The business journal for doctors in private practice
In this issue
Making competition work
Private consultants’ questions are answered by PHIN’s chief executive Dr Ian Gargan P18
Time to reform the regulator
Urgent changes are needed at the GMC to ensure doctors get a fair hearing, says the MDU’s Dr Udvitha Nandasoma P24
Ten tips for defusing an angry situation
n See page 14
Using the right business structure?
Solicitor Kirsty Odell outlines the differences between the types of business structure P40
Becoming an expert witness gets harder
By Robin Stride
Lucrative expert medical witness work may be harder for some doctors to find following action launched by the Expert Witness Institute (EWI).
With the scrutiny of expert witnesses increasing in recent years, the courts have responded with both criticism and some severe penalties for individuals who put themselves forward as expert witnesses but who do not understand the role or their obligations.
But the EWI believes its new certification of expert witnesses will drive improvements in expert witnesses’ quality and provide lawyers with a pool of experts they can rely on to deliver.
Following two successful pilot studies, the Expert Witness Institute is rolling out its new Certified Expert Witness Membership, a ‘goldstandard’ register of experts whose knowledge, skills and practice have been thoroughly validated by the institute.
This will assure lawyers that by instructing an EWI certified expert, they are enlisting a professional who understands their role and can ultimately deliver.
In association with
Simon
Berney-Edwards, chief executive, Expert Witness Institute
To get EWI certification, applicants must already be highly experienced experts, with the assessment process building on the vetting procedures in place for EWI membership.
They will be assessed on all the core competencies required to be an expert witness, recognising those who can demonstrate excellence in report writing, discussions between experts and giving oral evidence in court.
Crucially, applications for certification and revalidation of certification, are assessed on the expert’s ability to demonstrate actual practice in real scenarios.
➱ continued on page 3
HOW THIS WILL IMPACT ON EXPERT MEDICAL WITNESSES
SIMON BERNEY-EDWARDS, CHIEF EXECUTIVE AT THE EXPERT WITNESS INSTITUTE:
‘Our hope is that as the new certified scheme gains greater levels of recognition among the expert witness and legal community it will encourage existing expert witnesses to seek certification so they can instantly demonstrate that their practice as an expert witness has been assessed and validated. For newer expert witnesses, this sets out a standard to aspire to.’
Will it mean less work for some existing medical expert witnesses as lawyers opt for those with certification?
‘Unless we see a complete change from the judiciary in saying that all expert witnesses must be registered with a professional body representing expert witnesses I suspect that this will not happen in the first instance, especially as we are aware that many lawyers will use the same experts and/or agencies time and time again rather than looking for a new expert witness for each instruction.
‘However, with the regularity that expert witnesses are appearing in the legal press for being criticised in the courts, we are seeing an increase in lawyers being more cautious when searching for and appointing new experts.’
Will new doctors wanting to be expert medical witnesses need to get certification to stand a good chance of getting work?
‘Not initially. There will always be pathways for new expert witnesses to gain experience and recognition’.
How many expert medical witnesses are there?
‘I wish I had the answer to that question! We know how many we have on our books but because there is no requirement for expert witnesses to be registered with any specific organisation or the courts, it is difficult to find an answer to this question’.
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Ouch! Many independent practitioners are still reeling from those huge HMRC bills last month – not helped by the ongoing pensions tax crisis affecting their NHS earnings.
It will be little comfort to know that things could have been much worse if they had been paid the salaries they deserved over the last decade.
As we reported in our website news section last month, a BMA dossier has found consultants’ NHS work earnings have dropped by more than a third in the last 14 years due to Government meddling in the ‘independent’ pay review process.
A variety of fiddling by all four UK governments has resulted in their earnings falling by a huge 34.9% in real terms since 2008.
Little wonder, then, that with current high inflation, especially in running a medical practice, so many feel the pinch.
We wait to see the results of rec-
ommendations from some medical accountants for independent practitioners to review their fees for the new financial year.
Meanwhile, there is an obvious opportunity to increase private work for those doctors who are not as hot as they could be at keeping their website information updated.
According to the boss of the Private Healthcare Information Network (PHIN) – see feature starting on page 18 – the organisation’s website analytics show consultants providing complete fee and other information get many times more clicks to their practice than those who have not got around to it yet.
A timely review of your online presence, suggested by Civica Medical Billing and Collection (page 36), will also help put you in the best light. Even those with no website may be on multiple sites including hospitals they work at and Bupa’s profile.
How can we find a new partner?
Troubleshooter Jane Braithwaite responds to a query from consultants seeking advice on how best to recruit a new partner for their clinic P10
Attract patients by getting emotional
Marketing expert Catherine Harriss examines the huge part harnessing social media can play in helping create a more successful private practice P21
The secret of being ‘best group’ How looking after your workforce paid dividends for Spire Healthcare, winner of the coveted ‘Hospital Group’ prize at the LaingBuisson Awards P26
Bosses pay heed to workers’ burnout
Bupa medical director Dr Robin Clark discusses the findings of Bupa Global’s latest Executive Wellbeing Index, revealing high levels of burnout P28
Beware the risk of remote reporting
Outsourced remote radiology reporting has increased in recent years, but there are risks for both hospital and private radiologists, says Dr Emma Green P34
Don’t get your pocket picked Costs really do matter. Benjamin Holdsworth of Cavendish Medical gives the lowdown on the high charges that can harm your investment returns P38
PLUS OUR REGULAR COLUMNS
Accountant’s tips: Ten ways to save tax in the year ahead
Alec James of Sandison Easson gives ten tips to boost your finances before the end of the tax year P43
Business Dilemmas: Keeping records after retirement
The MDU’s Dr Kathryn Leask gives advice to a surgeon with a medico-legal practice who is retiring P46
Doctor on the Road:
A premium SUV with affordable price tag
Dr Tony Rimmer gets behind the wheel of a premium SUV that undercuts its rivals by £10k-£15K P48
Review your NHS pension before taking any action
Consultants urged amid health service consultants’ exodus
By Edie Bourne
Doctors considering leaving the NHS or reducing hours in a bid to remove punitive tax bills on their pension savings should have their figures rechecked, warn specialist financial planners Cavendish Medical.
Many NHS consultants are facing additional five-figure tax liabilities thanks to the unusual way their NHS pension growth is calculated – but some of these tax charges could be lowered by the outcome of the McCloud remedy.
Tax-free pension savings are limited to £40,000 every year for most people, known as the annual allowance. Higher earners will face an even lower limit called the ‘tapered’ annual allowance which can be as little as just £4,000.
Doctors can easily breach the allowance because in defined benefit schemes such as the NHS, the value of pension savings is determined by
the deemed ‘growth’ in the year, not by the actual contributions.
The growth is calculated using the previous year’s September inflation figure, meaning pensions could rise by more than 10% this year.
Patrick Convey, technical director of Cavendish Medical, explained : ‘The medical profession is already tackling the most challenging of times in the NHS, but the pensions mess continues to add to their problems. Many believe they are effectively paying to come to work and are forced to reduce their hours accordingly.
‘However, we would urge anyone facing tough decisions to double check their position with expert support to ensure the figures they are working from are accurate.’
He told Independent Practitioner Today: ‘First of all, we see many pay and pension figures that are wrong – computer-generated errors are commonplace in NHS trust admin-
istration. This means your starting point is incorrect before you start modelling possible solutions.
‘Secondly, it is entirely possible that the McCloud remedy will reduce the annual allowance figures for individuals.
‘The McCloud remedy means that NHS members deemed to have suffered age discrimination when the 2015 pension scheme was introduced will eventually receive their original benefits from the 1995 or 2008 scheme for the five years of the “remedy period”.
‘No part of the NHS Pension Scheme is ever easy to work out, and the McCloud remedy is no different – but it is possible that it could bring positive news for some.
‘We have found that doctors checking their last three years of annual allowance figures, for example, calculate significant tax charges, but when reworked over seven years, this is reduced. We look at seven years because we add
an extra two years to the five-year remedy period, as the annual allowance can be carried forward for up to three years if not used.’
‘Of course, we will see more problems of this nature in the future as those same doctors start to build up pension in the 2015 scheme once more, but it can be a welcome reprieve for the time being.’
An NHS consultation was launched in December to consider proposals to introduce partial retirement flexibilities to the 1995 Section of the NHS Pension Scheme and to reduce the impact of inflation on pension growth. It is due to finish at the end of January.
Mr Convey added: ‘Jeremy Hunt had promised to tackle doctors’ harsh tax bills before he became Chancellor, but, as such, there have been no concrete announcements. We await the outcome of the latest consultation, but many doctors could have already left the NHS before change has been actioned.’
Recertification every five years for expert witnesses
Consultants wanting to be certified as expert witnesses will have many hoops to jump through to stay on the accredited list.
Under the Expert Witness Institute scheme, certified experts must commit to undertaking continuing professional development and will be required to go through the certification assessment every five years to revalidate their practice and retain their certified status.
Experts who have achieved certification will be identified as such and appear at the top of search results on the Institute’s Find an Expert Directory.
EWI Certification has been SCQF
credit-rated by the Scottish Qualifications Authority (SQA) and has been awarded 15 SCQF credit points at SCQF level 11.
The new gold standard has been warmly received by the judiciary in both the English and Welsh and Scottish jurisdictions.
Lord Hodge, deputy president of the Supreme Court, responded: ‘I welcome the EWI’s initiative in creating a certification programme for expert witnesses.
‘The complexity of much of modern litigation means that expert witnesses often play an essential role in the administration of justice.
‘Unfortunately, judges have had to criticise experts for failing to
understand and comply with their duties. Such failures can result in injustice and such criticism can cause serious damage to a person’s professional reputation.
‘I hope that the initiative will assist experts, the parties who instruct them to give evidence and the judiciary in their collaboration to ensure high standards in the administration of justice.’
Also welcoming the EWI’s move, the Right Hon Lord Carloway, Lord President of the Court of Session, said it was critical that expert witnesses were properly trained and qualified so they could comply with their duties to the courts and tribunals.
