bishop of Norwich’s inquiry into his ‘reprehensible behaviour’, it said it was gratified that the majority of the ‘sensible’ recommendations had been accepted.
As reported by Independent Practitioner Today in late December, there were 17 recommendations signalling some major changes for some consultants.
Nine were accepted, five more in principle, one was not accepted
In a detailed analysis of the recommendations, FIPO said the integration of practice data should allow for earlier identification of concerns, but this would need to be viewed within an independent professional goverance framework.
A peripheral benefit would be to ease the data capture burden for doctors working at multiple sites.
It thought the matter of consent for surgery was less likely to be an issue in the private sector where the consultant would be getting the informed consent and performing the surgery, normally with a time gap for the patient to consider what they had been told.
Regarding multidisciplinary team meetings, these were considered in many instances to be best practice, stated FIPO.
However, the routine adoption of these meetings compliant with national standards throughout the sector would need professional monitoring to ensure that, as was the case with Paterson, this did not degenerate into a tick-box exercise.
FIPO added: ‘However, these meetings are very resource- and time-intensive in terms of assembling the necessary skill sets to perform them.
‘There is also the issue that cur-
rently neither the hospital providers nor the private medical insurers (PMIs) reimburse the doctors and other professionals involved for their time. Although some of the PMIs have done so in the past, they now refuse to do this.’
Regarding complaint resolution,
‘Most
FIPO said some private providers had for some years supported the Independent Sector Complaints Adjudication Service to allow for independent assessment of complaints when in-house procedures had failed to satisfy complainants.
➱ continued on page 4
Mr Richard Packard, chairman of the Federation of Independent Practi tioner Organ isations – which through its membership organisations is representative of around 15,000 consultants working in private practice – said:
‘I believe that the majority of private consultants are pleased with the Government’s endorsement of most of the Paterson recommendations and think this will restore public confidence and the general perception of private healthcare which provides such a helpful adjunct to the NHS in these challenging times.
‘The consultants will need support from their providers in order to make sure these recommendations are implemented.
‘In particular, funders will need to
take responsibility for financially supporting their expert input to ensure effective multidisciplinary team meetings where indicated.
‘It is important that professional integrity is maintained and while independent oversight is necessary, we are keen to ensure that box ticking mechanisms are not adopted at the expense of medical professionalism.
‘As the original architect of guidelines for medical advisory committees, a member of the Medical Practitioners Assurance Framework advisory group and a provider of appraisals, FIPO is keen to start working with providers to develop independent professional oversight by doctors for doctors and their patients and this should start immediately.’
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Results of a new Medical Defence Union (MDU) study must inevitably raise questions about how fit some doctors are to do their private practice, let alone any NHS work.
Of worrying concern is the huge level of tiredness out there right now, heightened due to the pandemic.
A priority for many doctors should be – if they can get it – a well-deserved, good, long sleep.
The MDU’s startling survey of 532 members, mostly consultants and GPs, found as many as a quarter of doctors admitted being so tired that it impaired their ability to treat patients.
As we report on page 3, in 40 cases they admitted there was a near miss and there were seven cases of a patient coming to harm.
Six in ten confess to worsening sleep patterns during the pandemic and over a third felt sleep deprived at least once a week.
The survey did not divulge the private practice commitments of the 201 consultant responders, but we assume many have independent work.
Two-thirds said tiredness resulted in poor concentration, decision-making difficulties (39.5%), mood swings (35.7%), memory problems (28%), intolerance with patients and relatives (21.7%), and impaired technical ability (17.8%).
And if you find yourself these days feeling more intolerant with colleagues than in the past, then you are not alone; 34.4% of consultants cite the same problem.
Sleep medicine consultant Dr Michael Farquhar has offered a timely warning: sleep deprived doctors can lose insight, meaning they can persevere when doing the wrong thing.
Sadly, they are also more likely to be involved in a serious RTA when driving home . . . for the sleep they need.
He leaves a PHIN legacy
Dr Andrew Vallance-Owen, retiring as chairman of the Private Healthcare Information Network, looks back at the drive to bring transparency P14
Prepare for a new way of working
Many doctors’ businesses are now adapting their workspace to the new world of working, says accountant Julia Burn. How about you? P16
Relieve yourself of chore of billing
Outsourcing medical billing and collection is often the preferred route for doctors in private practice. Here are some of the main reasons why P24
How we can avoid burn-out at work
Dr Stephen Priestley outlines ways independent practitioners can sustain physical and mental well-being and help their team perform at its best P28
David Furness of the Independent Healthcare Providers Network explains the benefits of the deal between the NHS and the private health sector P30
It’s a marathon, not a sprint
We are all prone to fear of missing out when we see stellar stock performance, but Benjamin Holdsworth shows why the best investors think long-term P32
Doctor on the Road: Its a charger, not a thoroughbred
Dr Tony Rimmer finds the new electric Mustang Mach-E a very different beast to its muscle car predecessor P40
Private Patient Units: Time to collaborate
Philip Housden’s monthly round-up analyses PPU growth in NHS trusts across the North-East region P42
Profits Focus: What a bumper year
Our benchmark survey reveals a hefty rise in profits for gynaecologists, but the reasons why are puzzling P45
Doctors asking the Government to pay their large tax bills caused by breaching annual pension savings limits in 2019-20 are being warned not to miss the crucial deadline for applications.
Specialist financial planners
Cavendish Medical are reminding doctors that they must apply for ‘Scheme Pays’ to settle their tax charge by 31 March 2022.
The annual allowance limits the amount of tax-free pension savings. The standard allowance is £40,000, but this tapers on a sliding scale to as low as £4,000.
The Government agreed to pay the tax charge of clinicians in
England and Wales who breached the annual allowance for the tax year of 2019-20 – but only if those affected apply for ‘Scheme Pays’ to claim the compensation.
Patrick Convey, technical director for retirement planning advisers Cavendish Medical, explained:
‘The Scheme Pays deadline normally falls on 31 July each year, but was extended to March this year to support those dealing with the impact of the Covid pandemic.
‘When individuals elect to use Scheme Pays, the NHS Pension Scheme pays their annual allowance tax bill to HM Revenue and Customs on their behalf, with that
member’s benefits in retirement being reduced accordingly.
‘Time is running out to get this application submitted – and remember that the compensation form must be countersigned by your hospital trust.
‘As the rules surrounding the NHS pension and taxation change again this year, I would urge everyone to get their figures and finances double checked.
‘The much talked about McCloud judgment could mean that the numbers for the last few years need to be changed retrospectively and it would be wise to ensure you start with accurate figures.’
The ‘McCloud’ judgment ruled that moving some doctors to the 2015 NHS Pension Scheme was discriminatory and that compensation would be offered to those affected.
New Covid-19 guidance for GMC fitness-to-practise officials, advising them to take account of ‘sustained and extreme periods of fatigue’ among doctors, has been welcomed by the Medical Defence Union (MDU).
The GMC warned decision-makers to consider the ‘exceptional pressures’ on healthcare professionals due to the pandemic, including sustained fatigue.
MDU head of advisory services, Dr Caroline Fryar, said it was good the GMC was recognising the chal-
lenging circumstances doctors were enduring and their fatigue.
‘As memories inevitably begin to fade of the pressures healthcare professionals are under, those holding the profession to account – regulators like the GMC, the courts and, indeed, employers –must properly take the Covid-19 context into account.’
The council’s edict came a day after a startling MDU survey of 532 members, mostly consultants and GPs, found a quarter of doctors admitted being so tired that it
impaired their ability to treat patients.
In 40 cases, they admitted there was a near miss and there were seven cases of a patient coming to harm. Six-in-ten medics also reported worsening sleep patterns during the pandemic. Over a third said they felt sleep-deprived at least once a week.
MDU chief executive Dr Matthew Lee said: ‘Doctors and their healthcare colleagues are running on empty. Our members have come through a period of immense pres-
sure caused by the pandemic and it is affecting all aspects of their life, including sleep patterns.’
Doctors reported side-effects due to sleep deprivation included poor concentration (64%), decisionmaking difficulties (40%), mood swings (37%) and mental health problems (30%).
The most popular actions to combat tiredness were taking a short break (56%), drinking coffee/ other caffeine drink (55%), snacking (37%), exercise (34%), mindfulness and breathing exercises (16%).
Private patient treatment will continue as usual under NHS England’s new deal with the private healthcare sector, the Independent Healthcare Providers Network says.
Its policy director, David Furness, forecasts providers will be able to
meet the needs of growing numbers of self-pay patients. Writing in this issue of Independent Practitioner Today , he says: ‘Learning lessons from the previous NHS/independent hospital partnerships during Covid, this new agreement will also focus on ensuring the NHS can
make best use of the independent sector with capacity targeted in areas where it is needed most.’.
Independent practitioners should be reassured that private beds would only be used in very specific circumstances and as ‘an absolute last resort’.
Ten independent acute providers groups have agreed to the shortterm partnership to deliver a wider range of treatments – including vital cancer care – to the NHS until the end of March.
See ‘Uniting to crack the pandemic’ on page 30
Private specialists will be pleased to only practise with providers who have the correct assurances and governance in place, as outlined in the Government’s response to the Paterson inquiry’s recommendations.
That was the reaction of the London Consultants’ Association (LCA), which added: ‘Consultants wish to ensure that their patients can be confident not only in their medical care but also all the services and healthcare that contribute to their personal successful outcome.’
It said: ‘The London Consultants Association supports the comments of FIPO and welcomes the Government’s response to the Paterson inquiry and the need for transparency in safety standards
The Government’s response to the recommendations of the former Bishop of Norwich’s independent inquiry into rogue surgeon Ian Paterson signals some major changes for many private consultants and hospitals to take on board and act on.
It responded to 17 recommendations – recommendations six and 12 have each been split into two parts –accepting nine, another five in principle, not accepting one, and not accepting another but keeping it under review. The result of another recommendation is pending an outcome.
Recommendation 1
We recommend that there should be a single repository of the whole practice of consultants across
enforced across both the private sector and NHS.
‘LCA is committed to high-quality individualised care for patients with multidisciplinary teamworking and information-sharing between the various health organisations.
‘An independent body to support the complaints process of providers is also welcomed.
‘Patients seen within the private sector have always been included in copies of correspondence to GPs and other specialists. There is a requirement to ensure that detailed medical data performed in the private sector is included within correspondence to ensure the completeness of the medical record.
‘The LCA supports high-quality
verified performance data held centrally which is accessible to patients, independent health providers and the NHS.
‘There must also be an acknowledgement of the increased workload to comply with these requirements with an increase in fees provided by the medical insurers.
‘Many recommendations are already included within the current practice of our consultants; for example, indemnity cover and range of practice.
‘Evidence of compliance with these standards are discussed annually at a comprehensive and supportive appraisal process and we fully endorse the supportive nature of professional appraisal such as that provided by FIPO.’
continued from front page
In its analysis of the Government’s recommendations, FIPO added:
‘We wholeheartedly support universal adoption of ISCAS and its principles by providers but also believe that there should be better independent processes for complaints made by doctors about remote clinical decision making by insurers about individual patients.
‘Currently, the insurers are regulated by the Financial Conduct Authority and, since clinical decisions may be made on financial grounds, FIPO believes that there should be independent professional medical monitoring of such complaints.
‘Recent cases have highlighted the need for a clear understanding of the responsibility and liability of both hospital providers and consultants.
England, setting out their practising privileges and other critical consultant performance data – for example, how many times a consultant has performed a particular procedure and how recently.
This should be accessible and understandable to the public. It should be mandated for use by managers and healthcare professionals in both the NHS and the independent sector.
Government response –accept in principle
Significant progress has been made on the collection of consultant performance data in the independent sector and the NHS.
In 2018, the Acute Data Alignment Programme (ADAPt) was launched to move towards a common set of standards for data collection, performance measure
methodologies and reporting systems across the NHS and the independent sector, with potential to be fully implemented by 2022 to 2023.
This data will be made available for managers and healthcare professionals across the system to help support learning and identify outliers.
Over the next 12 months, we commit to reaching a decision with key stakeholders on what information can be published
and whether further Government action will be needed to achieve this.
We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient’s GP, rather than writing to the GP and sending a copy to the patient.
Government response –accept
Guidance across the healthcare system now states that consultants should write directly to patients and in a way that they understand. Key stakeholders have committed to writing to their members to encourage uptake.
Over the next 12 months, we will explore with providers how their systems can change to make the process of writing to patients easier for healthcare professionals and how this can be monitored.
Recommendation 3
We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised is explained clearly to patients who choose to be treated privately, or whose treatment is provided in the independent sector but funded by the NHS.
This should include clarification of how consultants are engaged at the private hospital, including the use of practising privileges and indemnity, and the arrangements for emergency provision and intensive care.
Government response –accept
The Government will commission the production of independent information to make people aware of the ways in which their private care is organised differently from the arrangements in the NHS.
Created in partnership with patients, families and carers, this will be published in 2022 and will include expert views on a range of relevant areas that are backed by data and evidence.
Recommendation 4
We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures to allow them time to reflect on their diagnosis and treatment options.
We recommend that the General Medical Council monitors this as part of Good Medical Practice
Government response –accept in principle
Many key organisations, including the General Medical Council (GMC), have taken steps to update their guidance and to confirm that doctors should give patients sufficient time to consider their options before making a decision about their treatment and care.
During annual appraisals, doctors must provide supporting information to demonstrate that they are continuing to meet the principles and values set out in Good Medical Practice . The Care Quality Commission (CQC) takes all GMC guidance into account during its assessments.
Recommendation 5
We recommend that CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-todate national guidance on MDT (multidisciplinary team) meetings, including in breast cancer care, and that patients are not at risk of harm due to non-compliance in this area.
Government response –accept
The CQC has now added more detailed and specific prompts on multidisciplinary teamworking to the inspection framework for diagnostic imaging services in NHS and independent acute hospitals, including reference to NHS England and Improvement’s (NHSEI’s) guidance on streamlining multidisciplinary team meetings for cancer alliances. When assessing providers in the NHS and the independent sector, the CQC will continue to seek assurance that patients are not at risk of harm due to noncompliance with this guidance.
Recommendation 6a
We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and the independent sector.
Government response –accept
The Parliamentary and Health
Service Ombudsman (PHSO) is currently piloting the NHS Complaint Standards, which set out in one place the ways in which the NHS should handle complaints, including the need for organisations to ensure that people know how to escalate to the Ombudsman.
These have been developed with the Independent Sector Complaints Adjudication Service (ISCAS), who have included it in their code of practice.