EWI chairman Sir Martin Spencer
said: ‘We are delighted to add this new level of membership to our Find an Expert Directory which provides the legal profession with a pool of talent with the relevant education, training, understanding and experience to provide expert guidance to the courts.’
The scheme was made available to members via a soft launch, since when 40 members have upgraded to become a Certified Expert Witness over the last seven months.
The EWI said the scheme was open to experts from all disciplines who could demonstrate an excellent level of practice against the core competencies. It costs £325 for EWI members and £425 for non-members to apply.
➱ continued from front page
Austerity may hit private care boom
Recent private healthcare growth risks being sunk by current tough economic conditions, a new report warns.
The financial situation could drive a wider health inequalities divide between high-income households and those in the lower earnings bracket, it says.
The King’s Fund publication, Independent Healthcare and the NHS, forecasts that in the near term the private sector is likely to have an important role in supporting the NHS’s recovery from the pandemic, particularly in working through the elective backlog.
This is against a backdrop of the proportion of NHS spending on the private sector flatlining over the last decade and last year’s Health and Care Act undoing many market-based reforms that some believed opened the door to more private involvement in the NHS.
The report, written by researcher Jonathon Holmes, says: ‘As NHS waiting lists have grown and public satisfaction rates have plummeted, evidence is emerging that more people – including groups with lower disposable incomes –are choosing to self-fund their health care.’
But it adds that this growth may be stifled by the prevailing economic conditions, including inflationary pressures and the rising cost of living.
And while long waiting times for NHS care persist, access inequalities may widen because households with more disposable income will be better able to selffund health care and avoid NHS waiting lists.
While those with lower disposable incomes may still choose to self-fund to get faster treatment, they will then run the risk of
greater financial hardship if they do so.
The report notes some market analysts and commentators have forecast significant growth in private healthcare for the next few years and that some independent sector providers have invested significantly to expand their capacity in England.
But it warns that turbulent prevailing economic conditions and mounting concerns about the cost of living are likely to dent consumer confidence and limit demand.
It states: ‘While 2021 saw a rapid growth in the number of people self-funding a wide range of treatments and procedures, it is unclear whether that trend will continue, and whether the relationship between long waiting times and people ‘opting out’ [of the NHS] will also continue.’
US trauma clinic opens first base in UK
All Points North (APN), a health company ‘offering innovative treatment for the mind, body and soul’ announced the launch of its first location outside the US at this year’s Arab Health exhibition earlier this month.
Opening next month in the Harley Street Medical Area, the clinic will specialise in treating trauma, depression, anxiety and substance use disorder.
The facility will offer mental health therapies such as deep transcranial magnetic stimulation, ketamine-assisted healing, quantitative electro-encephalogram brain mapping, neuro-feedback and stellate ganglion block.
A fitness and personal training boutique will offer discounted rates for clients in therapy.
APN founder and chief executive Noah Nordheimer said: ‘When we first opened APN in the US, a large
majority of our clients were flying in from the UK and surrounding countries throughout Europe and the Middle East – which demonstrates a need for more accessible mental health resources in that region of the world.
‘Harley Street is a hub for the UK’s behavioural health sector, and we are pleased to call London our new home to build the bridge between APN, Europe and the Middle East and start helping a massively underserved market.’
PHIN boss on drive to get doctors to display fees
The doctor boss of the Private Healthcare Information Network (PHIN) says it aims to work more closely with consultants to inform them about the organisation and to get their feedback about how it can help and support them.
Dr Ian Gargan, its chief executive, told Independent Practitioner Today the plan was to boost the number of consultants featuring on its website, currently just over 9,000, to include all consultants in private practice before the middle of 2026.
He said PHIN was regularly writing to consultants who have either not supplied their fee information, or who have done so, but have not quite completed the process to allow the network to publish that information.
‘We have also recently been contacting consultants to let them know that the CMA is investigating enforcement action and we want to avoid them being on any escalation list,’ Dr Gargan said.
‘We encourage consultants to review the data that is submitted to PHIN from the private hospitals where they work. There are processes to approve data about the volume of procedures that they perform and the length of stay for those procedures.
‘Consultants can also notify hospitals if they want to review or raise a query about data that has been submitted to PHIN.’
In an exclusive interview, he said PHIN did not want to see anyone undergoing enforcement action and it was supporting consultants to ensure the process was as straightforward and painless as possible.
PHIN, which has mushroomed from six employees to 45 staff, has a dedicated consultant support team and doctors can also ask questions through the network’s consultant portal: https://portal. phin.org.uk.
See the full interview starting on page 18
Government reinforces private patients’ safety
By Robin Stride
The Government has reported ‘good progress’ towards safer practices affecting independent practitioners, hospitals and patients in the wake of the inquiry into disgraced former surgeon Ian Paterson.
In a statement, given alongside an update* on developments following recommendations from the former Bishop of Norwich’s inquiry into the affair, junior health minister Maria Caulfield highlighted some of the most important developments.
Patient-centred information
She said: ‘Patients now have more access to information relevant to their treatment than they did during Ian Paterson’s time practising.
‘This includes access to information about the performance of consultants working for independent-sector healthcare providers and specialties in the NHS.
‘These continue to be added to, so patients will have more, and better, access to independent information before choosing a consultant.
‘NHS England (NHSE) will work with the professions so that meaningful consultant-level information on the numbers and types of procedures performed should be made publicly available.
‘If patients choose to be treated in the independent sector, there is now more information about what to expect, with further information to be made available over the coming year.
‘Patients now have the right to access their treatment records and clinicians are aware of the need to write to patients directly following a consultation or treatment, rather than only writing to their GP.
‘This information gives patients a record of their condition and test results to reflect on or to seek a second opinion, if required.
‘This is re-inforced by ensuring patients get the time they need to consider treatment options and have access to a range of new resources to help them consider their options; options that patients will also be able to discuss with medical professionals who are equipped to handle these conversations.’
Making challenge heard
The former nurse, who is undersecretary of state for mental health and women’s health strategy, said:
‘Doctors across more specialties now have independent data on their practice available and will be required to use this as part of their appraisal and revalidation processes. This will help to identify issues and fix them.
‘Staff in the health system also have more opportunities to make their voices heard about a patient’s care, including through clarified guidance and assessment of multidisciplinary team use as a forum.’
INDEMNITY AND INSURANCE
The Government is working to ensure any future changes to indemnity and insurance arrangements will be made ‘using the best evidence base available’.
Maria Caulfield, under-secretary of state for mental health and women’s health strategy, said in her progress statement: ‘This includes a thorough assessment of the impact on patients, healthcare professionals, providers, and the wider market; with the aim of improving the position for patients when receiving treatment from any regulated healthcare professional, regardless of the setting.
‘The Government’s ambition is that when this work concludes, patients have confidence that they can access appropriate compensation if harmed while receiving care, including when harm arises from criminal/intentional acts or omissions.’
The Care Quality Commission (CQC) has updated its guidance on complaints processes in early 2022 and it is now easier for patients to raise concerns about treatment and to access independent resolution of their complaint if unsatisfied with the provider’s handling.
NHSE has introduced measures to advance safety and the response to harm, while the Government has appointed the first ever Patient Safety Commissioner for England, Dr Henrietta Hughes.
Ensuring accountability
Ms Caulfield said the CQC published its new single assessment framework in July 2022, setting out what good care looks like, and the National Quality Board issued national guidance on System Quality Groups, setting out quality governance requirements in integrated care systems.
‘Alongside this, we have seen significant culture change in the independent sector, now leaving
Midlands breast surgeon Ian Paterson performed inappropriate surgery on many hundreds of patients. Concerns about his practice were first raised in 2003 and he was suspended from his NHS trust and private hospitals in 2011 and imprisoned in 2017.
In December 2017, an independent, non-statutory inquiry into Paterson’s malpractice, chaired by the then Bishop of Norwich, the Rt Rev Graham James, was set up and reported in February 2020.
no doubt that independent providers must take responsibility for maintaining high standards of care in their facilities, irrespective of how the medical professionals involved are engaged by them through employment or practising privileges,’ Ms Caulfield said.
‘This has been supported by Independent Healthcare Providers Network’s refresh of the Medical Practitioners Assurance Framework in September 2022. NHS Resolution launched new exclusion guidance in April 2022.’
Putting things right
The minister added: ‘Patients who are impacted by potential issues with their care will be reviewed through recall processes which are now better informed of how to put patients at the centre of their focus. The new national recall framework was published in June 2022 to facilitate this.
‘Patients will continue to receive apologies from healthcare professionals and providers for potential issues with their care when appropriate.
‘Enhanced training and resources are now available to clinicians to ensure these apologies are delivered effectively and meaningfully.’
* See https://tinyurl.com/ cwcd94mx
Cromwell is first private unit to recycle gasses
By Olive Carterton
Cromwell Hospital has become the first UK private hospital to trial an innovative medical device which captures and recycles waste anaesthetic gases, preventing them from polluting the atmosphere.
The trial was made possible through Bupa’s eco-disruptive programme, which sees employees partner with sustainability startups to tackle environmental challenges.
About 95% of the anaesthetic used during surgery is exhaled by patients and released into the atmosphere as waste. This equates to 97,000 tonnes of carbon dioxide equivalent (CO2e) each year in the UK alone.
But the SID-Dock, developed by SageTech Medical, can capture 99.9% of this waste anaesthetic, helping to reduce hospitals’ carbon footprint.
Sarah Melia, general manager health services at Bupa UK said: ‘Sustainability is at the heart of Bupa’s purpose. We know that the health of the planet and people’s
health are intertwined and it’s essential we’re looking after both.
‘To do this, we need innovative solutions to the sustainability challenges we face, and our trial of SageTech Medical’s system is a good example of the steps we’re taking to become net zero.’
SageTech was one of six start-ups that made it through to the global final of the 2022 eco-disruptive programme. As well as reducing direct emissions through its unique circular economy solution, it has developed purification technology so the waste anaesthetic can be reused.
This means the volume of virgin drug that needs to be manufactured is also significantly reduced, conserving natural resources and reducing the associated emissions.
Iain Menneer, SageTech Medical chief executive, said: ‘It’s been fantastic to work with Bupa on this programme. Partnering start-ups with a big corporate organisation can help fast-track pioneering solutions in healthcare and we’re proud to work with Bupa and Cromwell Hospital to help
advance their sustainability agenda.’
The SID-Dock fits easily and safely into hospital operating theatres, without having to make changes to any existing equipment. It works by capturing the waste anaesthetic breathed out by a patient during an operation. This is safely stored in canisters. When they are full, SageTech collect them from the hospital and take them to its processing facility where the captured anaesthetic is purified and recycled back into pharmaceuticals, ready to be used again by hospitals.
Mehnuhlik Lynch, anaesthetic team leader at Cromwell Hospital is leading the trial. He said: ‘Clinicians are becoming more and more aware about the impact their clinical practice is having on the environment.
‘Using SageTech’s solution, we can help reduce the carbon footprint of anaesthesia and give patients a greener choice for their healthcare.’
Cromwell Hospital is also working with Upcycled to provide uniforms and scrubs made from waste plastic collected from the sea and landfill.
Honours for private providers’ spokesman
Independent Healthcare Providers Network (IHPN) chief executive David Hare has been awarded an MBE in the 2023 New Year’s Honours List for services to healthcare, particularly during Covid-19.
Since his appointment in 2014, membership has grown from 26 to almost 100 members and the organisation’s role has expanded to include critical work to improve standards and patient safety in the sector. This has been seen through his work in bringing together independent healthcare providers to implement the Medical Practitioners Assurance Framework – used by the Care Quality Commission in assessing how well-led an independent service is. It is now a requirement for all independent providers under the NHS’ 2022-23 Standard Contract.
IHPN’s chairman Lord Patel of Bradford said: ‘This award is in recognition of David’s invaluable contribution to the pandemic response, which resulted
in millions of NHS patients being able to access treatment in the independent healthcare sector which they would otherwise not have been able to.
‘Under his leadership, IHPN has gone from strength to strength and his commitment to ensuring a thriving independent healthcare sector which delivers the highest quality care to both NHS and private patients is recognised across the entire healthcare sector.’
Mr Hare is on the Government’s NHS backlogs taskforce which is looking at how independent providers can be better used to reduce waiting times for NHS patients.
He said: ‘The award is a reflection of the great contribution which the independent healthcare sector makes to the health of the nation, and in particular the care that was delivered to millions of patients during the height of the Covid-19 pandemic.’
See ‘Optimism is in the air’, page 32
Mehnuhlik Lynch, anaesthetic team leader at Cromwell Hospital, and the SID-Dock anaesthetic gas capture device
Compiled by Philip Housden
On The Move: Shams Maladwala, head of Royal Marsden Private Care
The managing director for The Royal Marsden Private Care, Shams Maladwala, is leaving after nine successful years.
Under his leadership The Royal Marsden Private Care has won numerous prestigious LaingBuisson Awards.
He has championed the hospital’s NHS Foundation Trust’s integrated model, which enables all profits from private care to be reinvested into the trust to provide high standards of service for all patients, whether NHS or privately funded.
Shams and the team have grown the service significantly from £67m in 2013-14 to £141.6m for the 2021-22 financial year, while also managing capacity and the demands of working within an NHS environment.
The Royal Marsden Private Care is by far the largest earner of private patient income, delivering 26% of the total for all England NHS trusts in 2021-22.
Shams has also delivered innovative new services and facilities including, most recently in April 2021, the successful opening of The Royal Marsden Private Care at Cavendish Square.
The diagnostic and treatment centre in the Harley Street medical district has supported The Royal Marsden Private Care to significantly grow international referrals from the Middle East and China.
Shams said: ‘It has been a privilege to lead The Royal Marsden Private Care, and I’m confident
that our integrated and researchled care model will continue to drive growth and provide worldleading treatment and care for patients.”
His new role will be helping establish Dubai’s first comprehensive cancer centre as executive director of the Hamdan Bin Rashid Charity Cancer Hospital.
Maternity suite re-opens at University College Hospital University College Hospital’s Fitzrovia Suite has been re-opened following a major refurbishment and modernisation programme.
The ward includes a new dedicated reception area, new private waiting, five en-suite bedrooms and two new delivery rooms, meaning private vaginal births can now be offered as well as the caesarean sections previously provided.
The Fitzrovia Suite is staffed by a team of dedicated private midwives and all profits from private maternity services are reinvested back into NHS maternity services, which then benefits all patients in the hospital.
Renewed call for private units to tackle NHS waits
Latest NHS performance figures have prompted a renewed call from private hospital providers to take on more patients from the health service.
David Furness, director of policy at the Independent Healthcare Providers Network (IHPN), said the NHS’s 7.19m waiting list underlined the need for all parts of the healthcare system to work together to tackle the backlog. He urged the NHS to use ‘all the tools in its armoury’ to ensure patients can access the treatment they need.
Mr Furness added: ‘This includes making greater use of the independent sector and bolstering patient choice – key factors in getting NHS waiting times down in
the 2000s – and we welcome the Government’s recently announced taskforce to look at this very issue and ensure that the capacity and capability available in the independent sector is being fully utilised for the benefit of NHS patients.’
NHS figures show the total number of people waiting for consultant-led NHS hospital treatment has fallen for the first time since the start of the Covid-19 pandemic, with 7.19m on the list in November 2022 compared to 7.21m in October.
The most common long-waits seen were for:
Trauma and orthopaedic treatment, such as hip and knee replacements: 242,785 – 31%;
ENT treatment: 60,891 – 11%;
General surgery: 108,197– 25%.
Prof Neil Mortensen, president of the Royal College of Surgeons of England, called the task ahead ‘gargantuan’.
He said: ‘In some areas, surgeons are telling us that they are dealing with more complex cases, more frequently, as patients’ conditions deteriorate while on long waiting lists.’
At the Prime Minister’s NHS Recovery Forum in January, he made the case again for more surgical hubs to be set up as quickly as possible.
Prof Mortensen added: ‘The Government must look at where surgical hubs feature in the New Hospital Programme, and work with
‘The new environment is making a real difference to everyone that uses the ward, from patients, to visitors to staff,’ said lead private midwife Debbie Bridgewater.
Director of private healthcare, Kerensa Heffron, said: ‘I am delighted that we are able to provide such wonderful facilities, which will complement the world-class treatment we were already offering to our patients.
‘This new environment reflects back the quality of the expertise and care we provide every day.’
UCLH Private Healthcare is based across eight specialist sites in and around Bloomsbury, central London, providing a wide range of private services including neurology and neurosurgery, fertility, maternity, teenage cancers and ear nose and throat treatment.
It reported private patient revenues of £7.3m in the trust’s 202122 annual accounts. This is a rise of £1.4m and 25% on 2019-20, although still well down on the pre-Covid earnings of £20.4m in 2019-20.
Philip Housden is director of Housden Group
David Furness, director of policy at the Independent Healthcare Providers Network
integrated care systems to identify under-served parts of the country.
‘Unless the Government moves fast on this, and the workforce plan it has promised, I fear the waiting list will take many years to bring down.’
Shams Maladwala
HCA starts unique admission service
By Douglas Shepherd
HCA Healthcare UK has launched what is billed as a rapid ‘unparalleled’ 24/7 acute admissions service in London, not matched by any other private provider.
Designed for GPs and consultants, it cares for urgent, unplanned admissions at four of its hospitals: The Wellington Hospital, The Lister Hospital, The Princess Grace Hospital and London Bridge Hospital.
The service, built on an established acute care offering, aims to provide swift and streamlined treatment pathways for patients with acute conditions, such as:
Respiratory conditions – including pneumonia and chronic obstructive, pulmonary disease;
Neurological conditions –including acute confusion, worsening dementia and seizures;
Cardiac conditions – including heart failure, arrhythmias, blood clots, pulmonary embolism and deep vein thrombosis;
Patient admissions following postoperative medical complications;
Gastro-intestinal,liver and hepatobiliary conditions, including acute biliary problems, acute appendicitis and intestinal obstruction.
The hospital group’s 365-days-ayear service manages the entire acute admissions referral process for GPs and consultants from across the UK.
At a time of increased pressure on acute services, HCA UK said it has the capacity to support admissions from both private and NHS referrers seeking care for their private medical insurance or self-pay patients, who must be over 18.
A spokesperson said: ‘One call to HCA UK’s dedicated concierge centre – London’s first, and only, medical concierge CQC-registered clinician-led service – is all it takes.
‘From paperwork to transport, the concierge team manages the entire admissions process for referrers, where patients can be admit-
ted within a two-hour time frame, subject to the circumstance of the referral.
‘The concierge team will also keep referrers fully informed of their patient’s treatment and progress.’
The hospital group runs a new private ambulance service, managed by the concierge team, to collect patients from their home, GP practice or an NHS or private hospital and transport them to one of its four hospitals.
Neil Buckley, vice-president of HCA UK’s Physician Services Group, said the service was much needed.
‘The 24/7 co-ordination from our medical concierge centre team and personalised patient care provided by our consultants, doctors and nurses, coupled with the launch of our new private ambulance transfer service, will ensure that patients with acute conditions receive the quick, quality care that they require.
‘No other private provider has
an acute admissions service on this scale; it’s truly unparalleled.’
An on-call rota of consultant physicians across the hospital network deliver on-site rapid patient assessment supported by comprehensive medical cover in key specialties.
The hospitals have 125 ICU beds. Referrers can admit patients to HCA UK’s acute admissions service on 020 3993 4999.
The hospital group said its concierge centre team would guide GPs and consultants on appropriate referrals and each admission would be independently assessed. 999 should be rung for medical emergencies and life-threatening conditions.
Once the patient is stable and appropriate to transfer, it can facilitate a bed-to-bed transfer via private ambulance if required.