We will continue to work closely with key organisations involved to ensure that standards are reinforced.
Recommendation 6b
We recommend that all private patients should have the right to mandatory independent resolution of their complaint.
Government response –accept in principle
The CQC will strengthen its guidance to make clearer that it expects to see arrangements in place for patients to access independent resolution of their complaints regarding independent sector providers.
We will review uptake across the independent sector in the next year, and if uptake is not widespread, we will explore whether current legislation needs to be amended to ensure that all providers make provision for independent adjudication.
Recommendation 7
We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled and to communicate with any who have not been seen.
Government response –accept
By August 2020, University Hospitals Birmingham NHS Foundation Trust had contacted all known living patients of Ian Paterson.
By the end of June 2021, the trust had ensured that all known former patients had had their care reviewed and that any outstanding concerns were
addressed in a way that was determined by the patient.
Recommendation 8
We recommend that Spire should check that all patients of Ian Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in the same way that has been provided for patients in the NHS.
Government response –accept
By December 2020, Spire had proactively contacted all known living patients of Ian Paterson to check that their care had been fully reviewed, and that they were getting any ongoing support and treatment that they needed.
Spire have now reviewed the care of over two-thirds of the patients concerned. Spire have prioritised the review of patients according to clinical need, with the most likely in need of new intervention being reviewed first. We have asked Spire to provide the Department of Health and Social Care (DHSC) with an update on progress in 12 months’ time.
Recommendation 9
We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated.
This framework or protocol should specify that the process is centred around the patient’s needs, provide advice on how recall decisions are made and advise what resource is required and how this might be provided. This should apply to both the independent sector and the NHS.
Government response –accept
A national framework has been developed that outlines actions to be taken by organisations in both the NHS and the independent sector in the event of a patient recall.
The National Quality Board (NQB) will own the framework, which will be published in 2022 and periodically updated.
➱ continued on page 6
➱ continued from page 5
Recommendation 10
We recommend that the Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals in light of the serious shortcomings identified by the inquiry and introduce a nationwide safety net to ensure patients are not disadvantaged.
Government response –pending
In 2018, the Government launched a consultation on appropriate clinical negligence cover for regulated healthcare professionals. This sought views on whether to change legislation to ensure that all regulated healthcare professionals in the UK not covered by state indemnity hold regulated insurance, rather than discretionary indemnity.
The Government has now extended this programme to consider the issues raised by the inquiry and is committed to bringing forward proposals for reform in 2022.
Recommendation 11
We recommend that the Government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this inquiry.
Government response –accept
System and professional regulators have an overarching statutory objective to protect, promote and maintain the health, safety and wellbeing of the public.
The healthcare regulators referenced in the inquiry (GMC, Nursing and Midwifery Council (NMC), and CQC) exist to protect patient safety and this is reflected in their new corporate strategies. They have also taken a
number of actions to encourage information sharing between organisations and to enable patients and professionals to raise concerns.
DHSC’s 2021 consultation regulating healthcare professionals, protecting the public sets out proposals that address the issues raised in the inquiry, including a proposal to place a duty to cooperate on all regulators. DHSC plans to draft legislation in relation to the GMC in 2022.
Recommendation 12a
We recommend that if, when a hospital investigates a healthcare professional’s behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional.
Government response –do not accept
We agree that exclusions and restriction of practice can be necessary, and in some cases immediate exclusion is an appropriate response while an investigation is ongoing. However, we do not believe it would be fair or proportionate to impose a blanket rule to exclude practitioners in such cases. Such a step may inadvertently cause a
chilling effect, dissuading healthcare professionals from raising concerns and negatively impacting patient safety. It is vital that investigations are robust and conducted in a timely manner. Guidance has been put in place to ensure that concerns are taken seriously, appropriate action taken and that robust investigation processes are implemented, and that clarity on when to exclude a healthcare professional is provided.
Recommendation 12b
If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Government response –accept in principle
The Government agrees that, where patient safety is at risk, information should be shared with other providers. However, there must be an element of judgement by providers as they will be taking on responsibility to ensure that this information is appropriate and accurate. Regulators have taken key steps to make it easier for people and organisations to share information regarding patient safety risks.
The Medical Profession (Respon sible Officers) Regulations
2010 (revised in 2013), which apply to all medical practitioners, have also set out prescribed connections for sharing information regarding performance concerns between health organisations.
Recommendation 13
In the NHS, consultants are employees and the NHS hospital is responsible for their management, and accepts liability when things go wrong. The situation is very different in the independent sector where most consultants are selfemployed.
Their engagement through practising privileges is an arrangement recognised by Care Quailty Commission (CQC). However, this recognition does not appear to have resolved questions of hospitals’ or providers’ legal liability for the actions of consultants.
We recommend that the government addresses, as a matter of urgency, this gap in responsibility and liability.
Government response –accept in principle
The Government is clear that independent sector providers must take responsibility for the quality of care provided in their facilities, regardless of how the consultants are engaged.
The Medical Practitioners Assurance Framework (MPAF), published in 2019 by the Independent Healthcare Provider Network (IHPN), was created to improve consistency around effective clinical governance, and to set out provider and medical practitioner responsibilities in the independent sector.
The CQC will continue to assess the strength of clinical governance in providers as part of its inspection activity, taking account of relevant guidance such as the MPAF.
As covered in our response to recommendation 10, we have set out a programme of work that will consider the case for reforms to the provision of indemnity cover. We will use this as our initial approach to dealing with the challenges faced by patients of Ian Paterson in accessing compensation.
Recommendation 14
We recommend that, when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability.
Government response –accept
Healthcare organisations have a statutory duty of candour, which sets out specific requirements providers must follow when things go wrong with care and treatment, including providing truthful information and an apology. This duty is regulated by the CQC.
NHS Resolution has consistently advised its members to apologise when things go wrong and to provide a full and frank explanation at the earliest possible stage, irrespective of the possibility of a legal claim.
More work is underway to ensure that this NHS Resolution guidance is promoted.
Recommendation 15
We recommend that, if the Government accepts any of the recommendations concerned, it should make arrangements to ensure that these are to be applicable across the whole of the independent sector’s workload –meaning private, insured and NHSfunded – if independent sector providers are to be able to qualify for NHScontracted work.
Government response –do not accept – keep under review
This recommendation, if implemented, would change the way in which independent sector providers qualify for NHS contracts. As demonstrated in our response to the other recommen
dations, independent sector providers are fully committed to implementing changes alongside NHS providers.
They must already meet the same regulatory standards, as required by CQC.
We will continue to monitor the independent sector uptake of the other recommendations and we will review our position on this recommendation in 12 months’ time, setting out further steps if necessary.
The Departement of Health and Social Care will provide an update on this work 12 months after the publication of this response. This followon report will update on the progress made against the ‘Implementation plan’ below.
The full Government response can be found at https://bit. ly/3rOv88s
Compiled by Philip Housden
The NHS National Planning Guidance details ten priorities for 202223, all based on an assumption that Covid19 returns to a low level.
Guidance focuses on the ability of NHS trusts to make significant progress in the first part of the new financial year from April 2022 to restore services and reduces backlogs.
In support of this, an additional elective recovery fund of £2.3bn will be available to trusts next year and healthcare systems will continue to receive fixed allocations for Covid 19 services, but at a reduced level of 57% less when compared to 202122. However, no support will be available to NHS trusts for the loss
of nonNHS income as a result of the pandemic.
This is a material sum, as across England trusts reported a 44% reduction of private patient revenues in 202021, a drop of £294.5m on the record total of £674.4m achieved in 201920.
This fall averages at an approximate £2.1m per trust.
The ability of trusts to resume private patient services depends on various factors including the extent to which any dedicated capacity has been protected through Covid and/or re opened after a period of support for core NHS services.
Sulis Hospital Bath, the 51bed unit bought from Circle in 2021 by the
city’s Royal United Hospital NHS Trust, has achieved Joint Advisory Group on GI endoscopy’s accreditation for the unit’s endoscopy suite.
The assessment, managed by the Joint Advisory Group on GI Endoscopy, includes a site inspection.
Head of nursing and allied health professionals, Jennifer Anstey, praised the team for their commitment to high standards: ‘We are delighted that we have achieved accreditation for another fiveyear period. A big congratulations to the hospital and to the team for achieving this accreditation.’
Recently, the hospital announced that Sulis Hospital treated more than 700 NHS patients in support of the region’s waiting list initiatives.
In 2020 21, the trust reported private patient incomes of £585,000, down 34% from £882,000 the year before.
This is a decline from 0.27% to 0.16% of total trust income and in line with the NHS wide impact from Covid.
But the trust’s private patient revenues can be expected to significantly increase as the market recovers in 2022 and as the trust inherits a proportion of the prior activity of Circle.
Bath Hospital, the previous name for Sulis, which treated 2,910 private and 3,800 NHS patients in the year to June 2021.
Philip Housden is a director of Housden Group. See his feature article on PPUs in the North-East region on page 42
By Agnes Rose
Robots are on the march and ready to train surgeons at HCA Healthcare UK.
The hospital group has spent £7m on four da Vinci Xi robots, which it says confirms its status as the largest provider of robotic surgery in the independent sector.
Consultants will benefit through a training hub set up to develop their robotic surgery skills, now at The Lister Hospital as well as The Princess Grace Hospital.
The fleet of HCA da Vinci systems totals seven across five hospitals. The others are at The Wellington, London Bridge and The Christie Private Care.
HCA announced it now has capacity to perform over 2,500 robotic-assisted procedures a year.
It is a landmark moment for The Lister Hospital, bringing the option for minimally invasive robotic assisted surgery for soft tissue via da Vinci technology to its patients for the first time, with an expected annual procedure rate of more than 250.
Chief executive Suzy Canham said: ‘We are proud to become HCA Healthcare UK’s second robotic surgery training hub, supporting
consultants to develop their already extensive skills and bringing new opportunities for our theatre teams.’
Company president and chief executive John Reay said: ‘Our £7m investment in robotic surgery is part of a long-held commitment to ensuring that across our healthcare system we have the infrastructure and technology and capability to offer the consultants that practise with us, and the patients we care for, access to the latest in innovation and the breadth and depth of treatment options to support their individual needs.
‘Our capacity to deliver over 2,500
robotic surgeries a year presents us with a unique opportunity in the independent sector to play a leading role in the training of surgeons with robotic skills, which will have wider benefit as the use of robotic surgery continues to develop.’
HCA UK’s heritage of robotic innovation goes back to 2005 when it became the first in the independent sector to acquire a da Vinci robotic system.
David Marante, regional director at the robots’ makers Intuitive UK & Ireland, said its aim was to bring about better team and patient outcomes at a lower total cost to treat per patient episode.
A new world-class facility offering diagnostic services and outpatient care has opened in London by independent hospital King Edward VII’s.
The Kantor Medical Centre opposite the main hospital on Beaumont Street is the charity’s latest purpose-built facility, spanning seven floors with 28 more consulting rooms.
It hosts a 3T MRI, CT scanner, two X-ray facilities, two ultrasound and two minor procedure rooms. A waiting area and pharmacy are at
ground level, while other floors are dedicated to expanding outpatient services.
The facility has been developed in line with the hospital’s clinical strategy to expand its offering within musculoskeletal, women’s health, urology and digestive health.
Kantor Medical Centre will also host centres of excellence in other specialties such as ophthalmology, dermatology and ENT.
Hospital chief executive Lindsey Condron said: ‘The opening of this
facility marks an exciting new chapter for King Edward VII’s Hospital and represents our largest single investment in facilities since we opened the current hospital building in Marylebone.
‘The development of this new specialist centre has been made possible by the extremely generous support of the Kantor Charitable Foundation, for which we are enormously grateful. This investment in innovative technology will enable us to provide advanced treatment to even more patients.’
Cromwell Hospital has welcomed a new helper to treat patients needing complex surgery – a da Vinci Xi Robot.
The surgical system can be used for gynaecology, urology, general surgery and colorectal procedures.
It is the most advanced robot of its kind and is an upgraded version of the Cromwell’s previous da Vinci robot – the ‘X’.
Gynaecologist Mr Amer Raza said: ‘Robots are new to gynaecology and we’re one of the few hospitals in London to use the da Vinci Xi for our gynaecology procedures.
‘The accuracy and precision of the robot works really well for keyhole procedures such as hysterectomies, complex endometriosis and large fibroids surgery.
‘Using the da Vinci Xi reduces trauma, bleeding, pain and scarring, meaning our patients are able to leave hospital and recover from the surgery quickly.’
The Kantor Medical Centre in London’s Harley Street enclave
By Douglas Shepherd
Independent eye health provider
Newmedica has plans for further expansion in the UK this year, following the opening of two more clinics this winter.
The two new clinics, in Shrewsbury and Norwich, have already started to relieve pressure on local health systems Shropshire and Norfolk, which still face challenges due to the ongoing impact of Covid-19.
Now the provider plans to open six new clinics and surgical centres in the first half of 2022.
And it said it was already looking for more sites to increase the geo-
Ramsay Health Care has appointed Nick Costa as chief executive of Ramsay Health Care UK. He has been the company’s chief operating officer since 2018.
Before joining Ramsay, he was the regional operations and transformation director at Nuffield Health, with responsibility for the delivery of high-quality services and standards, as well as the business transformation agenda.
Ramsay boss Craig McNally said: ‘His seasoned leadership will strengthen our UK business and put us on the front foot as healthcare evolves into new and integrated services.’
Mr Costa takes over from Dr Andy Jones, who has been appointed Ramsay Health Care’s first group chief growth officer to lead the global business transformation strategy.
graphical spread of its operation later in the year.
Newmedica managing director
Rebecca Lythe said: ‘With NHS waiting times at an all-time-high in some parts of the country, now feels like the right time to expand our business and, in doing so, support the NHS to deliver services in a timely way for the benefit of local patients.
‘Patient choice is really important, and we hope that our new clinics will give NHS patients referred by GPs and opticians, and private patients, the chance to experience our efficient, caring and personalised service for themselves.’
Newmedica is one of the leading providers of NHS-funded ophthal-
mology in England, and currently runs more than 23 services caring for over 120,000 patients a year.
Newmedica Norwich opened in November, and currently employs 30 staff with plans to grow the workforce as services expand.
An all-female team of partners has opened a new eye health clinic and surgical centre.
Newmedica Shrewsbury brings together operational director Cinty Yarnell and consultant ophthalmologist partners Miss Carmel Noonan and Miss Kaveri Mandal. They are offering NHS and private treatment for cataract surgery and aftercare, YAG laser treatment, medical retina clinics and general eye surgery, including minor oculoplastics.