Two new developments for Optegra eye clinics
Specialists at Optegra Eye Hospital Manchester have used a new treatment for wet AMD which they say means excellent outcomes and fewer ongoing visits to hospital. Unlike other injection treatments, Vabysmo was designed to target two chemicals within the eye, rather than one. This effectively means double the treatment all in one go, which works to stop the vessels growing and also stops them leaking and bleeding.
Consultant Mr Sajid Mahmood said: ‘We are excited that we can offer this new treatment. Medical advances mean that we can now extend the time between injections, possibly up to four months (after the first four monthly injections) which is much more
pleasant and convenient for patients and importantly, costsaving for the NHS’.
Early diagnostic tests on the first patient showed improvements so the team was excited to continue this treatment, he added.
A new eye clinic opened by Optegra Eye Health Care in Uttoxeter, Staffordshire, says it is purely dedicated to NHS cataract patients, in an effort to reduce the long wait lists as a result of the pandemic.
The firm’s NHS Director Richard Armitage said: ‘We are eager to support the NHS as ophthalmology is the second largest waiting list for treatment.’
He added that the clinic was committed to offer treatment within six weeks of referral to its leading ophthalmic surgeons.
‘Cataract patients simply need to ask their optician or GP to refer them to Optegra Eye Clinic Uttoxeter and we look forward to welcoming them.’
Mayor Helen Headech cuts the ribbon to open Optegra’s Eye Clinic Uttoxeter, with clinic manager Paul Haydon (left), optometrist Gareth Towers and staff
Ophthalmologist Mr Sajid Mahmood
Neil Buckley of HCA
Hunterian Museum re-opens after refit
By Agnes Rose
The Hunterian Museum, which has helped in the training and education of unknown thousands of doctors, is re-opening to the public next month following a five-year £4.6m redevelopment.
England’s largest public display of human anatomy, named after the 18th century surgeon and anatomist John Hunter (17281793), re-opens free of charge after a five-year closure at the Royal College of Surgeons of England’s headquarters at Lincoln’s Inn Fields in central London.
The 3,000 objects and specimens on display will not include the skeleton of Charles Byrne, known as the Irish Giant – something which has attracted widespread press interest.
But it will still be available for bona fide medical research into the condition of pituitary acromegaly and gigantism.
The display of more than 2,000 anatomical preparations from Hunter’s original collection, alongside instruments, equipment, models, paintings and archive material, trace the history of surgery from ancient times to
the latest robot-assisted operations.
Dawn Kemp, director of museums and special collections at the college, said: ‘The Hunterian Museum is one of the very few places in the UK where the public are able to see specimens prepared specifically to show human anatomy.
‘Under the Human Tissue Act, it is only possible to publicly display human remains known to be more than 100 years old. The history of surgery is dramatic and often unsettling with stories of terrible human suffering.
‘Yet historic medical collections like the Hunterian are also incredibly valuable in giving us a better understanding of our own health and well-being and the complex issues that have arisen in the development of the art and science of surgery.’
The museum has a long association with the college. After John Hunter’s death, the UK Government bought his collection of 14,000 specimens and preparations and gave it into the safekeeping of the Corporation of Surgeons – later the Royal College of Surgeons of England – for medical education and training.
THE SKELETON OF CHARLES BYRNE
The best-known human anatomical specimen in Hunter’s collection is the skeleton of Charles Byrne.
He had an undiagnosed benign adenoma, which caused acromegaly and gigantism. Living with these conditions he grew to be 7’7’’ (2.31m) tall.
In the last years of his life, he made a living exhibiting himself as the ‘Irish Giant’.
He died in 1783 and it has been said that to prevent his body being seized by anatomists, he wanted to be buried at sea. Hunter paid Byrne’s friends to handover Byrne’s body.
Three years later, Hunter displayed Byrne’s skeleton in his Leicester Square museum and part of it is shown in the background of the portrait of Hunter by Sir Joshua Reynolds.
This portrait will be on public display in the new museum for the first time in over 200 years.
During the museum’s closure, the Hunterian Collection’s board of trustees discussed the sensitivities and the differing views surrounding the display and retention of Charles Byrne’s skeleton.
Access to brain health care transformed
Brain and wellness analytics company MYndspan has collaborated with award-winning cognitive health provider Re:Cognition Health to provide up to 2,000 patients a year with its technology.
During the 45-minute service at the latter’s London clinic, a user simply sits in a chair, with their head in a scanner using a non-invasive scanning technology called magneto-encephalography (MEG).
This measures the electrical signals between neurons to form a detailed map of brain activity and is used alongside app-based games
to test cognitive function like attention and memory.
Within 24 hours of having a scan, MYndspan sends people a personalised, easy-to-understand report of their brain health – helping individuals assess how lifestyle factors such as sleep, exercise and diet impact their brain.
Re:Cognition Health supports over 2,000 patients with cognitive health conditions like autism, Alzheimer’s disease, Parkinson’s, concussion and other traumatic brain injuries – providing them with bespoke diagnostic assess -
ments and treatment plans to help manage and optimise their brain and mental health.
With MYndspan’s technology, these patients will have access to detailed data about their brain health, and how it might have improved in response to treatment.
Re:Cognition Health’s chief exec utive Dr Emer MacSweeney said she was thrilled at the collaboration, describing MYndspan’s data-driven quantification of brain health using MEG technology as ‘ground-breaking’.
TROUBLESHOOTER: RECRUITING A NEW PARTNER
How can our group
Independent Practitioner
Today’s troubleshooter Jane Braithwaite (right) gives her advice to a doctor’s question:
‘Our
group is working very successfully
attract a
and we would like to
new
partner
to join us. How do we find the right person and ensure the group continues to thrive?’
FIRSTLY, CONGRATULATIONS on founding a thriving group where the partners are working well together and the practice is growing.
The decision to recruit a new partner is usually driven by an increased patient workload that needs to be shared by a greater number of doctors and this is a great position to reach.
Another reason might be that one partner wishes to reduce their workload, which will need to be picked up by a new partner.
Whatever the reason, recruiting a new partner often comes with some anxiety. When a tightly bonded group works successfully
together, there is an understandable concern about introducing a new person to the group and potentially changing the group dynamics.
Aligned goals
An ideal group is formed when all the partners have aligned goals. When the original group was created, discussions were likely held to identify common goals and objectives.
These goals may relate to the practice’s growth and utilising complementary skill sets to offer patients a wider range of services. There may also have been a goal to
find a new partner?
create economies of scale and reduce the costs of running individual practices by sharing the overheads.
Running a group is effectively managing a business, and the current partners will have agreed responsibilities for the various business functions, including finance, marketing and medicolegal responsibilities.
Financial arrangement
One of the most challenging aspects of running a group is ensuring all partners are satisfied with the financial arrangement. While most doctors do not enter
the profession purely for monetary rewards, they expect to be rewarded fairly for the work done and the expertise provided to patients. On day one, the group agreed on how finances will be managed, which will be important when recruiting a new partner.
In most cases, the group will have created a contractual agreement to state the objectives and goals of the group, clarify responsibilities and expectations and describe the financial model.
If this is not the case, it would be wise to do this before embarking on the recruitment of a new partner, forming the basis of a new partnership agreement to reflect the expanded group. The partners themselves can produce this or you may prefer to engage professional support via your accountant or a legal adviser.
Describe your ideal partner
A new partner can expand the group in more ways than pure size. Rather than just co-opting the first consultant that has the right experience and shows an interest, it is wise to consider what skills and knowledge would complement your own.
Is there special training or background that may help the group expand revenues and offer new services to patients in the future?
There is a job description for most jobs, defining the role itself and objectives and also clarifying
terms and conditions. When looking for a new partner, a good starting point is to build a job specification based on your ideal world view of the right person for your team.
The specification will include the expertise and skills required, possibly similar to the current partners or possibly with a different and complementary set of skills.
Also state the group’s objectives, goals and aspirations so that you can assess if your new partner is a
➱ continued on page 12
Struggling to attract new referrals?
time to go in a different direction
HOW TO FIND YOUR NEW PARTNER
You are effectively undertaking a recruitment exercise; therefore, drawing from recruitment consultants’ and headhunting firms’ processes and models makes sense.
Not all of the standard procedures will be appropriate and you will need to adapt them to your circumstances, particularly how publicly you want to share your plans.
Your first task is to attract potential candidates for your role. A recruitment consultant would advertise the role on various recruitment sites and invite interested parties to apply.
This general approach may not sit well with you if you wish to proceed slightly under the radar, but there may be some associations that you are a member of that would be able to share your role in a professional manner.
A headhunter takes a more pro-active, but discreet, approach than a recruitment consultant and would research potential candidates and contact them directly. This may align more closely with your preferred style, but it will require an investment of your time.
The starting point is identifying the individual candidates who might be a good fit for the role and contacting each one to explore the opportunity.
As with most things in life, word-of-mouth recommendations are usually best and so it would be sensible to discuss your plans with colleagues who might know of a consultant who would be interested. Make the most of your own personal networks and utilise professional networks that you are a member of.
Once you have a number of potential candidates, you must make a shortlist of two or three individuals with whom to explore the opportunity in greater detail. Creating the shortlist is an activity in which all the current partners should ideally be involved.
Reflect on the job specification you created initially and take both a logical and an emotional approach to your decision-making.
Consider how well each individual matches the job specification, ranking each person, but also consider your instinct regarding who is the best fit in terms of aspirations, style and character. Your new partner needs to be a good fit in terms of skills, expertise and personality.
The next stage is the interview stage which should be a face-to-face discussion with one or more of the current partners. This meeting should be relaxed and open to allow both sides to determine if there is a good fit.
This is a big decision for everyone involved, so allow time after the meeting for everyone to reflect before agreeing on the next steps. You may need a second meeting before a decision can be reached.
Thinking back to our specialist recruitment companies, they would request references. While doing this might be considered unseemly, it would be perfectly acceptable to talk to colleagues who know the person well to gain as much background information as possible.
Finally, you have identified the right partner for your group and wish to offer the role to your chosen partner formally. Congratulations. The role can be offered verbally but also confirmed in writing, subject to the agreement of the Partnership Agreement.
Be prepared for some negotiation and agree between the current partners on what aspects of your offer you are prepared to adjust, if needed.