Their centre is reducing waiting times for patients for essential eye surgery across Shrewsbury, wider Shropshire and further afield.
The clinic, at Shrewsbury Business Park, was officially opened by the town’s Mayor who was delighted to see the team had installed an electric car charging point.
Councillor Julian Dean was joined in cutting the ribbon by Doug and Dame Mary Perkins, founders of Specsavers.
The service is owned by five partners: consultant ophthalmologists Mr Anas Injarie, Miss Aseema Misra, Mr Nuwan Niya durupola, Mr Narman Puvana chandra and Mr David Spokes, working alongside operations director Karen Hansed.
The outgoing chairman of the Private Healthcare Information Network (PHIN) has welcomed the appointment to its board of a former director of regulation at the Association of British Insurers (ABI).
Welcoming Hugh Savill, Dr Andrew Vallance-Owen said private medical insurers were major stakeholders in PHIN’s work and had a clear interest in seeing highquality information made available to patients, so participation from someone they nominated and trusted was crucial.
Mr Savill said: ‘I have extensive experience of the twilight zone between the public and private sectors, and it was this that attracted me to PHIN.
‘I am pleased to be joining the PHIN board at a time when increasing amounts of data on the cost and quality of private healthcare are now being published.
‘This will make a real contribution to the ability of patients to make informed choices about their healthcare.’
A look back through our journal’s archives of a decade ago reveals that although times change, some issues are not so new
Doctors with a private practice were being advised to think hard about how they could protect their business from collateral damage in the wake of the Poly Implant Prothese (PIP) scandal.
As angry patients with the PIP breast implants demanded their money back and ‘tweeted’ their fury at operators, private clinics covering other specialties were reaping the whirlwind and reporting up to a 50% drop in inquiries.
But according to former British Association of Aesthetic and Plastic Surgeons (BAAPS) president Mr Nigel Mercer, the scandal could bring positive benefits if it makes the private sector think more carefully about what it does.
He said: ‘Hopefully, the market will take a hard look at itself and,
in doing so, improve its services to patients in all sorts of ways. There is going to be a sharp focus on how procedures are sold. It will make people think about how they do their sums.’
Many doctors were still unaware of impending Government changes which we warned could cost them hundreds of thousands of pounds in their retirement.
They were often unaware of the need to act immediately to protect their future income.
Independent practitioners at a series of financial planning seminars for doctors, run by advisers at Cavendish Medical, were shocked to discover they could lose up to £165,000 from their pension pot after April.
The lifetime allowance limit on the amount an individual could accumulate tax-free in pension funds was due to be cut from £1.8m to £1.5m. The penalty tax rate above this allowance was a staggering 55%, we warned.
Cavendish Medical’s Dr Mark Martin said: ‘This allowance might seem generous at first glance, but anyone with a current or projected NHS pension of £50,000 a year and/or significant private pensions should urgently seek advice. Protecting your allowance is the only way to safeguard your future income.’
Doctors would soon pay less for their GMC annual retention fee, following the council’s efficiencies, which led to more than £8m savings in 2011.
The fees would drop from £420 to £390 on 1 April.
The independent healthcare sector trade body aimed to launch a ‘patient pester power’ campaign to pressure cosmetic injectables providers to join its quality mark ‘Treatment You Can Trust’ register.
Public pestering was seen by the Independent Healthcare Advisory Services as vital to protect patients from an escalating number of rogue providers.
Incomes for independent practitioners treating NHS patients in private facilities might be reaching a cyclical high, a market analysis suggested.
Latest figures showed as much as a quarter of private unit income came from this source, compared to 14% in 2005.
But Laing’s (now LaingBuisson’s) Healthcare Market Review 201112 warned of a static market and growing competition among independent providers, who had 515 hospitals at mid-2011, compared with 454 a year earlier. Self-pay patients provided 14% of revenues to private hospitals, up by 0.5%, but their private medical insurance business was 58.5% in 2010 against 60.5% in 2009.
Insured patients were being advised to get consultants –especially anaesthetists – to be up front about their fees before they committed themselves to treatment.
The Association of Medical Insurance Intermediaries (AMII) –now the Association of Medical Insurers and Intermediaries – was also telling patients to contact their insurer before starting treatment so they could make an informed decision about whether to go ahead with a particular consultant.
TELL US YOUR NEWS
Share your experience of what has and has not worked in your private practice. Even if it’s bad news, let us know and we can spread the word to stop others falling into the same pitfalls.. Contact editorial director Robin Stride at robin@ip-today.co.uk
Following King Edward VII’s Hospital’s win in the management excellence category at the LaingBuisson awards, where judges praised the team’s values and diversification, its chief executive Lindsey Condron (below) outlines what has been behind the success
OUR MANAGEMENT approach has always been informed by our commitment to providing safe and compassionate care to every patient.
We aim to attract the best in the field and our specialists are known for setting industry standards worldwide.
Our organisational culture has been developed, ensuring that the voices of our patients and staff are heard and acted upon through the fearless learning culture we have embedded.
At King Edward VII’s, we aim to be collaborative in the way that we deliver care. We bring specialists together in multidisciplinary teams of consultants, specialist nurses and other healthcare professionals to give patients access to an entire team of experts to assess, plan and manage care jointly.
As such, we can offer the best treatment options and manage
patients efficiently. This is one of the elements that allow us to remain innovative, drawing from the team’s expertise in collaboration with myself and the rest of the leadership team to drive the hospital forward.
The values of our organisation are embedded throughout and this is underpinned by a commitment to be kind to each other.
We also strive to provide a personalised service to each patient that visits the hospital and to ensure that our staff retention, well-being and recognition are at the heart of our decision-making.
What is the hospital proud of in terms of treatment and technology?
One of the most notable successes of the last year has been our pioneering approach to cancer surgery.
Our dual surgery DIEP flap reconstruction, with a lymphatic
microsurgical healing approach, has reduced the risk of secondary breast cancer-related lymphedema.
Without the procedure, patients risk excess fluid collecting in the tissue, but our cancer team’s ground-breaking approach, born from a dedication to improve outcomes, is able to redirect waste from the lymphatic system into the veins.
We’ve also adopted technologies to improve treatment. Already having a well-established robotics programme in the urology department, the team identified an opportunity to use the hospital’s expertise in colorectal surgery.
Utilising technology and drawing on our excellent clinicians allows procedures to be precise and less invasive. So far, the team has carried out 500 major procedures, which have seen patients’ pain reduced and faster recovery times.
And finally, our work with the clinical informatics company, Copeland Clinical AI lets us analyse data to provide specialists with risk-adjusted, benchmarked outcome data about mortality and avoidable harm rates in inpatient care to identify patterns, triggers and discover any areas that could be improved.
This has already improved productivity and efficiency and we’re looking forward to continuing to advance in this area in 2022.
How is the hospital giving back to society?
Outside of transforming patient management, our longstanding charitable status means we are committed to supporting the Armed Forces.
Beyond providing medical grants, our team has set up a pain management programme to support veterans. Our hospital-based
service exclusively for veterans has delivered, to date, 33 programmes and provided 450 veterans with life-changing treatment to reduce dependence on medication and manage pain.
The success of the programme speaks for itself, 100% of veterans attending the programme would recommend the service.
We have also worked with the NHS throughout the pandemic, with a particular focus on providing treatment to cancer patients.
We reported on the winners of the LaingBuisson Awards in our December-January issue
The award recognised the hospital’s commitment to wider social projects, including its Veterans’ Pain Management Programme which has catered to 450 members of the armed forces, managing health conditions and improving quality of life for serving and ex-service personnel and their families.
Kate Farrow, director of operations
‘Having an empowered and cohesive team is paramount to the success of our organisation.
‘Clinical and non-clinical teams across the hospital understand the connective role we play in a patient’s pathway and journey through the hospital.
We are proud to have treated more than 1,200 NHS patients in 2020.
colorectal surgeon
Mr James Kinross
‘As surgeons, we are always striving for the best outcomes for our patients, and we strongly believe that this means using a digital, data-driven approach, as well as the best in surgical expertise and robotic technologies.
It recognised exceptional clinical or patient outcomes, financial results and employee engagement, and the hospital’s colorectal robotics service and lymphatic microsurgical approach to breast cancer.
‘Working with a hospital that treats innovation as paramount allows us to prioritise our patients and provide them with the best care
‘We are there to support the patients, our clinicians and each other to deliver outstanding healthcare and foster a supportive and fun place to work while always looking at ways to improve our productivity and efficiency.
‘We have created a culture which allows us to make decisions quickly and drive innovation across the organisation at pace.
‘I think this is hugely appealing to our consultants and patients and makes for a great place to work’.
At Xyla Elective Care, we provide NHS-funded care both in acute hospitals and in the community
These services are designed to support new and evolving care delivery models to ensure patients can be seen virtually where appropriate as well as the usual face-to-face delivery options
Our purpose is to further the seamless integration of highquality care between primary and secondary institutions for the benefit of patients To achieve this purpose we recognise that we cannot do business as usual not only in the way we serve our clients, but the people we recruit into operational roles as well as those who join our frontline clinical teams
As part of the Acacium Group, we benefit from the infrastructure of a large, successful organisation with over 20 years of experience as the largest provider of workforce solutions to the healthcare sector in the UK and Europe
To meet the growing demand for our surgical and outpatient services Xyla Elective Care is recruiting experienced Consultants interested in joining our team to work alongside dedicated colleagues in a supportive environment and within an organisation with a reputation of having robust clinical governance and strong organisational structures We have job opportunities for this role in various locations across the UK
We are now hiring:
ENT Consultants
General Surgeons
Urologist
Ophthalmologist
Gynaecologist
“If you have the right work experience this is an excellent opportunity You must be fully trained and currently practising in the same field within the NHS There is a strong culture of teamwork and putting the patients first ” Tosin Ajala Gynaecologist at Xyla elective Care
Our clinician workforce undergoes a robust recruitment process and thorough competency review, so you can be assured that you will work for the best clinical teams
We are committed to innovate patient pathways – you will be given the opportunity to deliver patient care in new and exciting ways
We have a reputation for having robust clinical governance, so you can be assured that you will not be exposed to unmitigated clinical risks
We regularly ask for your feedback to allow us to tailor work to suit your needs
Detailed operations manuals ensure you are adequately prepared to support each contract
How to join our team
Are you still thinking about it? Find out more about Xyla Elective Care and make the smart career choice to expand your experience
After more than nine years as the chairman of the Private Healthcare Information Network (PHIN), Dr Andrew Vallance-Owen has announced his intention to step down.
He believes PHIN has an important role in ensuring greater transparency across private healthcare by collecting and publishing information on performance measures under a mandate from the Competition and Markets Authority.
Here he reflects on his time with the organisation and tells Independent Practitioner Today what that has meant for the landscape of private healthcare – and what PHIN’s future holds for consultants offering private services
IT WAS nearly ten years ago that PHIN’s chief executive Matt James asked me to take up the position of chairman.
This was before the publication of the Competition and Markets Authority’s (CMA’s) Private Healthcare Market Order in 2014, but private sector providers had already come together to establish the Hellenic Group to start thinking about how the production of comparable information to private-sector patients could be achieved.
I had been a vocal advocate within the UK for the value of Patient Reported Outcome Measures (PROMs) and other measures of clinical performance, so becoming involved as the first chairman of PHIN’s board, after my retirement from Bupa, provided an exciting opportunity to take this work forward in the private sector.
The publication of the CMA order gave us a clear agenda to pursue, working with stakeholders across the sector, and what turned out to be an interesting and sometimes challenging journey.
PHIN has achieved many things over those years, not least the establishment of an excellent board and executive team led by Matt, who, as Independent Practitioner Today has reported, is stepping down this year. Working with people who have similar professional values and a passionate belief in the mission has been a great privilege.
The challenge of engaging with many competing providers to gain agreement to new ways of processing data, to common standards and definitions and, above all, to building a data-set designed to enable patients to make informed choices was slowly overcome.
That said, although much progress has been made, so far it has taken four years longer than the CMA’s original target, and there is no immediate date for final delivery of the complete set of information for patients and people considering their care options.
PHIN has built a reputation in the sector as an advocate for the patient and consumer-centred approach laid out by the CMA and I am proud of that advocacy.
Unfortunately, following an initial burst of enthusiasm and engagement from consultants, too many remain unaware that there are legal obligations that fall on them to engage with PHIN DR ANDREW VALLANCE-OWEN (below)
Jayne Scott, the new chairwoman of PHIN
This is evidenced by our engagement with the Paterson Review and Baroness Cumberlege’s review First do no harm and I am particularly proud of PHIN’s website, achieving more than 20,000 visitors a month since the relaunch, without promotion, which is a great achievement for the team.
I am convinced that the private sector does provide high-quality care and treatment and, as I look towards stepping down from my role as chairman, I only wish we could be collecting more consistent high-quality data to demonstrate that quality and that we could fill the obvious gaps on the website.
Unfortunately, following an initial burst of enthusiasm and engagement from consultants, too many remain unaware that there are legal obligations that fall on them to engage with PHIN.
Clearly, consultants have a really important role in helping patients and consumers make informed choices.
While they have legal obligations, I would hope consultants will increasingly see the important role they play in ensuring that patients have access to information about safety, quality, and price.
The world is becoming more consumer-centric and, frankly, private healthcare is a consumer market which must keep up with increasing customer demand to know and understand the quality offered within the sector.
The key challenge for PHIN going forward is to continually improve our process for constructive, strategic engagement with consultants and providers, which concentrates on delivery of the CMA order’s requirement to publish comprehensive, comparable information to help consumers and patients to make informed choices, within a clearly defined time-scale.
I am confident that our new chairwoman, Jayne Scott, can take PHIN forward positively, building on the progress already made; her first challenge being the appointment of a new chief executive. I wish Jayne well in what is likely to remain a challenging period for PHIN in the time being.
For my part, I intend to continue to advocate for the further development of PHIN’s data-based, website and its widespread promotion, and I hope this will start to be seen as an asset for consultants wanting to promote their services.
I will also continue to promote the use of PROMs across our healthcare system. It has been good to see the progress, particularly by some specialties, towards the routine use of PROMs and measurement of quality-of-life following treatment.
But more needs to be done to get listening to and acting on the objective feedback of patients into the mainstream.
You have not heard the last of me yet!
Many doctors’ businesses are now adapting their workspace to the new world, says Julia Burn (right). How about you?
PANDEMIC-INDUCED financial pressures have led many businesses to make some big changes. They have adapted their workspaces, adjusting the way they work with their clients and changed how they sell products to their customers.
These inflicted changes had to be implemented at speed with little or no time for planning -and they have affected medical practices as businesses as well as the clients they individually serve. Now it has become the norm for businesses to have flexible working hours and arrangements to enable people to work in the office as well as the home.
Doctors’ businesses have been able to review their office and clinic space requirements and, where applicable, some have reduced spaces by hot-desking.
In many cases, this may have required additional administrative resources to manage the flow of people and they have utilised bespoke software to enable people to book their desk and equipment requirements to allow this to work.
This has meant some consultants and employees are managing their time differently. And, for many, this has resulted in office/ clinic time becoming more focused on appointments/clinics and collaborative working.
Report-writing and admin work is now often being performed from home rather than the office. This has then allowed for faceto-face meetings and appoint -
ments to be organised for the days that people are in the office/clinic.
Some businesses have reported that productivity has increased as commuting time has been cut when staff are working from home and also time savings have been created by utilising online meetings.
But others have struggled with the restrictions and have found it almost impossible to continue to run their businesses as they once were.
Many businesses have expressed concerns over training and onthe-job learning, as they feel that this has been lost with the lack of face-to-face working.
On the plus side, however, businesses can save on very expensive rental costs by reducing the amount of time needing to be ‘on site’, with the possibility of sharing clinic space and therefore cost with other professionals.
Some clinics may reconsider their options where they own a property. Owning a property is a long-term investment and may be right for your firm if the geographical situation of your business is important to the business itself –for instance, the clinic is known by its name and that is associated to the address of the clinic.
But locking into a property can be very restrictive. You often get a lot more flexibility with renting space and can downscale or upscale as and when required depending on client demand.
Remember that the Government still has some useful tax incentives in place; for example, a limited company can utilise super-deduction for corporation tax for money spent on plant and machines, fixtures and fittings, and computers.
The available deduction allows limited companies to deduct £1.30 for every £1 spent against their profits chargeable to corporation tax, therefore offering some relief against the annual corporation tax liability. To use this superdeduction, the money needs to be spent by March 2023.
Partnerships and sole traders cannot use the super-deduction, unfortunately, but can claim an annual investment allowance of
Businesses can save on very expensive rental costs by reducing the amount time needing to be ‘on site’, with the possibility of sharing clinic space and therefore cost with other professionals
£1m, which allows 100% deduction from taxable profits on eligible capital expenditure in that tax year. This relief is available until March 2023 when the limit reduces back to £200,000.
Many people wonder whether we will go back to where we were before the pandemic or whether there has been a permanent change to how people work.
I think there will always be an element of flexibility/smarter working, including some virtual appointments, where appropriate, as well as face-to-face ones.
And people will become smarter about the tasks that they perform which need to be face to face as well as those tasks that can be performed outside of the office environment.
Key issues to consider when changing the way you work are:
Wellness;
Ventilation;
Dedicated well spaces;
Inclusivity spaces;
Infrastructure ;
IT resources;
Sufficient security for confidential online meetings;
Collaborative areas;
Ability to encourage training and collective learning experiences.
The element of learning on the job must not be lost with staff working from home and the issues above will need addressing to continue to maintain a happy, focused and motivated workforce.
Julia Burn is a director at Blick Rothenberg and part of the team that advises medical practitioners
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In a new series, Jane Braithwaite (right) turns troubleshooter to answer independent practitioners’ frequently asked questions on business matters.
This month, she takes up issues related to employing a medical PA
I need to employ a medical PA, but I have never employed anyone before. What are my responsibilities?
BECOMING AN EMPLOYER is an exciting part of the journey in establishing a private healthcare business and creating good processes as an employer from day one will ensure a positive experience.
As an employer, you have responsibilities from a financial and accounting perspective as well as from an HR and management point of view.
You must register with HM Revenue and Customs (HMRC) as an employer before you are able to pay your first employee. You will need to decide what salary to pay and ensure you adhere to the Government rules regarding minimum wage.
You will also need to check if you are responsible for registering your employee for a pension.
Check that your employee has the right to work in the UK and also arrange any checks; for example, a Disclosure and Barring Service (DBS) check.
All employers must have employers’ liability insurance with a minimum cover of £5m.
Every employee must have a written statement of employment or contract of employment. This should confirm salary, holiday entitlement, sick pay arrangements and all other relevant terms and conditions.
You must state clearly if the offer of employment is subject to any checks, which may include qualifications and reference checks.
It is very important to ensure the contract is signed by your employee as soon as possible. Many employers produce a solid contract but then fail to follow through to signature.
As an employee and manager, you are legally responsible for providing a safe and secure working environment and you should check whether you are responsible for having a first aider. You must also ensure all of your employee’s personal data is stored securely.
Given all of these responsibilities, you might wonder whether you are better to employ someone on a self-employed basis, but be aware that you need to take care to avoid falling into problems.
HMRC advises that you must check whether an individual is self-employed in both tax law and employment law. You can be held responsible for unpaid tax and penalties if a mistake is made.
According to the HMRC website, an individual is probably selfemployed if most of the following statements are true.
The individual is: In business for themselves,
responsible for the success or failure of their business and can make a loss or a profit;
Able to decide what work they do and when, where or how to do it;
Able to hire someone else to do the work;
Responsible for fixing any unsatisfactory work in their own time;
Paid a fixed price for their work by the employer – it does not depend on how long the job takes to finish;
Using their own money to buy business assets, cover running costs and provide tools and equipment for their work;
Able to work for more than one client.
The use of the words ‘probably’ and ‘most’ by HMRC make it hard to have 100% clarity and so it is best to proceed with caution. If you are in any doubt, please take professional advice.
Becoming an employer for the first time is an involved process and it is important to make sure you get everything right from day one to avoid issues later on.
If you are uncertain about the best way forward for you, then you would be wise to take expert advice which could save you time and money in the long term.
WHEN INTERVIEWING for a medical PA, it is important to ask questions to understand experience and expertise.
You need to ensure an individual is qualified to do the role, but also to focus on the softer skills relating to dealing with patients, working with others on the team and dealing with the wider community, including insurance companies and hospital booking departments.
Ideally, you are looking to find the best medical PA to suit your practice, with the skills that you need and the attitude and behaviours that fit well within the culture of your team and in line with your values.
Every individual in your team has an impact on the quality of patient experience that you deliver and choosing the right team members is of the highest priority.
But an initial word of caution. In my experience, many employers assume the medical PA role can be managed by an individual with general PA or receptionist skills and I have seen numerous new employees thrown in at the deep end. This has resulted in a stressful outcome for both employer and employee.
The medical PA role is a very specialist role and completely different to a general PA role. If you are interviewing a candidate who has limited experience of the medical PA role, you will need to devise a thorough training plan to implement once your PA is on board. Prepare for the interview by rereading the candidate’s CV and highlight any areas where you would like to explore in more detail or any gaps between employment that you would like to understand.
Write a set of questions that ensure you explore the candidate’s CV. This will also provide a gentle opening to the interview by focusing on the individual’s past experience.
Secondly, consider your job
The medical PA role is a very specialist role and completely different to a general PA role
description for the medical PA role and highlight areas that have not been addressed by the CV.
Start by ensuring the candidate has an adequate level of expertise and experience to undertake the role. Is there evidence of working in equivalent roles?
Does the candidate know the systems you use?
If typing is required, has the candidate confirmed their capabilities? You may want to test typing skills separately. Create a list of questions that allow you to check thoroughly for experience and expertise.
The final part of questioning should relate to the attitude of the potential medical PA, their approach to patients and teamwork to allow you to assess whether the individual would be a good fit in your practice and within your team.
You should ask relevant questions about past experiences and how the individual handled them, such as:
Describe a situation in which you dealt with an unhappy patient;
Give an example of a time when you made a mistake and how you would do things differently now;
How do you maintain good working relationships with your colleagues?
What has been your greatest achievement?
Describe an example in your previous role where you improved the efficiency of the practice.
There are some questions that you must not ask in an interview, in particular in relation to age, sex, race and religion.
Conversations about whether a candidate has children that may take place as introductory small talk could be viewed as potential discrimination, so should be avoided. Similarly asking an individual where they come from is not appropriate.
Finally, it is important to remember that every interview is a two-way process.
The employer is assessing whether the candidate is the right employee for them and the candidate is keen to assess whether this is the right role within the right organisation for them.
You should be prepared to talk openly about your practice, your objectives for the future and your values. It is helpful to be clear about your expectations and what the career prospects are for the potential employee.
Recruiting the right individual for your team is always a challenge, but following a thorough process of interviewing and following through with reference checks should help to ensure a positive outcome.
Are your values aligned? I believe the best way to assess this is to use the competency-based interview technique.
You should ask relevant questions about past experiences and how the individual handled them. There are some examples that might be useful in the box above.
Jane Braithwaite is managing director of Designated Medical
ANTIMICROBIAL RESISTANCE
Antimicrobials are key to protecting population health and well-being and, without them, even routine surgery will become hazardous.
The World Health Organization (WHO) has listed antimicrobial resistance (AMR) as one of the urgent health challenges for the next decade.
Dr John Burke (below), medical director, Healthcare Management, Bupa Global and UK Insurance, explores the issue of AMR and offers some tips about discussing it with patients
ANTIMICROBIAL RESISTANCE (AMR) describes pathogens that are resistant to drugs such as antibiotics, antivirals, anti-parasitics and antifungals.1
Antibiotics, such as amoxicillin and tetracycline, are a major type of antimicrobial used to treat bacterial infections and resistance occurs when bacteria change in response to the use of these medicines.
It is the bacteria, not humans or ani-
mals, which become antibiotic resistant. These bacteria may then infect humans and are harder to treat than non-resistant bacteria.2
AMR is a broad term, covering resistance to drugs that treat infections caused by other microbes as well as bacteria, such as:
Parasites – for example, malaria;
Viruses – for example, HIV;
Fungi – for example, Candida.
Resistance happens when microorganisms change as they are exposed to antimicrobial drugs, which results in the medicines becoming ineffective. Infection then persists within the body and this increases the risk of the microorganisms spreading to others.3
Methicillin-resistant Staphylococcus aureus (MRSA) is a wellknown example of a micro-organism that developed AMR and is resistant to several widely used antibiotics.4
The scale of the problem
Despite efforts, significant levels of resistance have been reported in countries of all income levels and almost every type of bacteria has become less responsive to antibiotic treatment.
Currently, at least 700,000 people die each year due to drug-resistant diseases, including 230,000 people who die from multidrugresistant tuberculosis.5 If allowed to grow unchecked, it has been estimated that AMR will kill 10m people per year globally – more than cancer and diabetes combined – and cost society approximately $100-200 trillion by 2050.6
The escalating costs are associated with expensive and intensive treatments and an increase in resource utilisation. Treating patients with resistant infections by using a combination of regimens may be ineffective and, as a result, they may need longer hospital stays.
In addition, hospitals may also need more intensive care units (ICUs) and isolation beds to prevent the spread of infec tion. 7 Outbreaks of healthcare associated infections with resistant pathogens may mean that hospital wings need to be closed and elective surgeries cancelled, costing hospitals money.
As well as these direct effects, AMR causes a burden on the health care system through secondary effects. 8 These effects happen when procedures where antibiotics are used to decrease the risk of any infection after surgery are performed less often due to AMR increasing the risk of adverse events. It is clear, that AMR is a major concern for the healthcare industry.
It is therefore no surprise that the WHO has listed AMR as one of
the urgent health challenges for the next decade, noting that ‘AMR threatens to send modern medicine back decades to the pre-antibiotic era’.9
The direct and indirect impacts of Covid-19 on AMR are becoming increasingly clear, but the net effect still remains to be seen.10
It could be argued that AMR will be reduced due to the efforts made to curb the spread of Covid-19, such as improved population hygiene measures or restriction of travel.
Extra vigilance around hygiene and additional sterilisation procedures in the clinical setting may contribute to reducing the spread of resistant infections locally and on a global scale.
Similarly, the increased use of antimicrobial soaps and disinfectants due to changes in infection prevention and control policy and individual habits may help to reduce the direct spread of AMR micro-organisms.
But the concentration of these products in the environment is important. If it is too high, although they would inhibit the spread of AMR, they could cause significant impacts in situations where bacteria perform a beneficial role. Too low and this could provide an opportunity for AMR to evolve.11
The use of antimicrobials to treat Covid-19 era infections may also increase the prevalence of AMR. As many as 70% of patients with Covid-19 receive antimicrobials and unnecessary use is likely to be high, potentially contributing to an increase in AMR.12
Patients may receive antimicrobial therapy because their Covid19 symptoms can resemble bacterial pneumonia 13 or they acquire secondary co-infections which require antimicrobial treatment.14
The presence of AMR will influence the choice of antimicrobials prescribed to those with Covid-19, and there is also concern that potential infection with resistant pathogens could lead to unnecessary prescribing of last resort antimicrobials to patients with Covid-19.14
Antimicrobial stewardship principles should guide the antibiotic management of patients with
Covid-19. However, guidance on this differs. So we need clear and consistent guidance on which patients with Covid-19 would benefit most from empiric antibiotics, and in which patients the risks of antibacterial therapy exceed the benefits.12
It’s not easy to achieve a global consensus on any emerging disease and this demonstrates how the pandemic is impinging on prepandemic plans to tackle AMR.
Collecting data comparing the prevalence of AMR infections before and after the pandemic will help to realise the longer-term implications of additional sterilisation procedures in the clinical setting and changes to practice on the spread of AMR.
There is a significant lack of research on new antimicrobials, which heightens the problem of AMR for both developing and developed nations.15
Currently, the process is not commercially viable – reportedly taking 23 years before profit is
achieved. 16 This is because commercial return for any given new antibiotic is uncertain until resistance has emerged against the previous generation of drugs.
Also, the present focus on antibiotic stewardship to reduce AMR also presents an obstacle to antibiotics development. To safeguard the efficacy of new antibiotics, it is desirable to limit their use to those cases that cannot be successfully treated with existing products.
However, this makes for a poor business case for investors, since sale volumes for new antibiotics reaching the market remain minimal, at least initially, and the low expected return on investment leads to reduced interest.17
This is critical to reducing the wide-reaching impact of AMR, keeping authorities and clinicians aware of where and when resistance is present and evolving. However it presents many challenges owing to its multi-host, multi-pathogen, multi-drug nature.18
To help tackle this issue, at Bupa we’ve created some resources to increase patient understanding of AMR and to support clinicians in conversations with them. Our web page and video explain AMR, what it means, how to prevent infection and how to use antibiotics correctly.