You must clarify the financial model offered to your new partner. Be clear and transparent. Refrain from the temptation to oversell the arrangements
good fit in terms of their own ambitions. For example, if your goal is to continue the group for the next ten to 15 years and a prospective partner plans to retire in two years, there may be a better fit.
What administrative and management responsibilities would you expect your new partner to take?
This might be an excellent opportunity to review the administrative workload of the current partners and share the burden more fairly. You may also have new initiatives you wish to explore and your new partner could take the lead.
Employ staff
If some of the workload could be managed without the direct input of a consultant, you could employ staff – for example, a nurse or a healthcare assistant – to undertake tasks on your behalf.
This can help ensure that your limited time is spent on activities only you can perform. If you do not currently employ clinical staff, advice is needed to ensure that you are providing a service that is safe and well-supervised, including the provision of training and professional development.
You may also explore outsourcing more of the administration and management tasks to an appropriate specialist company. For example, your book-keeping could be managed by an expert in this field, with the added benefits of bringing their skills and experience into your business.
Finally, and very importantly, you must clarify the financial model offered to your new partner. Be clear and transparent. Refrain from the temptation to
oversell the arrangements. It is far better to attract the right person with an honest and realistic plan than deal with disappointment later in the process.
Once complete, your job specification will provide you with a valuable tool to share with potential partners and also for you to use when short-listing and interviewing.
Revised partnership agreement
Once your new partner has accepted the role, a contract must be signed by both parties in the form of a revised partnership agreement.
As mentioned earlier, the partners can produce this or you may prefer to ask a specialist such as your accountant or a lawyer to draft the agreement for you.
Good communication is key to the success of any group. Diarise regular partner meetings on a monthly or quarterly basis and ideally face to face, at least for the first few months.
You may also choose one partner, in particular, to act as a mentor to your new partner, at least for the first six months. This could include monthly one-to-one review meetings, which provide an opportunity to review progress and for both sides to raise any concerns and address any issues.
Remember, it is normal for a new group to experience some challenges in the early months as described very helpfully in Tuckman’s stages of group development.
Bruce Tuckman first published his model in 1965 and described the ‘forming-storming-normingperforming’ model. His opinion is that it is necessary for all teams to work through every stage of the model, so prepare your group for the storming stage and embrace it positively.
Good luck. I wish you and your partners every success.
If you have any specific questions, you would like answered in upcoming editions, please do feel free to get in touch.
Jane Braithwaite is managing director of Designated Medical, which offers bespoke support across accountancy, marketing, medical PA and bookkeeping
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Ten tips for defusing
Conflict has become an increasingly frequent phenomenon in healthcare over the last 20 years. It is upsetting and timeconsuming for professionals and patients alike.
However, ask doctors and other health professionals how much training they have been given in recognising and managing conflict and the answer is usually none –or, at least, very little.
So Independent Practitioner
Today asked medical mediation expert Sarah Barclay (right) to produce this basic toolkit to help navigate those difficult conversations
defusing an angry situation
1
Acknowledge conflict –don’t avoid it
Ignoring conflict and hoping it will go away can be as detrimental to relationships between doctors and patients as ignoring the symptoms of a disease would be for a patient’s physical health.
Conflict can be the elephant in the room, because acknowledging its presence demands a response and, without the confidence to manage conflict appropriately, it’s often not clear what that response should be.
Acknowledging and naming conflict is the first step to managing it.
2 Understand the triggers for conflict
Being aware of what can trigger conflict with a patient or their family is an important step in preventing it.
These are five key triggers:
❶ Inappropriate use of language: What you say and how you say it can make the difference between conflict and genuine connection with a patient.
Avoid using complex medical jargon. It can leave patients and their families feeling confused and lost, especially if the news is bad.
❷ Speaking too quickly and filling silences with more information leaves little time for what you’re saying to be heard and absorbed.
Writing notes and/or looking at a screen at the same time as speaking to a patient can make them feel they’re not being listened to – or worse, unimportant.
❸ Conflicting messages: Patients and their families often report that they are being told different things by different health professionals, leaving them uncertain about whom to believe and, most importantly, whom to trust.
Try to manage communication as a team, particularly if the seeds of conflict have been sown. This
avoids important messages getting lost in translation.
❹ Making assumptions: Labelling a patient or family member as ‘difficult’ is one of the key triggers for conflict.
There are certainly patients or family members whose behaviour is challenging, but describing the situation as difficult or challenging rather than the patient themselves can make a real difference to the way that person is perceived by a treating team.
Labels, once attached, can be hard to remove.
❺ Previous history of unresolved conflict: If a patient or family member has had previous experience of healthcare which has damaged their confidence and trust in health professionals – including medical error, unkept promises or cancelled appointments – this needs careful exploration and authentic apology, where appropriate, in order to prevent further conflict escalation.
3
Recognise the warning signs
When conflict is brewing, conversations start feeling like battles and positions become entrenched –with professionals in one camp and the patient and/or their family in another.
Avoidance can become the norm because professional-patient encounters have become strained and unproductive.
Disagreements about treatment and ‘unrealistic’ expectations are often the cause of conflict, but what seems unrealistic to the professionals – particularly in relation to the limits of medical treatment – may seem very reasonable to patients and their families desperately searching for hope.
Professionals often describe patients and families attempting to ‘micro-manage’ care and label them as ‘difficult’. However, this ➱ continued on page 16
behaviour – which can feel threatening and frustrating to professionals – is often caused by a loss of trust.
If conflict is left unmanaged at this point, it can escalate significantly and fast, affecting all those involved.
4 Be curious: explore before you explain
Conversations between health professionals and patients often go off course because they focus on the giving or extraction of information rather than the acknowledgement and exploration of emotion, particularly anxiety or fear.
If health professionals are giving information to patients, especially if the news is unexpected or difficult, it is important to allow space in the conversation to explore how that news has been received and to allow time to acknowledge their response.
When time is short – as it all too often is – this can be the part of the consultation which gets left out and it can lead to conflict further down the line, because the patient is left feeling that their understandable emotions have been left unexplored.
5 Avoid premature reassurance
If a patient tells you ‘I’m worried about the operation’, the response will often be ‘You don’t need to worry’ or to tell the patient all about the operation, how expert the surgeons are or how often they perform that particular procedure.
The result can be that the patient feels their fears have been dismissed and genuine concerns left unexplored. It’s called premature reassurance and can be an important trigger for conflict.
Patients often say ‘I told them I was worried about… but they told me not to worry.’
Instead, be confident to ask the obvious question: ‘What is it you’re worried about?’
That question hands the agenda back to the patient, opens up the possibility of a much longer conversation than the available time allows and leads to questions that might feel more difficult to answer.
There are many reasons why a patient might be worried about
Conversations between health professionals and patients often go off course because they focus on the giving or extraction of information rather than the acknowledgement and exploration of emotion, particularly anxiety or fear
book Being Mortal sums up this conundrum perfectly: ‘I am in a profession which has succeeded because of its ability to fix. If your problem is fixable, we know just what to do. But if it’s not?’
Gawande is writing about the point at which curative treatment is no longer an option, but conflict can also lead us into what feels like unfixable territory.
One of the things we hear patients and their families say is ‘They’re just not listening to me/ us.’ Professionals often say the same.
One of the more painful consequences of conflict is that those involved stop being able or willing to listen to each other with genuine compassion.
For professionals, conflict can make them feel as if they’ve failed and that, in turn, can make them feel demoralised and defensive.
Patients feel dismissed and judged. If patients and professionals alike are experiencing similar emotions, it’s not hard to see why conflict can start to take root.
Listening with the intention of exploring and understanding not fixing is a core component of resolving conflict.
7 Don’t be afraid of anger
Where there’s conflict, anger is inevitable, but it’s the response to it which can make the difference between escalation or resolution.
If an angry patient or family member is met with defensiveness, dismissal, avoidance or punishment, the conflict is likely to escalate.
needs to be explored or agreed, who will facilitate, how will you begin and last, but definitely not least, how are you feeling?
Are you anxious, exhausted, hungry, thirsty? Is this the third difficult conversation you’ve had to have today?
Give yourself time – even if it’s only a few moments – to give yourself a quick MOT before you start that conversation. Clear your head, try to adopt a neutral stance rather than a defensive one.
You don’t have to agree with the patient or family member in front of you, but being willing to listen will go a long way to being able to re-establish trust if it has broken down.
9
Don’t say ‘I’m sorry you feel that…’
Apologies must be authentic if they’re to make a real difference. Telling a patient you’re sorry they feel let down by you or your colleagues can sound patronising and dismissive.
Instead, try ‘I’m really sorry this has happened and that it’s made you so angry/upset/frightened’. This statement acknowledges the impact that the situation has had on them. It doesn’t mean you’re accepting liability.
10
Talk like a human not an institution
their operation, but unless those worries are explored, the worry will remain, the patient will feel unheard and potentially serious concerns ignored.
6 Listen to understand –don’t dismiss or try to fix
Many health professionals – doctors particularly – tell us that they have been trained to be problemsolvers, to find solutions, to fix. But the landscape of conflict can require the opposite.
This quote, from the surgeon and author Atul Gawande in his
If, however, they’re met with calmness, compassion and a genuine willingness to listen, this is much more likely to result in deescalation. It’s hard to stay angry when the response is empathic.
That does not mean that professionals should be asked to accept behaviours which cross a threshold and are felt to be unacceptable.
But acknowledging that, in healthcare, anger is frequently triggered by fear, unmet need or expectations can help make it feel less like a personal attack.
8 Prepare yourself
Challenging conversations need preparation.
Who needs to be there, what
Faced with a conflict, the instinctive response of many health professionals can be to ‘armour up’ and adopt a defensive stance. They might talk about hospital ‘policy’ or tell a patient or family member that they ‘need to calm down’.
Far from resolving the conflict, this approach can have the opposite effect.
Having the confidence to remove your institutional hat and trying to engage on a human level can be the key to making a person feel heard. That, in turn, can begin the process of building trust.