Here are some points you may find helpful when talking to patients:
Antimicrobial resistance, or AMR, is what happens when very important medicines, such as antibiotics, stop working when needed.
AMR occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines, making infections harder to treat, leading to worse health outcomes.
Some antibiotics work by killing bacteria. Others work by stopping bacteria from growing and multiplying. This gives your body’s own defences time to find and kill them.
Antibiotic resistance happens when bacteria become resistant to antibiotics. The rise in AMR is caused by the over-use and misuse of these medicines.
Preventing infections is key.
Regularly wash your hands, avoid contact with sick people and ensure your vaccinations are up to date.
If you do need antibiotics, it’s important not to misuse them.
Make sure you take your antibiotics as they were prescribed by your doctor; your prescription will tell you exactly how long.
Only take antibiotics a health professional has prescribed for you.
Accept when an antibiotic is not needed; for example, they can’t help you if you have a common cold.
Don’t keep left-over antibiotics to use later.
Don’t flush them down the toilet or sink.
Hand any unused antibiotics you have to your pharmacist for disposal. You can find the Bupa patient resources at: www.bupa.co.uk/ newsroom/ourviews/antimicrobial-resistance
The WHO has developed the Global Antimicrobial Resistance and Use Surveillance System (GLASS). It is the first global system to incorporate official national data from surveillance of AMR in humans – monitoring of resistance and use of antimicrobial medicine – in the food chain and in the environment.
It provides a standardised approach for the collection, analysis, interpretation and dissemination of AMR data. So far, 109 countries worldwide have enrolled.
Currently, more attention is given to developing therapeutics rather than diagnostics, and most stakeholders agree that this is where the need is most critical.19 Both the therapeutics and the diagnostics ecosystems face similar market failures and lack of investment.
However, there is a growing demand for rapid antimicrobial susceptibility testing (AST) for bacterial infections to identify the antimicrobial treatment most likely to work.
Conventional diagnostic and AST technologies in clinical microbiology have long turnaround times – 18 to 36 hours – and, although new time-saving (two to four hours) automated AST technologies have been marketed, the conventional technologies are still being used and are usually expensive.20
This may be used to potentially help reduce the development time of new antimicrobial agents, improve diagnostic and therapeutic appropriateness.21
Recently an AI-based offline smartphone app for AST analysis demonstrated promising results. It uses the phone’s camera to capture images and guides the user throughout the analysis on the same device.
It showed that the automatic reading of antibiotic resistance testing could be feasible on a smartphone.22
The potential to predict bacteria’s resistance to antibiotics by determining the sequence of their
genome has long been discussed.
As well as diagnostic applications, next-generation sequencing techniques have the potential to provide a link between AMR surveillance in the environment and in the other aspects of the One Health approach to AMR – in the healthcare setting, agriculture and food producing animals.
This may add value to the monitoring approaches currently established in each of these fields individually.23
Telehealth continues to grow due to strong uptake, favourable consumer perception and significant investment. There is concern that virtual consultations can correlate with lower guideline-directed antibiotic prescribing and increased antibiotics compared with other settings. 24 Teleprescribing can also increase the speed of access to antibiotics which may lead to overuse. However, currently available evidence in primary care is insufficient to confidently conclude that this is the case, with variable results reported for different conditions.25
As virtual consultations become more commonplace, clinicians need to make sure that appropriate governance is in place to inform safe and appropriate implementation of remote consulting across primary, secondary and tertiary care to minimise the impact on AMR.24
1. Final Progress Report: Australia’s First National Antimicrobial Resistance Strategy 2015-2019. Australian Government, Antimicrobial Resistance 2021.
2. What is the difference between antibiotic and antimicrobial resistance? World Health Organization, Regional Office for the Eastern Mediterranean.
3. Antimicrobial resistance. World Health Organisation, last updated 13October2020.
4. MRSA. National Health Service, page last reviewed 24 March 2020.
5. No time to wait: Securing the future from drug resistant infections: Report to the secretary-general of the United Nations. Interagency Co-ordination Group on Antimicrobial Resistance (IACG). April 2019.
6. Hermsen ED, Jenkins R, et al. The role of the Private Sector in Advancing Antimicrobial Stewardship: Recommendations from the Global Chief Medical Officer’s Network. Population Health Management, April 2021.
7. Friedman ND, Temkin E, Carmeli Y. The negative impact of antibiotic resistance. Clin Microbiol Infect.
Antimicrobial stewardship (AMS) is relevant to the personal health and well-being of the global population. Antimicrobials are the only class of medication where one person’s use can impact on the effectiveness of the same medication in other people.6 We know that one of the main drivers accelerating the spread of AMR is a lack of awareness and knowledge.26 So encouraging our patients and also colleagues, across both primary and secondary care, to increase their understanding and change their behaviour in relation to antibiotic prescribing and use plays a key role in slowing the spread of AMR.27
Public understanding of the issue of AMR is mixed. One of the most common misconceptions is that resistance will only affect patients who over-consume antibiotics. A second is that antibiotics effectively treat all types of infections and viruses such as those that cause colds and flu. Patient pressure for antibiotic prescription is frequently reported by clinicians, particularly so when being requested on behalf of children.
Considerable efforts in educating the public have been made with varying degrees of success.28 Studies suggest that a combination of media campaigns to disseminate information, medical professionals fully explaining prescribing decisions and prompting the public to seek pharmacist advice on symptoms before visiting their GP is key to changing the public’s behaviour.29
Inappropriate prescribing of antibiotics can reinforce the belief that antibiotics ought to be prescribed and are effective in circumstances when they are not.28 Stewardship programmes supporting clinicians with guideline implementation, including audit and feedback processes and real-time decision tools for use at the point of care, play an important role in ensuring antibiotics are only prescribed when appropriate.30
2016; 22(5):416–422. doi:10.1016/j. cmi.2015.12.002.
8. Naylor NR, Atun R, et al. Estimating the burden of antimicrobial resistance: a systematic literature review. Antimicrobial Resistance and Infection Control. 2018.
9. Urgent health challenges for the next decade. World Health Organisation. January 2020.
10. Global Response to AMR: Momentum, success and critical gaps. Wellcome. November 2020.
11. Murray AM. The Novel Coronavirus COVID-19 Outbreak: Global Implications for Antimicrobial Resistance. Frontiers in Microbiology. May 20200.
12. Langford BJ, So Miranda. Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis. Clinical Microbiology and Infection. April 2021.
13. Harding M. Microbes, Germs and Antibiotics. PatientPlus. Patient, last edited 09 March 2018.
14. Knight GM, Glover RE. Antimicrobial resistance and COVID-19: Intersections and implications. eLife. February 2021. Accessed on 07/10/2021
15. Chokshi A, Sifri Z, et al. Global Contributors to Antibiotic Resistance. Journal of Global Infectious Diseases. 2019.
16. Hersh AL, Stenehjem E and Daines W. RE: Antibiotic Prescribing During Pediatric Direct-toConsumer Telemedicine Visits. Paediatrics. August 2019.
17. Morel CM, Lindahl O, et al. Industry incentives and antibiotic resistance: an introduction to the antibiotic susceptibility bonus. The Journal of Antibiotics 2020.
18. Truswell A, Abraham R, et al. Robotic Antimicrobial Susceptibility Platform (RASP): a nextgeneration approach to One Health surveillance of antimicrobial resistance. Journal of Antimicrobial Chemotherapy. April 2021.
19. Chowdhury, A.S., Call, D.R. & Broschat, S.L. PARGT: a software tool for predicting antimicrobial resistance in bacteria. Sci Rep10,11033 (2020).
20. Kaprou GD, Bergšpica I, Alexa EA, AlvarezOrdóñez A, Prieto M. Rapid Methods for Antimicrobial Resistance Diagnostics. Antibiotics (Basel). 2021 Feb 20;10(2):209. doi: 10.3390/antibiotics10020209. PMID: 33672677; PMCID: PMC7924329.
21. Fanelli U, Pappalardo M, et al. Role of Artificial Intelligence in Fighting Antimicrobial Resistance in Pediatrics. Antibiotics. November 2020.
22. Pascucci, M., Royer, G., Adamek, J.et al. AI-based mobile application to fight antibiotic resistance. Nat Commun12,1173 (2021).
23. Borghi V. The role and implementation of next generation sequencing technologies in the coordinated action plan against antimicrobial resistance. European Commission, EU Science Hub.
24. Zhang N, Marra L. Direct-to-consumer telemedicine visits demonstrate decreased antibiotic prescribing quality in paediatric clients with acute respiratory infections. BMJ Journals. 2019.
25. Han SM, Greenfield G. Impact of Remote Consultations on Antibiotic Prescribing In Primary Health Care: Systematic Review. JMIR Publications. November 2020.
26. Antimicrobial resistance factsheet, World Health Organisation. 17 November 2021
27. Behaviour change and antibiotic prescribing in healthcare settings. Literature review and behaviour analysis. Public Health England.
28. Pinder R, Sallis A, Berry D, Chadborn T. Behaviour change and antibiotic prescribing in healthcare settings: literature review and behavioural analysis. Public Health England. 2015
29. Tackling antimicrobial resistance 2019–2024 The UK’s five-year national action plan. HM Government. 24 January 2019.
30. Dimitri M. Drekonja, Gregory A. Filice, Nancy Greer, Andrew Olson, Roderick MacDonald, Indulis Rutks and Timothy J. Wilt. Antimicrobial Stewardship in Outpatient Settings: A Systematic Review Cambridge University Press. 22 December 2014.
Outsourcing private practice medical billing and collection is often the preferred route for consultants in private practice. Simon Brignall
explores some of the main reasons why this is the case
THE FIRST few months of a new year are often the time when a business seeks to focus on renewal and growth – and independent practitioners should be no exception.
For consultants in private healthcare, this can mean an extensive review of the practice finances, which often brings to light issues around medical billing and the impetus to do better.
Outsourcing of this key function has been a growing trend over many years.
As Medical Billing and Collection starts its 30th year in this sector, we are well positioned to see this in action because we have grown every year and we currently partner with more than 1,600 consultants across the UK.
A demand for the services of a billing company is now a wellestablished trend that even the pandemic failed to dent.
Consultants especially favour outsourcing when they are new to private practice and want to spend
their time developing their practice. There are also many benefits to outsourcing for practices of all ages and size.
The most important, and often overlooked, benefit from outsourcing is that your medical secretary can focus on the patient’s clinical journey without having to worry about the business side of the practice.
Outsourcing allows this key relationship to remain warm and engaging as the two sides of the practice are split, leaving the billing company to focus on the financial side and those difficult conversations about money.
This not only improves the patient experience, but it is often also beneficial to the practice, as the secretary now has the time to respond to new and existing patient inquiries. This often translates into increases in revenue.
The years of training that consultants go through to become experts in their field do not often prepare them for the challenges of running a business when they first venture into private practice.
Even busy practices that have been running for many years still can find this difficult, as procedures are not as robust as they should be and quite often not routinely followed.
As with some other billing companies, our fees are calculated against received income which means that we share the same objective. This important difference in a medical billing company’s business model means there is an inbuilt incentive to always bill the optimal amount and then ensure that these invoices are settled as soon as possible.
It is not uncommon for me to come across consultants who do
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their own billing, but this is never a valuable use of their time or experience.
Remember, time is a valuable resource and it is far more rewarding to use it more productively by choosing to see patients and leaving the billing to experts.
One of the main reasons practices contact me are problems with their cash flow arising from their outstanding debt.
These challenges can be the result of a variety of reasons, including:
Invoicing delays;
Problems with payment reconciliation;
Lack of a robust chase process;
Poor practice financial data; Visibility of any of the above; Limited patient payment options.
I regularly meet with practices where they have been writing off 5% in bad debts a year and sometimes even as much as 10% because of the challenges they have in this area.
As a professional medical billing company is purely focused on this role, they have robust procedures in place to manage these issues and often can provide you with a range of payment pathways.
The combination of all these factors will ensure your bad debts are kept to a minimum. Our bad debt level is less than 0.5% across the firm.
Staffing issues can be hard to manage at a practice level. I often get inquiries from consultants where an experienced medical secretary has retired and their replacement is struggling with aspects of the billing role.
Outsourcing often provides a simple yet effective solution to a range of staffing issues, because a well-resourced billing company means that the vital financial side of the practice is not impacted when the secretary is on holiday or is taken unwell.
This can be extremely beneficial with growing practices or groups where sometimes binary decisions about staffing need to be made due to the natural ebb and flow of their patient activity or group size.
Outsourcing means you always have the capacity of the billing firm on tap to meet your specific needs.
Service levels are maintained as key dependency risk is eliminated and issues that arise from problems such as the pandemic can be more effectively managed.
We at Medical Billing and Collection have had to switch many times between office and remote working in line with the latest Government guidance. We have been able to do this effectively, as all our systems are cloud-based to ensure maintenance of high service levels.
Medical billing is a complex task requiring experience and training. Remember that there are more than 2,000 Clinical Coding and Schedule Development group (CCSD) procedure codes as well as diagnostic codes to choose from.
On top of that, each insurance company has its own price list and rules in relation to how these codes can be billed, including formulas about the billing of multiple codes.
The CCSD schedule is updated monthly, so keeping on top of this can be challenging.
But failure to do so can mean the practice loses out on income or, worse, result in issues with the insurers from incorrect billing. I still come across practices that are not billing what they could due to errors in this key role.
Chasing outstanding debt requires a specific skill set and, for many medical secretaries, this is a task they do not relish, which in practice means it is often put off. A medical billing company provides a wealth of experience in this task, as it is core to what it does.
Outsourcing can be the simplest way to provide a range of new functionality that was previously unavailable to the practice. And these new payment pathways often mean the patient journey is improved.
There is a similar impact on the practice finances too.
Billing functions that we offer clients include:
E-billing of private medical insurers and patients;
24/7 payment collection via our card portal;
Billing and collection of self-pay patients ahead of treatment;
Client self-pay platform – for collection on the day;
Settlement of all outstanding invoices in one go.
A common complaint I receive from consultants is the lack of visibility they have about their practice financials. Many consultants do not have easy access to up-todate and accurate financial data about their practice.
This is vital, as all practices rely on this information as the first step in the bill chasing process, otherwise the whole system is flawed. More importantly, without this data, consultants are not able to make informed decisions about their practice.
Our clients are given access to a full array of reporting tools to review their practice data via our software.
And they can access their information 24/7 allowing them to view reports detailing:
Amount invoiced – available at a summary or granular level;
The billing and especially the chasing side of private practice is not something medical secretaries enjoy and they are often happy to relinquish responsibility for this task
Payments received – available at a summary or granular level; Patient activity; Aged debt.
These can be viewed based on a range of criteria including patient type, payment company and location
Cost alignment
It is always good business practice to ensure your costs are correlated against received income, and as most billing companies work on a cost structure that is calculated against received income, this is an advantage
The pandemic’s impact has only reinforced the merits of this model.
What’s stopping you?
Practices give a range of reasons for delaying outsourcing.
The most common is the perception of a loss of control. This is best addressed through transparency.
It is important to understand what the billing company is doing for you, so access to practice data is key because then their performance can be reviewed. Transparency allows trust to be established – the bedrock of any partnership.
Some consultants worry about upsetting their secretary. But in my experience, the billing and especially the chasing side of private practice is not something medical secretaries enjoy and they are often happy to relinquish responsibility for this task.
Partnership is key
To establish a strong partnership with your billing company it is important to make sure you understand how it operates, its work flow and who will be responsible for your practice.
Our ‘intensive care’ onboarding process is managed by a senior dedicated personal account manager whose role is to foster a good working relationship with the secretary/consultant and understand the nuances of the practice.
By removing the billing and chasing functions, this allows the secretary to focus on the highervalue activity such as patient engagement, which often leads to increases in revenue.
Simon Brignall (left) is director of business development at Medical Billing and Collection
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The nature of private healthcare has changed over the course of the pandemic and that has bought with it a host of new challenges and pressures. Dr Stephen Priestley outlines ways independent practitioners can sustain their physical and mental well-being and help the team perform at its best
DOCTORS ARE humans first and have been exposed to the same feelings as others during Covid 19. We doctors, too, have suffered feelings of anxiety, an acute sense of personal threat and a loss of control as the uncertainty of the pandemic continued to manifest and impact on both personal and professional lives.
Some private doctors have experienced financial pressures as the country went into lockdown, others had to divert their resources to support the NHS.
More than ever, the well-being and safety of your team members is critically dependent on the performance of those they work with. Working together and looking out for each other will help keep all of us performing at our best, so that we can face these challenges together and maintain our performance for the long haul.
Prof Don Berwick, a leading authority in healthcare improvement and safety, states that ‘without a physically and psychologically safe and healthy workforce, excellent health care is not possible’.
Maslow’s hierarchy of needs
In thinking about caring for others – and indeed self-care – as we face pressure and stress, we can draw on a concept developed by Abraham Maslow in 1943.
His ‘hierarchy of needs’ is a simple model that illustrates the range of human needs and how needs at a lower level have to be met before higher needs and aspirations can be addressed.
As Covid-19 threatens all layers of Maslow’s hierarchy, deficits across each of these core needs can
have negative consequences for our physical and mental health.
1Meeting the basic needs and ‘saying no for safety’
It is extraordinary that so many doctors downplay the importance of all team members attending to their basic physiological needs on a regular basis. Great performers know that this is fundamental to resilience.
In healthcare generally, we have not necessarily made it easy or acceptable to take a break, for a meal or a trip to the bathroom or a few minutes of rest. This is related less to individuals and more to the culture of our workplaces.
But, if we want to be at our best, we have to pay attention to those needs and make it easier for our team members to attend to their own well-being. This can be as simple as noting the needs of others and encouraging them to take a break.
There is evidence about the negative consequences of dehydration in doctors. A study by Lemaire from Canada compared an intervention of providing free healthy nutrition choices and enforcing nutrition breaks.
It found that the intervention group had greater nutrient intake and statistically significant reduction in dehydration.
Furthermore, cognition score testing indicated that dehydration can impair attention, short-term memory, visual perceptual abilities, psychomotor skills, alertness and increased fatigue.
So, at the basic needs level, we can think about simple things like providing access to things that we need at work such as showers, meditation or quiet rooms, healthy beverages and snacks, and safe transport home for team members and ourselves when fatigued.
The best idea of all may be to simply ask team members what they need.
Another principle that we firmly support at Medical Protection is the ability and responsibility of ‘saying no for safety’. By that, we mean the right to say no to some form of work activity, or extension of hours or doctors carrying out tasks beyond their scope of practice and training
because they believe it to be unsafe – for either their patients or themselves.
Saying ‘no’ often creates enormous anxiety. This anxiety comes both from within ourselves and external expectations. This ties up with the rescue model of healthcare.
When people ask for help, we often automatically rescue them. I know that most of us would miss a meal break or put our own needs aside to attend to a patient in need.
At the moment, for some, uttering a firm ‘no’ may require moral courage, but evidence suggests we promote safety more effectively by being clear and holding those boundaries.
We should validate to team members that saying no for safety is ultimately a professional action.
2 Physical and psychological safety and support for habits/routines
Physical safety might seem an obvious priority; however, psychological safety is also vital to consider. A working definition of psychological safety is ‘If I make a mistake or ask for information or help, others will not punish me or think less of me’.
A psychologically safe environment can be created by supporting our team members’ right to contribute, by genuinely listening to them and by refraining from being judgemental. It is important to invite others to speak up or ask for feedback from them.
Additionally, when we show appropriate vulnerability and admit when we are wrong, this also creates psychological safety for others.
Supporting your team members in maintaining resilience is worthwhile, as habits and routines require very little cognitive effort; they can be protective in times of stress and overload.
We can actively develop habits that support both our performance and well-being. While initially requiring deliberate planning and action, positive behaviours eventually become subconscious, thereby reducing cognitive load and assisting you to maintain your performance in times of lower willpower and motivational energy.
Routines can also be powerful, as they can act as a ‘psychological inoculation’, giving us a sense of confidence, security and safety.
It is worth considering if there are routines or rituals that have been disrupted during Covid-19 that need to be re-instated or reimagined.
Enjoying workplace camaraderie and a shared sense of purpose are powerful protectors of well-being at work.
But this may have been much harder during the pandemic due to working with changing guidelines, perhaps reduced availability of communal space and time to speak to team members.
It is important to look creatively at how team members who may still be working in isolation can be supported and feel included, and ensure that all are treated appropriately when it comes to the sharing of tasks and resources, and rewards and recognition.
4 Esteem and attaining self-actualisation
Civility at work is even more important during times of crisis. But courteous respectful communication in our workplace can be challenging because our emotional state can sometimes get in the way.
A useful phrase that is well supported by the literature is ‘civility creates safety’.
A growing number of peerreviewed papers in health and safety literature support the conclusion that a civil and respectful environment is safer for patients, promotes better communication and enhanced teamwork. Indeed,
A psychologically safe environment can be created by supporting our team members’ right to contribute, by genuinely listening to them and by refraining from being judgemental
the value and the contribution of all roles should be recognised and celebrated.
Psychologist Carol Dweck described in her book Mindset: The New Psychology of Success that showing appreciation encourages the development of a growth mindset, a valuable resilience factor .
Her research found that our personal growth can be encouraged when we recognise others – not simply with empty praise – but through articulation of not just the outcome but the effort and the process that the team member went through to get that outcome.
Caring for others also leads us to the very top of Maslow’s pyramid: self-actualisation. Many doctors may have been facing challenges in the area of professional fulfilment in the last 18 months as we are pressured to work in a different way. So is there also an opportunity for creative or professional individual growth and to foster the potential of others? Remaining engaged in meaningful work is such a powerful well-being factor and warrants personal investment.
Medical Protection members can view the full webinar on this topic at https://prism.medicalprotection.org/course/view. php?id=1222.
Well-being support services are also available at http://medicalprotection.org/ireland/wellbeing.
Dr Stephen Priestley (right) is senior medical educator for Medical Protection’s Risk Prevention, and Cognitive Institute
David Furness (right) says the new deal between NHS England and the private healthcare sector ensures that private treatment can continue, but provides a sensible insurance policy in case pressures on the NHS prove unsustainable
2022 MARKS the third year that the UK will be dealing with the coronavirus pandemic. And the past few months alone has proved Covid still has plenty of twists and turns to offer us.
Indeed, the Omicron variant detected in early December has led to a stratospheric number of Covid cases being confirmed.
While, thankfully, the virus appears milder than previous incarnations, hospitals across the country are – as I write – seeing huge rises in admissions with real pressure
on the system to deal with both Covid cases and the growing backlog of care caused by the pandemic.
This fast-moving situation led to new calls for independent sector support for the NHS and, at the request of the Secretary of State for Health and Social Care, ten independent hospital provider groups signed up in January to a new deal to support the NHS this winter as Independent Practitioner Today reported on 11 January.
But what does this deal mean for independent healthcare practi -
tioners and the delivery of private treatment?
Clearing the backlog
With the Omicron variant running rampant through much of the country and having a significant impact on both services and staffing, the Department of Health and Social Care was keen to ensure the health system could access the high-quality, green pathway sites that the independent sector provides and ensure the services could continue as much as is possible.
As a result, ten independent acute providers groups have agreed to a short-term partnership to enable it to deliver a wider range of treatments – including vital cancer care – to the NHS from January this year until the end of March, which will help the NHS to focus on growing numbers of Covid patients. Continuity rather than change is a key principle of this new contract though, with independent providers primarily being used by the NHS to continue its work of the last year in clearing the elective backlog.
This is an important role, given that the latest NHS performance figures show waiting lists have now reached six million.
And at the same time, treatment delivered to private patients will continue as usual in the coming months under the new arrangement, with providers able to meet the needs of the growing numbers of people who are now choosing to pay privately for their care given the pressures on the health system.
Learning lessons from the previous NHS/independent hospital partnerships during Covid, this new agreement will also focus on ensuring the NHS can make best use of the independent sector with capacity targeted in areas where it is needed most.
Therefore, in areas facing the most extreme Covid pressures, the new arrangement enables local systems to access the staff, beds
and equipment of local independent providers.
Providers and independent practitioners should, however, be reassured that this will only be in the very specific circumstances and used as an absolute last resort in the event that a local NHS system faced unsustainable levels of hospitalisations or staff absences –something all systems and partners will be looking to avoid.
Moreover, in the – hopefully extremely rare – circumstances where a ‘surge’ is triggered by the NHS, urgent private treatment, including cancer care, will still continue.
And even in areas where ‘surge’ is triggered, this will simply prompt a conversation between NHS England, local regions and independent sector providers about how to best deal with the local situation and not necessarily lead to a blanket suspension of routine private treatment.
NHS England has struck the ‘surge’ deal with:
Aspen Healthcare
Circle Health Group
Healthcare Management Trust
Horder Healthcare
KIMS Hospital
Nuffield Health
One Healthcare
Practice Plus Group
Ramsay Health Care UK
Spire Healthcare
The pandemic has caused huge upheavals in the delivery of healthcare in England since 2020 and we, of course, recognise the frustrations of many of those working in the system of yet more
changes due to the Omicron virus.
But, as I write, with early signs that the variant is now peaking in many areas of the country, this latest deal with the NHS provides a measured and targeted response to Omicron.
It ensures that private treatment can continue, with the sector providing a sensible insurance policy in case the pressures on the NHS prove unsustainable.
There is no doubt that these few months will be tough for all healthcare providers and practitioners.
But, from all of us at IHPN, we want to thank all independent practitioners on the front line in the sector who are working so hard to deliver the best possible care to millions of patients in the most challenging of circumstances.
David Furness is director of policy at the Independent Healthcare Providers Network (IHPN)
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IT CAN sometimes feel that the markets have gone a little mad. Almost everything you hear on the news or read about investing suggests that everything is going up.
At the time of writing, the US market is up by around 44% in the past year in dollar terms and Tesla’s share price has risen by 124% over the same period.
Furthermore, Lucid Motors, who have just started production on its electric car in Q3, for which it has a mere 13,000 orders, floated on the New York Stock Exchange and already has a market capitalisation greater than that of Ford, after its share price doubled in a month.
In the US, call options on individual company shares, which provide investors the right to buy a stock at given date in the future at a predetermined price in return for a premium payment, currently exceed the value of actual shares traded by value by almost a half. Options are a way of leveraging exposure to a stock without having to come up with the face value of buying the stock directly. They are a sure sign of speculation, not least by retail investors.
There is no doubt that when markets become ‘frothy’, investors are prone to a fear of missing out (FOMO) that makes them wish that they were invested in something that has done well – mostly identified with hindsight.
This can tempt some to lose discipline and plunge in, hoping that the magic (luck) will continue. When things do not go as hoped, there is a temptation to cut losses and run.
The ARK Innovation ETF –Exchange Traded Fund, which is a type of security that tracks an index, sector or commodity – has hit the investment news headlines as one of the best performing funds in 2020, gaining over 150% in US$ terms.
It is a very concentrated portfolio of technology and healthcare innovators. It holds more than 10% in Tesla and the top ten of 45 or so stocks make up more than 50% of the portfolio.
The firm also owns more than 10% of the shares of a number of portfolio stocks, which raises
liquidity risks – you may remember what happened to Woodford Investment Management.
In the case of ARK Innovation, it had a stellar run from April 2020, out of the bottom of the Covidinduced sell-off until December 2020, but has struggled since then, falling almost 35% at one point in the first few months of 2021.
It is worth noting that the fund had inflows of just US$25m in Q4 2019 but these peaked at almost US$7.8bn in Q4 2020.
You do not have to be a mathematician to work out that the investor money that went into the fund at the back end of 2020 will have not captured the bulk of the positive returns of 2020 and suffered the subsequent downswing.
A rough calculation using monthly performance and fund flow data suggests that, from the start of October 2019 to the end of
Stay invested, remain diversified and be thankful that your financial well-being does not lie in the hands of any one fund manager owning just 45 stocks
October 2021, the fund delivered an annualised return of 66% a year. However, the average investor return was around 25% a year, which is over 40% per year difference.
ARK Innovation relies on manager skill – or luck – in picking a mere 45 or so companies out of the many thousands of companies around the world. The risks are very high.
The fund management world is littered with the corpses of such ‘stellar’ funds. In the UK for example, over the past 20 years or so, around half of all investment trusts launched have failed to survive in their original form.
It is hard not to suffer FOMO at times like these, but it is worth remembering that investing is a not a sprint but a marathon.
When markets rise substantially, as they have done recently, regular rebalancing results in the sale of assets that have performed well and banks the excess proceeds.
Seemingly irrational markets can persist for a long time and, as the old saying goes, no one rings the bell at the top of the market. Stay invested, remain diversified and be thankful that your financial well-being does not lie in the hands of any one fund manager owning just 45 stocks.
Remember that it is the tortoise who wins the race.
Dr Benjamin Holdsworth is a 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.