Try saying ‘I can’t imagine what this situation must be like for you, but I really want to try and understand’. It’s surprising how often this can de-escalate a challenging conversation.
Sarah Barclay is director of The Medical Mediation Foundation, www.medicalmediation.org.uk
A look back through our journal’s archives of a decade ago reveals that although times change, some issues are not so new
A trawl through the archives: what made the news in 2013
Docs miles worse off
Consultant were poised to pay HM Revenue and Customs thousands of pounds in expense claims following a judge’s ruling on a doctor’s mileage test case.
The long-awaited judgment, affecting the majority of independent practitioners, meant the miles they drove between a home office to consulting rooms or operating theatres were not allowable against tax.
After six months’ deliberation of evidence in a first-tier tax tribunal, Judge Mr Kevin Poole decided there was a dual purpose in travelling to and from home, so the expense could not be allowed.
Specialist medical accountants said this would curtail much of the claim a consultant made for motor expenses. Many consultants had regarded their home office as the starting point of their private practice journey.
One explained: ‘This case now stipulates there is no dispute that this home office is a business base for the purposes of tax. But because it is at home, then there is a non-business motive for travelling to and from that home.
‘This is specifically not allowed for a tax deduction under the legislation of the “wholly and exclusively” test found in the Income Taxes Act.’
Surgeon gets his op on Twitter
A consultant bariatric surgeon’s operation at a private hospital was claimed to be the first in the UK to be tweeted live.
Regular reports followed Mr Pratik Sufi doing a gastric bypass operation at Spire Bushey Hospital, Watford, Hertfordshire.
Each step was tweeted to more than 500 social medica followers over two and a half hours. A spokesman said the patient decided to take part as he believed it would educate the public.
Doctors are owed £50k unpaid fees
As many as 4,000 private consultants were owed at least £200m in uncollected fees, according to ‘conservative’ estimates from one billing firm.
It said the average consultant it met had over £50,000 of debt greater than a year old.
This ranged from £15,000£20,000 for newer independent practitioners to over £500,000 for individual consultants, tracking back over six years.
It was found that a proportion of what doctors appeared to be owed had, in fact, been paid but was never reconciled due to poor record-keeping.
Cosmetic curbs backed
Tighter aesthetic sector rules would be backed by 85% of clinicians, a survey found.
Two-thirds thought the line between non-surgical and surgical treatments was dangerously blurred and, of those, almost three-quarters (73%) believed this endangered patients.
The Clinical Cosmetic and Reconstructive (CCR) Expo survey found 74% of medical professionals feared the public thought ‘plastic’ and ‘cosmetic’ surgery were interchangeable terms.
Bid to ban roving surgeons
Plastic surgeons called for the Government action to ground what they declared were large
numbers of ‘fly-in-fly-out’ surgeons who depended on UK-based salesmen and middlemen to recruit patients.
In a three-point plan, the British Association of Aesthetic Plastic Surgeons (BAAPS) urged for private consultations to be held only with surgeons who ultimately performed the operation.
It said surgeons based overseas would find it unfeasible to take on so much travel.
Patients were said to be experiencing increased problems in trying to track down and secure compensation from surgeons based outside the UK.
Secret of a good clinic
The very best medical secretary support is often behind the most successful private practices.
Announcing the annual Private Medical Secretary of the Year Award, sponsor Kingsley Hollis called medical secretaries ‘the unsung heroes of the healthcare industry’.
TELL US YOUR NEWS
How about making the news today? Independent Practitioner Today is always keen to hear from doctor entrepreneurs willing to share their stories in private practice – and from independent practitioners embarking on the journey.
Contact our editorial director Robin Stride at robin@ip-today. co.uk
The man making competition work
In an exclusive interview, Dr Ian Gargan (below), chief executive of the Private Healthcare Information Network (PHIN),
answers some of the big questions on many a consultant’s mind
How concerned are you that many consultants in private practice don’t know what PHIN is?
The Private Healthcare Information Network (PHIN) is a government mandated, not for profit, organisation that exists to help make the private healthcare sector more transparent, serving patients by making their healthcare decisions easier to make.
We want every consultant to be aware of PHIN and participate with us, as this is a legal requirement under the Competition and Markets Authority’s (CMA) Private Healthcare Order. They should also be making patients aware of us.
As part of this work supporting stakeholders, we have been contacting consultants to let them know about the CMA Order since 2017 and an everincreasing number are not only aware of us but are engaging with us to supply information about their fees.
Why should I bother with PHIN? How many consultants are engaging so far, how many aren’t and what is your target for mid2023 and ultimately?
Engaging with PHIN isn’t an option, it is a legal requirement, and the CMA is already looking at enforcement action against consultants who have made no effort to work with us.
On the other hand, those consultants who supply us with full information for their profiles on our website see higher page views and direct contacts from potential patients, so have another avenue to help build their practice.
We are aiming to work more
closely with consultants to inform them about PHIN, but also to get their feedback about how we can help and support them.
We already have over 9,000 consultants on our website and our aim is to have all consultants in private practice on the website before the middle of 2026.
How many potential patients use the PHIN website? 12k a month has been mentioned. How many should it be when you consider how many people are seeking private doctors?
Website traffic has been increasing steadily since we redesigned and relaunched the site in summer 2021. We now receive an average of 34k visitors per month and also see significant numbers choosing to make direct contact with consultants and hospitals. There were over 7,000 contacts last September for instance.
With over 800k to a million private procedures taking place each year, there is considerable scope to grow this number, and that is what we aim to do, with the support of consultants and others in the sector.
Most visitors to our website who complete our short questionnaire say they can find the information they are looking for. If they have a complaint, it’s mostly around missing consultant information.
We would encourage all consultants to create a profile so information about them and their practice is always available to patients. This is good for consultants and avoids patients being disappointed if they cannot find information about their chosen consultant.
Why have I received a letter from PHIN? What do I need to do and why?
We regularly write to consultants who have either not supplied their fee information or who have done so but have not quite completed the process to allow us to publish that information.
We have also recently been contacting consultants to let them know that the CMA is investigating enforcement action and we want to avoid them being on any escalation list.
We encourage consultants to review the data that is submitted
to PHIN from the private hospitals where they work. There are processes to approve data about the volume of procedures that they perform and the length of stay for those procedures.
Consultants can also notify hospitals if they want to review or raise a query about data that has been submitted to PHIN.
Am I obliged to send out information about PHIN?
Yes, under the Order, consultants are required to provide patients with information about their consultations and any investigations. They must provide additional information if a patient requires a procedure.
In many cases, hospitals where the consultant practises have taken on the role of producing the relevant letters on behalf of consultants, not least because they have a responsibility to ensure the information is provided.
How can PHIN help me? What do I get out of it?
PHIN is here to help consultants comply with the Order. We don’t want to see anyone undergoing enforcement action and we support consultants to ensure the process is as straightforward and painless as possible.
We have a dedicated consultant support team and consultants can also ask questions through our consultant portal: https://portal. phin.org.uk/
In terms of value for consultants, our website analytics show that doctors with complete information receive many times more clicks to their practice than those who don’t provide the data.
Tell us more about the PHIN portal – how to log onto the portal, how to submit fees or related issues to fee submission and how to create a profile or related issues to profile.
The PHIN portal is the website where hospitals and consultants can submit data and access information about their performance. When a consultant first visits the portal, they will need to sign into their account. There is a button to this at the top of the page. They then add their email address and request a security code
and create a password. We’ve tried to make the process easy, but we are happy to talk consultants through it if they have any issues and offer ‘virtual session’ where we can answer any questions.
As well as consultant details, we also publish other information that is of relevance to the sector, including around measures.
I have concerns about my information in the portal.
PHIN provides consultants with a view of the data it has received from independent hospitals and private patient services in the NHS. We also provide a view of data received from NHS Digital covering NHS funded care. We don’t modify the data.
We are aware of the potential for data errors – for example, around different procedures which have been performed – and there is a process to raise queries and have errors corrected on the privately funded data.
We are happy to work with any consultants who have concerns to review and verify the information that is submitted about their practice before it is published online.
This is a really important task for ensuring that PHIN and private hospitals can publish information in line with the CMA Order and support greater transparency for patients considering private healthcare.
Any consultants who do not engage in, or have ceased to engage in, private practice or who have retired can have their profiles removed on request.
Consultant fees are a small proportion of package prices. Is this made clear to patients?
We know that cost is a primary factor for patients, particularly for those patients who are paying for their treatment themselves. We make clear that the fees are the consultant fees only.
Where consultants tell us that they have a package price arrangement in place with their hospitals, we present that information to patients and advise them to contact the hospital so that they have a complete understanding of the full costs of a particular procedure/ course of treatment.
We will continue our dialogue
Consultants are required to provide patients with information about their consultations and any investigations. They must provide additional information if a patient requires a procedure
with hospitals on how we can make it easier for patients to access package prices.
Is PHIN’s published fee information only for selfpayers?
The fees published for consultants are those for selfpay patients. We have worked with stakeholders to identify an approach on insured fee arrangements and are looking to launch that in the PHIN portal in mid2023.
How long would it take for an average full-time private practice general surgeon, for example, to submit everything you want and keep it up to date throughout the year?
We estimate that a consultant can submit fees, review and verify their practice information and complete a profile in approximately an hour.
To help with the process, we would always suggest that consultants join one of our virtual sessions so that we can take them through the portal and each of the processes that we ask you to complete.
Having set the information up, we will contact consultants to let them know when new data is available to review. This is usually episode data for a three month period.
We will formally contact consultants a minimum of once each year to ask that they review their fees to ensure that these are reflective of current charging practice.
We will also let consultants know when they have received sufficient feedback information to have a score on PHIN’s website. Consultants are free to review and update their information any time.
➱ continued on page 20
Can PHIN provide any training for PAs/secretaries to load up the information on consultants’ behalf?
We hope to provide secretaries with direct access to the portal during the next year. In the interim, we are happy to welcome PA/medical secretaries to our virtual sessions so that they can become familiar with the processes on PHIN’s portal.