Cavendish Medical Ltd is the go-to company for retirement planning for doctors. It has over 600 medical families as clients and £500,000,000 in client assets under administration. It operates a transparent investment policy and a fee-based approach allowing independent financial planning advice.
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
Independent practitioners inevitably find litigation can be stressful, time-consuming and expensive.
In the first of a series of three articles about the employment tribunal process, Julia Gray (below) explains the key stages and how doctors who employ staff can avoid common pitfalls experienced by others
BEFORE MAKING a claim in the employment tribunal (ET), claimants have to speak to a conciliator from The Advisory, Conciliation and Arbitration Service (Acas) about the possibility of reaching a settlement without bringing legal proceedings.
This stage is called ‘early conciliation’. Usually, the claimant will authorise Acas to contact the employer – known in the ET as ‘respondent’ – to discuss early conciliation before a claim is issued, so it is a good idea to ensure practice staff know where to direct HR-related inquiries such as this.
Engaging in early conciliation is optional for the employer. In some cases, it is best to wait and see whether a claim is forthcoming before making an offer of settlement.
It can be tactically effective to provide a robust denial of the allegations via Acas to deter a claim, but you will only be able to do this if the complaints have been properly described in sufficient detail, which they often are not at this early stage.
Remember that any discussions you have with Acas are ‘without prejudice’, which means they are confidential and cannot be referred to in legal proceedings. Claimants do not always want Acas to make contact, so the first you hear of a claim might be when
merit or appear to be addressed to the wrong person.
The deadline for responding to an ET claim is 28 days from the date when the papers are sent to you. The deadline date will be clearly stated in the papers.
The first page of the papers will look like our reproduced letter (left). The deadline for responding is underlined in the paragraph with bold text.
Parties to ET proceedings are not required to have legal representation, but respondents are usually represented by a solicitor. If you intend to instruct solicitors, do not delay.
You or your practice may hold an insurance policy or professional membership – for example, with the BMA – which covers the cost of defending an employment claim, so check this first.
their version of events does not stack up – it is important to submit a comprehensive response. If you do not respond in the given time limit, the claimant can win their case by default.
The ET3 can be accompanied by a supplemental document setting out your detailed response, called the ‘grounds of resistance’. This should include your version of the events set out in the claim and any other relevant information – it is important that you do not miss out any key points.
If your private practice receives papers from a court or tribunal, never ignore them. They should be treated with the utmost urgency
Drafting the response to the claim is a key stage when you should involve your legal adviser, if you have one. You will need to factor in time to collate and share relevant documents and other information with them.
Apart from the cost of legal advice and representation, it costs nothing to bring, or defend, an ET claim, as fees were abolished in 2017. And unlike some other types of court proceedings, the loser of an ET claim is not normally required to pay the costs of the winner.
A party may be required to pay towards their opponent’s legal costs where their conduct in the proceedings has been unreasonable – for example, missing deadlines and wasting the other parties’ time.
For example, if the claim relates to allegedly unlawful behaviour such as discrimination, then your response will need to address each instance of alleged behaviour including, where relevant, the motivation behind it.
The ET has different rules from the criminal court, but, as you have heard in many police dramas, ‘it may harm your defence if you do not mention something at this stage which you later rely on in court’.
A medical practice comprising partners is not usually a legal entity in its own right, so claims will usually be against all the partners and should be responded to on behalf of all partners.
Once your response has been accepted by the ET – and sometimes even before – the ET will issue instructions on how the parties should prepare for a hearing. These are called ‘case management orders’.
you receive official papers from the ET.
Most claims must be initiated within three months of the act complained of. For an unfair dismissal claim, for example, that is three months from the termination date.
Act fast to beat the deadline
If your private practice receives papers from a court or tribunal, never ignore them. They should be treated with the utmost urgency.
There are strict time limits in place for responding to claims, even those that appear to have no
Extensions to the response deadline are granted only in exceptional circumstances and must be obtained before the original deadline has passed.
If you miss the deadline, you will need to apply for your late response to be accepted out of time and there’s no guarantee you will be permitted to defend the claim.
Your defence to the claim is called the ‘response’ and the online form you must complete to submit the response is called the ‘ET3’6.
Even if you think the claim is hopeless – for example, the claimant was never employed by you or
They will set a timetable for key steps such as sharing relevant documents (‘disclosure’) and drafting witness statements for the hearing.
To allow time for these tasks to be completed, the final hearing (the ‘liability hearing’) will often be listed to take place in six to 12 months’ time.
In the next article in this series, we will look at case management and the process of preparing for an ET hearing. The final article will address the hearing itself and compensation awards.
Julia Gray is an associate solicitor at Hempsons
Dr Kathryn Leask (below) gives some useful detailed advice in response to a consultant’s query about appropriate action to take if a patient becomes abusive
QI had a very unpleasant private consultation with an intimidating and verbally aggressive patient who was referred to me with a frozen shoulder.
He raised his voice to my receptionist when she told him my previous consultation had overrun by a few minutes and refused to wear a mask in the waiting room, which made other patients uncomfortable.
During the consultation, he swore loudly at me when he felt some pain during my physical examination, although I had warned him that it might hurt.
Then he became angry when we discussed treatment options, after I recommended a course of steroid injections and physiotherapy, shouting that he had been in pain throughout lockdown and wanted surgery.
He then said he would think it over and has just emailed to request another appointment, but I really do not wish to see him again. We have a zero-tolerance policy on abuse, so can I simply refuse?
AThere is evidence that doctors have experienced an increase in abuse from patients.
Two-thirds (66%) of the 418 doctors who responded to an MDU survey said levels of abuse from patients and their representatives had increased and nearly half of doctors surveyed (49%) identified waiting times for treatment as the main reasons for patients and their relatives to become abusive.
Of course, this patient’s ongoing pain and frustration about the delay in accessing specialist care had a bearing on his actions, but
that does not mean you have to tolerate aggression.
The challenge is how to respond effectively to poor behaviour, without aggravating the situation or treating the patient unfairly.
As an independent practitioner, you have more freedom to decide who you will accept as a patient. However, you have already seen this man for an initial consultation and, from his perspective, you have agreed to treat his condition and established a professional relationship.
With this in mind, you need to be aware of GMC guidance which says you ‘should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient’ and that you ‘must be satisfied that your reason for wanting to end the relationship is fair and does not discriminate against the patient’.
Simply refusing to see the patient again without any warning or any attempt to restore your professional relationship is contrary to GMC guidelines and could aggravate the situation. It would also be hard to justify if the patient decides to make a complaint.
Instead, this is the moment to warn the patient that his behaviour during his first consultation
was unacceptable and give them the opportunity to change. You could set out your concerns in your response to his email and point to your practice’s zero tolerance policy and the consequences if he continues to swear or upset staff.
You could also clarify your practice’s policy on mask wearing and why, at the time of writing, the Government still recommends face coverings in indoor spaces, particularly healthcare settings. If the patient can’t wear a mask for any reason, this will be respected, but you will need to take steps to minimise the risk for other patients. Hopefully, the patient will apologise and change his behaviour, but he may decide that he does not want to attend your practice. But if his behaviour continues to cause concern, it would be reasonable to end the professional relationship.
In doing so, the GMC says you need to tell the patient your reasons, in writing and record this in their records, ensuring you ‘do not include anything that could unfairly prejudice [their] future treatment’. Finally, with the patient’s consent, you should ensure suitable arrangements are made promptly for his continued care and you pass on his records without delay.
Dr Kathryn Leask is a medico-legal adviser at the Medical Defence Union
QI’m a male, private GP who recently saw a 15-year-old girl, attending alone without her family who are regular patients of mine.
She explained she was very worried because, in the shower a few days ago, she thought she had felt a breast lump. She was tearful and anxious. She had not told anybody else about this and was very worried because her maternal grandmother had died in her 60s of breast cancer.
The patient was clearly very upset but was keen to be examined there and then.
I explained that I would like to discuss the matter further with her and that if I were to proceed with a breast examination then I would like to have a chaperone present.
The patient became very distressed and said she did not wish anyone else to be present and wanted the examination to take place as soon as possible.
Could you advise on how I should have proceeded?
AA chaperone is defined as an independent observer present during an intimate examination of a patient.
They are usually a health professional who is familiar with the procedures involved in the examination and can offer the patient reassurance and support.
The chaperone will usually, but not always, be the same gender as the patient.
The GMC’s guidance, Intimate examinations and chaperones (2013), states that doctors should offer the patient the option of a chaperone wherever possible before conducting an intimate examination, whether or not they are the same gender as the patient.
Although a chaperone should be a trained health professional, doctors should comply with ‘a reasonable request’ to have a family member or friend present alongside the chaperone.
The GMC guidance also highlights that, before conducting an intimate examination, a doctor
Dr Sally Old (below) explains how you should respond if an insistent patient refuses a chaperone
should give the patient a clear idea of what to expect. Explain why the examination is necessary, and what it will involve, in a way the patient can understand. Give the patient a chance to ask questions.
When dealing with a child or young person, you must assess their capacity to consent to the examination.
If they lack the capacity to consent, you should seek their parent’s authority.
Patients do have the right to refuse a chaperone. However, if you are uncomfortable with undertaking an intimate examination without a chaperone, you should explain why you would prefer to have one present.
You may be able to offer an alternative chaperone, or an alternative doctor, if the patient’s clinical needs allow.
You should document your discussion about the examination and chaperone in the clinical record.
Moving forwards, consider publicising your chaperone policy so that patients know the service is available and they are encouraged to make their wishes known at an early stage.
Dr Sally Old is a medico-legal adviser at the Medical Defence Union
PRIVATE
– Our series for doctors embarking on the independent journey
With the new tax year almost upon us, it is a great opportunity to ensure you have utilised your tax allowances, met important deadlines and your current circumstances are tax-efficient.
Ian Tongue (below) looks at some of the important areas you should be considering
There are several tax allowances that are lost if not used within a specific tax year.
One of the most common ones is the ISA allowance for savings, which allows you to shelter from tax £20,000 per taxpayer per tax year. If you have not yet used your allowance, discuss this with your financial adviser.
For individuals, there is a Capital Gains Tax annual allowance, which is lost if not utilised annually and is currently £12,300 for individuals.
Therefore, if you are considering disposing of any assets or have high gains that are unrealised on shares, you may want to consider whether utilising the allowance would save you money.
A UK taxpayer is allowed to pay into a pension up to £2,880 –£3,600 with the tax credit – in relation to a pension for their spouse or children. This would not form part or your £40,000 pension annual allowance.
They may not thank you for it now, but paying this into a pension from an early age for your children should provide them with a significant pension in later life.
For those with wealth in excess of the inheritance tax threshold, you may wish to consider giving away part or your estate, and £3,000 can be gifted in total to one or more persons which can actually be carried forward, so this would be £6,000 if you have not previously done this.
Therefore, between a couple, you may be able to give away £12,000 without this being sensitive for inheritance tax.
If you are thinking of paying into a pension and making gifts, speak to your accountant to ensure that you are within the acceptable limits for inheritance tax purposes.
This is usually the most significant decision when arranging your affairs to be tax efficient.
Many consultants use limited companies for their private practices and, no doubt for a substantial number, this will still be appropriate.
However, for some, the new tax changes relating to dividends
There are imminent changes to the rate of income tax payable on dividends. The rates increase by 1.25% from 6 April 2022 in line with the increases to National Insurance payable from the same date
to the historic annual allowance growth figures once the McCloud remedy has been implemented, so it is important that you are well placed to amend your historic figures to potentially avoid overpaying annual allowance charges.
If, while reading this, you are not aware of pension annual allowance-related matters for consultants, contact a specialist for advice right away.
Many of you will be familiar with the term capital allowances and these are the tax form of depreciation charges on the purchase of capital items for your business; for example, medical or computer equipment.
rise to other negative factors such as loss of pension annual allowances.
For those trading as a company, having a company car remains a popular choice. To date, there have been no proposed changes to the very low benefit-in-kind rates where a car is provided to a director or employee.
The most common way of obtaining a vehicle is by way of a lease, which is usually easily obtained for an established private practice.
from April 2022 and corporation tax increases from April 2023 will result in significantly more tax being paid and alternatives may need to be considered.
One of the key factors here is whether you tend to draw out of the company the majority of the profits. If this sounds like you, then speak with your accountant to see if your current arrangements are appropriate for your circumstances.
By now, most consultants will be aware of the dreaded annual allowance charges that have affected consultants in recent years.
Changes were introduced in the 2019-20 tax year to compensate NHS Pension Scheme members who incurred a tax charge in that year only.
The mechanism for reporting and paying the annual allowance charge remained the same for that year. But a compensation scheme was introduced which is an agreement between the member, NHS Pensions and your employing trust to make good the impact on the member’s pension from asking the pension scheme to pay the tax.
There are two stages to this process and it is important that you have both of these applied for by 31 March 2022, as you will no longer be able to apply from then.
There will be significant changes
These allowances are claimed as part of your accounts preparation and computation of taxes payable for both the self-employed and companies.
If you have a financial year-end for your business of the tax year of 5 April 2022 – or 31 March – it may be worth accelerating the purchase to obtain the tax relief on these purchases at the earliest opportunity.
For those trading as a company, there is a new ‘super’ capital allowance for purchases made between 1 April 2021 and 31 March 2023 to encourage investment, which allows you to expense 130% of the cost of qualifying expenditure.
As mentioned previously, there are imminent changes to the rate of income tax payable on dividends. The rates increase by 1.25% from 6 April 2022 in line with the increases to National Insurance payable – at the time of writing –from the same date.
The new rates after the £2,000 tax-free allowance have been used are:
For those with newer companies, you may need to accelerate the preparation of your practice accounts, so get these in to your accountant early to avoid the disappointment of not obtaining lease finance.
Another practical consideration is the time-scale for delivery of a new vehicle, which can be significantly longer than usual due to supply chain and semiconductor supply issues. If you are considering a new car, you may need to get your order in soon.
As always, speak with your accountant to understand the cost and savings for having an electric car through your company.
This is often an area overlooked, as it can be a difficult subject to consider, but the absence of a will should the worst happen can be extremely distressing and lead to significant financial loss through inheritance tax being payable.
Usually, will planning is carried out by solicitors or specialists, but often accountants are involved in this process as well. Make sure your will is up to date for your circumstances.
Depending on your circumstances, it may be worth considering whether additional dividends are paid from your company before the tax rates increase on 6 April 2022.
Before doing so, speak with your accountant to ensure that the additional income does not give
Approaching a new tax year is always a good point in time to consider tax planning opportunities that may be appropriate to your circumstances. Speak to your accountants and independent financial adviser to ensure that you are tax-efficient and utilising available allowances.
Next month: Avoiding financial problem areas when running your private practice
Ian Tongue is a partner with Sandison Easson accountants
Our tester Dr Tony Rimmer (right) finds the new electric Mustang Mach-E a very different beast to its muscle car predecessor
ANY HARD-EARNED positive image must be protected from becoming tarnished or damaged otherwise the risk to future profitability will be significant.
This applies to any business, the motoring trade included. Think of a successful and iconic car that continues over many decades of development, like Porsche’s 911, and you realise how vital it is that any future iteration of this sportscar continues to thrill and impress potential buyers.
This is why many of us are surprised but intrigued by Ford’s decision to name its first all-electric car the Mustang.
This iconic V8 muscle car first appeared in 1964 and, with the help of Steve McQueen in the film Bullitt, established itself as one of Ford’s most successful models ever.
Over the years, various updated versions were released, some more successful than others, and it is still in production in Michigan today.
You can currently buy a British RHD Mustang Mach-1 with a 5.0litre 454bhp V8 fire-breathing engine and a manual gearbox for £56,995, but it may be the last such model that Ford make.
The new electric Mustang Mach-E is a very different beast. Although it shares some styling cues from the original two-door coupé and sports plenty of galloping horse badgework, it is a fivedoor crossover that is aimed at the burgeoning family SUV market.
It is available with two battery size options, 75kWh or 98kWh and all-wheel drive or rear-drive only.
There is a range topping £67,225 GT with 480bhp that does 0-62 mph in 3.7 seconds, but I have been testing the more sensible £57,030 all-wheel drive range-extended version, with acclaimed 335-mile range, that has 346bhp and sprints from 0-62 mph in 5.1 seconds.
The cheapest version is the £41,330 rear-wheel drive model with 78kWh battery and 265bhp and a claimed 248-mile range.
The Mach-E looks smart with its coupé-like roofline and slim lights and large grille that emulate the original Mustang, but it is an SUV and cannot disguise its bulk.
Entry is by clever flush-fitting handles and when you take your place in the driver’s seat, the electric-drive environment is immediately obvious.
There is a large Tesla-like 15.5inch portrait touchscreen centrally and a narrower and simpler information screen directly ahead that displays the speed, range and battery state.
The seats are comfortable and the trim quality is on par with competitors such as the VW iD4 and Skoda Enyaq but not at a premium level like in the Audi Q4 or Jaguar i-Pace.
It is a pleasant enough place to
be and, unlike the original Mustang, there is plenty of space for passengers and luggage. Three adults can sit comfortably in the rear, aided by the flat floor of the all-electric platform.
So, does driving the Mach-E have anything in common with its coupé sibling? Well, in usual electric power style, acceleration is swift and instantaneous – but silent.
No lovely V8 roar that is music to the ear of petrolheads. As in most Fords, the steering is direct but not sharp enough to be called sporty.
The ride is firm, which helps body control through the corners but there is no way to disguise the over two tonne weight that is an inevitable consequence of large batteries. Subsequently, the suspension is slightly fidgety on anything but smooth roads.
As a keen driver, my overall onroad impressions are that the Mach-E drives better than many electric competitors but not the very best.
It cannot compete with some sporty internal combustion SUV competitors either. I did find that the predicted range generally matched reality if you drive normally, so that my test car would be able to cover a real-world 280–300 miles between recharges.
This is over my own theoretical psychological 250 miles barrier that makes long journeys a regular
possibility for most people, most of the time – impressive.
Charging can be up to 150kW, but this is obviously restricted by availability in the public charging network – still work in progress.
So, the Mustang Mach-E is a worthy entry to the electric car club. It drives well and has impressive range. It is roomy and familyfriendly. However, there are a lot of worthy competitors out there and the Mustang moniker could be misleading. It did make me think: perhaps we petrolhead medics should think about grabbing the last chance we might get to buy an old style Mustang Mach-1 with its wonderful V8 soundtrack, manual gearbox and sports-car handling.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
Body: Five-door hatchback. All-wheel drive
Engine: Two electric motors. 98kWh battery
Power: 346bhp
Top speed: 112mph
Acceleration: 0-62mph in 5.1 secs
WLTP consumption / Range:
3.3miles per kWh / 335 miles
CO2 emissions: 0g/km
On-the-road price: £57,030
1
If you practise in a PPU in the north-east of England, then check out how they are faring in Philip Housden’s monthly round-up. Here he analyses private patient revenue growth for NHS trusts across the North-East region covering conurbations of Tyne and Wear and counties of Durham and Northumberland
THIS REVIEW is the first to be based on the information from the most recently published trust Annual Accounts for 2020-21. This is a financial year fully adversely impacted by the Covid pandemic.
For this group of trusts, the 202021 accounts show that total private patient revenues fell, as expected, by 54.8% with total revenues of £2.6m, well down on the typical
values of recent years, which have ranged between £5.8 and £6.2m.
This level of income now represents only 0.1% of these trusts’ total revenues, a fall from 0.26% last year. This remains below the combined national average outside of London, estimated to now be 0.23%, down from 0.43% in 201920 and is also the lowest regional value in England.
The regional acute trusts performances by private patient revenues vary significantly and will be discussed by consideration of two potential groupings, north and south.
Dedicated facilities
First, in the ‘northern group’, the regional top earner remains The Newcastle Upon Tyne Hospitals
at £3.76m. However, this total was down £2,257,000 year on year (61.9%), now 0.13%, down from 0.36% of the trust’s total patient revenues.
The trust is the only one in the North-east with dedicated inpatient facilities, having a six-bed private patient facility, the Park Suite at the Royal Victoria Infirmary (RVI), and also dedicated private
outpatient consulting rooms located in The Lodge, again on the RVI site.
Northumbria Healthcare in Northumberland bucked the national trend with growth of £295,000 (256%) to reach a new total of £410,000, up from £115,000 in 2019-20 and now 0.08% of income (was 0.02%).
Northumbria has in recent years developed links with both Ireland and with China to share expertise on providing high-quality health and this commercial approach may also enable international patient services to develop over time.
The trust has recently strengthened its business development resource for private patient services.
Across the River Tyne, Gateshead Health delivered private patient incomes of £413,000, a decline of £238,000 and 36.6% from the £651,000 reported in 2019-20. This is now 0.14% of total trust revenues, a fall from 0.24%.
City Hospitals Sunderland merged in April 2019 with South Tyneside to form South Tyneside and Sunderland NHS Foundation Trust. The new trust’s combined private patient revenues last year were £206,000, well down on £375,000 in 2019-20.
This is a decline of £169,000 and 36.6%, and a fall from 0.07% to 0.04% of total trust incomes.
Turning to the second ‘southern’ group of three trusts, the first, South Tees Hospitals, is by far the largest in terms of private patient earnings and has in recent years been the second highest in the North-east.
However, revenues have consistently fallen from a high of £1.8m in 2015-16 at 0.35% of total income to £831,000 in 2019-20 at 0.14% and then to £165,000 at 0.02%.
The fall last year was therefore £666,000 and 80%. The trust still offers some limited private patient services from Friarage Hospital in Northallerton, North Yorkshire, where the Wensleydale Suite, with a four-room treatment and consul-
We take a break from our regional reviews to assess the wider overall findings for England NHS trusts from the publication of annual accounts for 2020-21
tation outpatient area, used to be the private patient hub.
The trust does provide private patient fertility and therapy services from James Cook University Hospital in Middlesbrough, where this is also a commercial arrangement with Sk:n, the dermatology provider for mole mapping and related services.
The other two trusts have for several years had little private patient revenue.
North Tees and Hartlepool’s income fell 88% last year from £125,000 to only £15,000 in 202021.
It should be noted though that the trust has provided private assisted conception services using the same provider as South Tees.
The final trust, County Durham and Darlington, also saw a reduction from the already low level of £34,000 to £14,000.
With the exception of Newcastle –the NHS’s regional and supraregional services centre – private patient earnings presently provide little in the way of significant additional income for these trusts in the North-east.
However, this appears to be a good healthcare economy and there does remain a vibrant private patient market demand, particularly fuelling growth in self-pay demand, given rising NHS waiting lists and access times.
The North East region’s relative geographic isolation means it is most likely that higher complexity insured patients are being treated locally within the NHS and there-
fore they are not picked up and charged.
For lower-acuity elective cases, patients do have a range of choices available from the region’s independent hospitals, but may also travel out of area.
The complexities of opening, managing and growing an inhouse private patient service mean that this is out of reach of many trusts if they start at a low base and so fostering trust collaboration across the new integrated care system could be the route to success.
Groups or ‘collaborative chains’, based on the proposed northern and southern groups as suggested – or some other locally developed variant – could potentially enable leadership and/or back-office cost sharing to give a fresh approach to drive growth from the Northeast’s NHS private patient offer.
Our benchmarking survey of income and expenses for gynaecologists reveals such a hefty rise in profits that accountants are scratching their heads and examining the figures. Ray Stanbridge reports
IT LOOKS at first sight as if gynaecologists had, to put it very mildly, a good year in 2019-20.
Gross incomes from private practice appear to have risen by 38.2%, from £149,000 in 2019 to £206,000 in the year to 5 April 2020.
And profit before tax appears to have shot up by a mouth-watering 64.1% – from £78,000 to £128,000. These gross figures are, unsurprisingly, far higher than consultants in other specialties have enjoyed.
While most gynaecologists
appear to have been busy in 201920, the figures we have calculated, based on actual data, far exceed what we would have expected.
We have been consistent in our analytical approach but do recommend that readers read this report with caution. These figures are, of course, averages and have been boosted by a few very high earners having an exceptional year.
Why has there then been such a large growth in income?
From informal discussions, it
INCOME AND EXPENDITURE OF
seems there may have been pentup demand from earlier periods, with some catching up historically prior to the Covid restrictions.
We know that a small but increasing number of gynaecologists offer specialist nursery services. These may relate to maternity or birth control support, which could be one reason for the increase.
There does seem to have been some growth in Choose and Book work, but this hypothesis has not yet been proved by the data.
We must, of course, remind readers that our sample is by no means statistically significant, rather it is an attempt to report on a typical gynaecologist’s private practice earnings and expense schedules.
Staff costs continued to show a rise, from £21,000 in 2019 to £26,000 on average in 2020.
There appears to be a shortage of dedicated gynaecologist support staff, which may have put up costs. There has also been some upward pressure on the costs of dedicated gynaecology nurses.
Consulting room hire costs have shown a growth, but perhaps not as high as we would have expected given the growth in activity.
It seems there may have been pentup demand from earlier periods, with some catching up historically prior to the Covid restrictions
Indemnity defence/insurance costs have risen and are higher than for many other disciplines because of the risks involved in some gynaecology maternity work. There are always time delays and we would expect further indemnity insurance costs in 2021 reflecting the growth in 2020 activity.
Use-of-home costs have risen as an increasing number of gynaecologists deal with their administrative and reporting work from their home office bases.
Most other costs have remained broadly constant or shown inflationary increases despite the growth in business. It may be that there is a time lag and that these costs will increase in 2020-21.
What then of the future? We anticipated that the financial year ending 2020 would be good for
gynaecologists, but not this good. In our report last year, we said: ‘We expect gynaecologists to continue to progress well on the whole’, but our analysis suggests a hefty underestimate about the increase in profitability and incomes .
The year 2020-21, the next year under review, will demonstrate the influence of Covid, which shows a slow increase in performance in the year, but suggests that gynaecologists recovered well in the latter part of 2020 and early 2021.
We are still reviewing what appears to have been a very good performance in 2019-20 to see if there are any peculiar factors that have inadvertently crept into our analysis or if we have made any incorrect observations.
If so, then we will revise these figures.
Our criteria for consultants in our survey are that:
Sample consultants earned at least £10,000 from private practice from the year under review;
They hold either a new-style or old-style NHS contract;
They have at least five years’ experience in private practice;
They are seriously interested in private practice as a business;
They work as a sole trader, a member of a formal or informal group, or are members of a partnership, limited liability partnership or a limited liability company.
We do not include fully private consultants in our survey.
Next month: Radiologists
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates Limited
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Coming in our March issue, published on 8 March.
A new way of paying for private healthcare is rapidly gaining pace and helping to fuel significant growth in self-pay business. In part 1, Richard Gregory introduces Point of Sale Finance and its impact on customer service and sales
Tips on avoiding financial problem areas when running your private practice, from medical accountant Ian Tongue
Our Troubleshooter Jane Braithwaite tackles three burning questions from independent practitioners:
1. There are so many patients on NHS waiting lists and many of these are considering self-pay private treatment. How do I attract these patients to my practice?
2. Should I charge patients for phone calls and answering their questions sent by email? Dealing with these takes up a lot of my time;
3. How do we charge patients appropriately for these new interactions?
With higher inflation rates often in the news, Cavendish Medical’s Dr Benjamin Holdsworth on why it is easy to get lost in the numbers. He warns that, left unchecked, inflation can be a dangerous foe to the long-term investor, eroding the purchasing power of one’s hard-earned cash over time
In our Business Dilemmas, Dr Sissy Frank, medico-legal adviser at the Medical Defence Union, tells a private GP how to respond to a court order provided by the police and responds to a consultant’s query about what to do if a patient requests access to their records
Profits Focus: Specialist medical accountant Ray Stanbridge examines radiologists
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Preparing for an Employment Tribunal hearing: In the second of our mini-series from Julia Gray of Hempsons solicitors, she considers the steps to prepare the case for hearing or otherwise resolving the claim
Medical Billing and Collection’s Simon Brignall presents pearls of wisdom for independent practitioners, compiled from the company’s 30 years in medical billing
Private Patient Units: We take a break from our regional reviews as Philip Housden assesses the wider overall findings for England’s NHS trusts from the publication of Annual Accounts for 2020-21
Robots on the march: Mr Jay Chatterjee, consultant gynae-oncologist at HCA’s The Lister Hospital, reports on the rise of robotics and the benefits of expanding these treatments
Visionary private business – how an all-female team opened their new ophthalmology clinic
Treating high-profile patients can often present a unique set of medico-legal challenges and it is important that doctors protect themselves, as well as the patient. Dr Emma Green, medico-legal consultant at Medical Protection, discusses the common issues and sets out some advice
Ten Years’ Ago: our archives reveal what taxed private doctors in 2012
Doctor On The Road – Dr Tony Rimmer reviews the Audi Q4
Plus all the latest news and views
And don’t forget to check out our additional news updates every week online
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