How are you going to ensure the public know about PHIN and see the advantages of using it? Aren’t there now other websites providing consultant and hospital fee information and so on?
There are other websites that provide some information to help patients. Generally, they are websites that promote patient reviews and comments.
PHIN is the only governmentmandated, not for profit source for private healthcare data in the UK and, as such, our data can be trusted. We are tasked with publishing a wide range of objective performance information about consultants.
That doesn’t mean we are in competition with other sites and will be looking at information partnerships in the future.
In the meantime, consultants, hospitals and private medical insurers all have a duty to inform their patients and customers about PHIN, so that is an important way to inform the public.
PHIN doesn’t have a marketing budget and relies on optimising our website and information to be search enginefriendly.
Do you think the CMA’s threat to get tough on consultants with fines and naming and shaming is serious and should be taken so by consultants? How have hospitals reacted to the threat? How many hospitals are you still chasing to engage?
The CMA is serious about ensuring hospitals and consultants comply with the obligations set out in the Order. We are in regular contact with them on the topic.
We will always work with consultants and the hospitals to avoid
escalation and the CMA commencing enforcement action where we can.
However, if consultants fail to participate, they should be under no illusion, the CMA will press ahead with enforcement measures as it does in many other sectors.
The majority of hospitals are engaged in the process, but we continue to work with the small number that do not yet, in the same way as we are for consultants.
Do you really think PHIN stands any chance of fulfilling its duties to the CMA?
In summer 2022, we agreed a sectorwide strategy and roadmap to deliver the Order, and we are very confident that, by working together, the sector will be able to fulfil its duties and patients will see the benefit of a more transparent sector.
How many people does PHIN employ?
At the beginning of the Order being laid, PHIN had no more than six or seven employees. That has grown as the scope of what was required grew, including consultant fees submission and as we were ready to tackle more complex measures and challenges.
We are currently around 40 45 staff and in total there will be just under 50 full time equivalent (FTE) staff at PHIN in 2022 23. These are divided between our functional teams:
➤ Informatics – the ‘engine room’ of PHIN, responsible for the analysis of data and data quality, and preparation and maintenance of performance measures information for publication.
➤ Technology – the development team responsible for development and maintenance of our databases, consumer website and member portal, and the Information Secur ity and Services team, responsible for maintaining the day to day systems and security, including ISO 27001 compliance.
➤ Engagement – is led by the member services director and comprises PHIN’s hospital and consultant engagement teams, engagement with other stakeholders and patients, our communication team that is
If consultants fail to participate, they should be under no illusion, the CMA will press ahead with enforcement measures as it does in many other sectors
How reliable is the data you are publishing? If you have any concerns about that, then how can it be more accurate?
We run numerous validation checks on the data we receive and give the hospitals and consultants submitting it the opportunity to review it before we publish, to ensure high levels of accuracy.
While we can check for validity and completeness, only the consultant and hospital know what treatment was actually provided. We have a process that allows consultants to raise queries with the relevant hospitals so that any issue can be reviewed and corrected.
responsible for the design and development of our website and portal products.
➤ Corporate – this function comprises the chief executive, chief financial officer and the director of people and process (corporate secretary).
This team is supported by an office manager and the project management office team, as well as outsourced data protection officers, HR, admin, legal and finance and accounting functions.
How much does it cost to run?
As a not for profit organisation, PHIN is always keen to provide transparency in how it spends its members’ funds, and details are published in the Financial Statements and Annual Report each December and available from our website.
Based on the audited cost base in 2021 22, the bulk of PHIN’s expenditure is on people and staffing costs which comprises around75% of our cost base.
Income for the year was 202122 was £4.6m.
Where does the money come from? How much do individual hospitals have to pay?
PHIN’s costs are covered by the hospitals providing treatment for private patients.
The method is set out in the CMA Order and is a fee for each patient record submitted. Therefore, the large hospital groups provide the majority of our budget.
How ridiculous is it that consultants are banned by the CMA for agreeing fees together, yet they can now go to the website to see what rivals charge?
The CMA Order is designed to promote transparency across the sector and encourage increased competition which should result in better patient care.
Our role at PHIN is to help consultants and hospitals make that happen by collecting and publishing the information for patients to help their choices and for all stakeholders to improve care.
At the recent BMA private practice conference, a consultant looked at the PHIN website to see info about some of his medical chums – he told the meeting they were not doing what was recorded there. What would you say to him?
We rely on the data supplied by hospitals and verified by consultants. There are also circumstances where consultants will verify their private episode data, but the activity that they undertake in the NHS may not be shown.
We take our responsibility to protect the identity of patients very seriously, so we will not show the number of a procedure performed where the volume is seven or fewer.
If anyone is aware of any errors or misattribution, then we would encourage them to visit the PHIN portal and make the necessary amends or to contact our consultant team.
Attract patients by getting ‘emotional’
How ‘social’ are you? Marketing expert Catherine Harriss (right) examines the huge part harnessing social media can play in helping create a more successful private practice
is due to the massive number of us who have smartphones. Since 2021, it has been possible to opt out of data tracking on an iPhone and now only around 16% of owners allow their data to be tracked. This means that although advertising on Facebook or other social media channels can be highly focused on an individual, because of Apple’s ability to give users the option, around 84% of iPhone owners are not receiving targeted ads, so are missing from a target population.
Social
advertising
Now in the UK, iPhone use is rising and it is still an aspirational product too. My electronic engineer son would say that this is due to iPhone finally becoming more like an Android in speed and usability.
ADVERTISING ON social media has often been seen as a way to promote business. But, for all the major social media companies, revenue is falling dramatically.
In part, this is claimed to be due to the economic climate of rising inflation, interest rates and so on, but there is still plenty of money about. People have not stopped spending.
Growth has slowed down, but the main reason that the decline in social advertising is happening
Looking back at my previous article for Independent Practitioner Today in April 2015, I suggested that social advertising should be encouraged to get around the many algorithm changes on Facebook and be seen by your perfect potential patients.
I would not be so hasty today, but would instead recommend ‘boosts’ of posts to those people who have ‘liked’ your page. There is a greater chance that money spent in this way will get to them.
➱ continued on page 22
Social conversions
If a website is performing well, then it should be attracting new business. A new visitor should be encouraged to complete a form of inquiry so that the process of meeting their needs can begin.
There are various ways this can be done, but, remember, the fewer keystrokes the better. Amazon may not be your preferred shopping portal, but it has researched how easy the buying process needs to be. The same applies to your website: make it easy.
Twitter, Instagram, Facebook and more have all made it very easy to enable purchases. I have linked up booking systems to social media sites and websites to enable potential patients to book in easily.
Remembering that our attention span is still falling – it is now less than a goldfish – there is now a window of four seconds or thereabouts for someone moving from a social media site to your website and sending a request for information email. Keep it simple too. Is there a button to link up to your website? If someone has to type to search, the chances are they will move on to another site. If a user cannot find what they
want on your site within seconds, they will move.
What will make them stay, and I have seen this many times, is an emotional story either in the written word or via video.
Emotions sell products and – as in the example of Nike (see the box above) – remember that much of healthcare is about emotions. Emotions really are a driving force for care and treatment. I will talk more about this later.
Social stars
In 2015, I wrote about the use of Google stars. These are stars allocated according to Google’s algorithm to a user review and, to use the well known phrase, ‘stars mean prizes’.
The prize of acquiring Google Stars is higher visibility on Google and this is still true today. It is sobering to know that 48% of consumers will not consider a business/practitioner with less than four stars with the maximum number available being five. Seeking reviews via Google will always be helpful, as they help your website ranking and boost credibility along with trustworthiness.
It is straightforward to write the
If a user cannot find what they want on your site within seconds, they will move
review; you just have to ask. As you will have provided a highquality service, it is highly likely you will obtain at least four stars and, hopefully in the majority of cases, five stars.
Obtaining likes on Facebook will be advantageous, as they show that others also like what you have to offer and these likes also help your reputation. Likewise, followers on Instagram work in the same way, building communities of likeminded people.
Now more than ever, there is a link in the user’s mind between the number of reviews, the number of stars, the number of likes and the number of followers. The more there are, the more they will notice and the more they will take note of what everyone who has reviewed, liked and followed before them has to say.
Social customer service
Over the last ten years, an increasingly significant amount of my time has been spent on Facebook and Instagram monitoring and responding to private questions from potential and past patients, thus providing a personalised service.
In this world of bots and virtual
assistants that we have all encountered when all you want is a human, the ability to respond quickly to a question is vital. It conveys competence, care and understanding. 65% of millennials and 42% of adults think it’s appropriate to contact their doctor through social media with a concern. 32% took a healthrelated action based on information they found on these platforms.
Over the past few years, I have found myself going to social media to find a quick solution to my problem and my experience has been mirrored with my clients. The outcome of this faster, personal service is the building of customer relationships.
I have noticed that, for my clients, tightknit helpful communities have been built and these support and provide opportunities for interaction between patients past, present and future. It is also an ideal opportunity to prevent ‘Chinese whispers’ and correct any false beliefs.
Increasingly, patients want quick answers. Quick answers increase confidence and help them make the right decision for them.
Medical secretaries still play a vital role, but too often the number of emails and tasks that they have to do means that there is a time delay through no fault of their own.
Responding via social media does mean that patients do expect quicker responses, and while this is beneficial, it is timeconsuming too.
That said, there are definite pathways for postop care and that is where a quick response to inform them that they need to send all information to the consultant as soon as possible is also beneficial.
I advise my consultants to not get involved with responding to social media questions, as this then blurs lines and causes confusion.
Obviously, there is a medicolegal pathway to follow to ensure that all due care is given and this should only happen away from Facebook and the rest.
Equally, if someone makes a complaint via any social media avenue, it is an opportunity to discuss why.
Most issues that I have come across are often a lack of communication and can be remedied with tact and care, thus changing
WHY CREATING AN EMOTIONAL TIE WITH YOUR PRIVATE PATIENTS IS CRUCIAL
In 2015, I wrote an article for this journal about how social media was changing. Looking back to then, I’m not sure how many of us could have predicted how it has changed and how it is affecting our lives.
But before I continue with an update, I feel it is necessary to talk about Nike, one of the most successful brands in the world. There are important parallels, particularly in today’s world.
Nike made many shoes for sportsmen from their original company, Blue Ribbon Sports, that was created in 1962. Later in 1978, it changed its name to Nike and, by then, various famous sports had been dominated by winners wearing Nike trainers.
The business was successful. It was when the company realised that its growth had plateaued, sales were falling and strong competition were appearing that it had a problem. It hadn’t really marketed its products.
Nike understood its consumers, but something was lacking. It knew what its customers wanted, so it simplified its message and realised that emotion was the key. It created an emotional tie with its consumer and, having done that, never looked back.
And that is the direct relevance to your private practice. You need to create an emotional tie with your potential patients. This is what will lift you apart from your colleagues, because so many people fail to do this. The best way to do this is via social media.
what can be a negative review into a positive one and assisting with the reputation of the clinician.
Social customer service is not going away. If 80% of people on social media use it for healthrelated information, then why not be at the forefront and guide the conversation and care to help those people who would benefit from your help?
Social stories
I have witnessed the lines blurring between privacy and the desire to inform others about an experience. This is a very powerful need that many people have and they create the most powerful social stories that could help your private practice.
The impact of surgery can be so profound that they want to thank you, as the surgeon or physician, for your help – and the best stories come some time after the event. By maintaining the channel of communication via social media, the stories or testimonials come.
People then read these stories and want to share their experience. This is the emotional relationship that you have with your patients. These are what help propel your private practice.
Of all the methods that are available to encourage feedback, social stories are the most powerful. Around 24% of people want to post online about their health experiences or provide updates, 27% enjoy commenting about health experiences.
63% of patients choose one provider over another based on a strong online presence. In my experience, I would define that as proactive engagement, assisting with questions, providing information and social stories.
In my 2015 article, I said: ‘Your words are your currency and tell the world who you are. They also build relationships and are a form of customer service enabling them to consider coming to you.
‘Your focus should be on accurately informing people about the healthrelated issues in your field so as to outshine misleading information.’ I still stand by this today.
Conclusion
Much has been said in the public domain about the role of social media and how it can adversely affect individuals. It’s not going away.
As it becomes more sophisticated and more demanding, there
is a need to be transparent and a need to monitor what you can control to ensure that those who need you find out accurate information to assist them.
Meanwhile, the return on investment on social activity is always difficult to assess in healthcare, but I do know one thing for certain: it needs monitoring and steering towards your aim. It is akin to a massive shipping tanker trying to turn in the Solent: slowly and carefully with assistance to ensure the correct course is kept.
On the positive side, though, your efforts will be rewarded with potential patients becoming more informed than they ever would have been previously. Social media activity changes the relationship between you and your patients.
It ultimately impacts how your potential patients view you and they, in turn, accumulate information from various sources, ultimately deciding to come to you, as your voice is the one they refer to and the one that they turn to. You become the one they emotionally relate to.
Catherine Harriss is the founder of MultiWorks Marketing. See https://attractdreamcustomers.com
DOCTORS UNDER INVESTIGATION
Time to reform the regulator
Urgent fitness-to-practise
improvements are needed at the GMC to ensure doctors get a fair hearing, says Dr
Udvitha Nandasoma (right)
IN 2021, the GMC received more than 9,000 fitness-to-practise inquiries from the public, employers and other sources.
While the vast majority (7,401) were closed at the initial triage stage, that still means more than 1,000 registrants found themselves under scrutiny by the regulator.
When you consider that there were over 350,000 on the register in 2021, the number of investigations is small.
But the fear of becoming involved in an investigation is palp able and the impact on affected doctors is significant.
Unfortunately, the investigation process is often protracted and distressing and there is also a real anxiety about whether the outcome will be fair. This is borne out by recent events.
The GMC has been criticised for its handling of the case against one of the MDU’s GP members. A GMC-commissioned independent learning review of the case reported recently.
This is the latest in a number of reviews into fitness-to-practise investigations. All point to the need for reform of the current system – something the GMC itself wants to see.
Key recommendations
Prof Iqbal Singh and Martin Forde KC concluded in the recent review that the case should not have been taken forward and that ‘the GMC missed multiple opportunities to stand back and assess whether the allegations were serious enough to be referred to a tribunal’.
The report’s recommendations – accepted in full by the GMC –include:
The need to collaborate with other organisations to produce a local resolution approach first to avoid unnecessary referrals;
Embedding a culture of professional curiosity among staff;
Considering how to ensure decision-making is fair and unbiased.
Significantly, the authors recognised that ‘referral to the GMC is hugely stressful and traumatic for any doctors, irrespective of the outcome.
‘They often feel trapped, humiliated and ill-treated. Going through such an experience affects not only their physical and
mental well-being but also their wider families.’
This chimes with the MDU’s first-hand experience of supporting doctors with GMC investigations, whether they are GPs or consultant specialists.
Our members look to us to listen, provide a robust defence and help with services like our peer support network, which links them to others who have been in their shoes.
However, our advisers and lawyers often find it painful to witness the emotional toll that the gruelling fitness-to-practise process takes on members, their families and colleagues.
We welcome the GMC’s apology to the doctor in this case and we will continue to do everything possible to stand up for members in this difficult situation.
Concerns about the fitness-topractise process are not new. A growing number of reviews have looked into the GMC’s procedures over recent years and pointed to the need for more compassionate and flexible regulation.
These include the Hamilton review into gross negligence manslaughter and culpable homicide (June 2019) and the Horsfall report (December 2014) into doctors who commit suicide while under investigation.
Reforming the system
In responding to the latest review, the GMC’s chief executive Charlie Massey said the regulator ‘shared the aspiration of the review’s cochairs that modern regulation should contribute to a better health system which is compassionate, fair and supportive’.
We would add ‘completed as quickly as possible’ to that list. Regardless of the support afforded to any doctor, an ongoing GMC investigation inevitably adds ongoing stress and anxiety that, at present, can sometimes go on for years.
We do, however, recognise that the GMC’s hands are tied when it comes to some aspects of reform of the system for regulating healthcare professionals.
Frustratingly, while the then Government was set to introduce the legislation needed to modernise regulation this year, it has been delayed.
Recommendation 18 of the review says: ‘The UK government should bring forward legislative reform for the regulation of healthcare professionals at the earliest opportunity.
‘This would enable our recommendations of compassionate, supportive, fair and proportionate regulation, by allowing the GMC to dispose of appropriate fitnessto-practise cases consensually.’
If the Government is looking for a policy that can demonstrate its commitment to doctors’ wellbeing and help workforce retention, then fast-tracking GMC reform in 2023 would be an excellent choice, as most of the groundwork has already been done.
As we have repeatedly said, all doctors deserve a regulatory system that is proportionate, timely and fair, while underpinning safe care. The current system falls far short of this standard.
Dr Udvitha Nandasoma is head of advisory services at the Medical Defence Union
WHAT TO DO IF THE GMC COMES CALLING
Involve your medical defence organisation as soon as you are aware of a GMC complaint
The evidence shows doctors have a better outcome with legal representation. Between 2016 and 2020, MDU solicitors representing members at tribunals achieved no finding of impairment in 42% of cases compared to the GMC average of 21.5%
Speak to your medical defence body before responding to a complaint or adverse incident, then write a statement of what happened while events are fresh in your mind
Get support from colleagues, your family or your GP, while respecting patient confidentiality
Take time to reflect on what you have learnt and what you would do differently. Evidence of insight and professionalism is an important element of resolving any fitness-to-practise concern
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The secret of being
Robin Stride describes how looking after your workforce paid dividends for Spire Healthcare, winner of the coveted ‘Hospital Group’ prize at the LaingBuission Awards
THE 8,000+ consultants with practising privileges at Spire Healthcare have been praised by its chief executive for helping it win the Hospital Group accolade in the LaingBuisson awards for 2022.
Justin Ash told them: ‘I congratulate my clinical and management colleagues who continue to focus their efforts to make a positive difference to people’s lives through outstanding personalised care.’
This, and the year’s Nursing Practice award, given at the same time, reflected the ‘amazing results’ from the groups’ teams.
Mr Ash believes companies who emerge well from recessions invest into recessions. In practice, with demand high for Spire’s in andout of hospital services, this means delivering consistently high quality care and patient
experience, focusing on cost management and, most importantly, looking after its workforce.
Spire’s aspiration, which it calls its ‘Purpose’ – with a capital ‘P’ – is to make ‘a positive difference to people’s lives through outstanding personalised care’ across its 39 hospitals, 30 clinics and a network of private GPs and occupational health services.
Commitment to people
It was recognised for a commitment to caring for patients, colleague training and development, and innovation in terms of delivering digital solutions to drive efficiency and improve patient communications.
The Hospital Group accolade, earned against many other leading independent sector providers, was
Our December-January issue of Independent Practitioner Today featured some of the category award-winners of the private healthcare sector’s ‘Oscars’ – the LaingBuisson Awards – including the ‘Hospital Group’, won by the Spire Healthcare team (left)
CARING FOR STAFF
Spire has committed to supporting staff health and well-being through mental health firstaiders at all sites, well-being one-to-one sessions for managers to check in with team members and nightcap sessions for those who might be lonely.
Support for those from abroad is also in place to help them find accommodation, open bank accounts and develop support networks.
It was the first private provider to have Freedom to Speak Up guardians/ambassadors covering all its hospitals, offices and consultant bodies.
The group says diversity and inclusion brings talent and energy to its business, with vibrant Let’s Talk networks on race equality, mental health and LGBTQ+ issues and new communication forums, recruitment materials and processes having been established.
Colleague engagement is high, with 84% saying they are proud to work for Spire.
called ‘best group’
received for ‘a clear commitment to its people and wider stakeholders, which is evidenced by the culture of inclusion and developing staff.’
Spire’s ‘Purpose’ of ‘Making a positive difference to people’s lives through outstanding personalised care’ means:
An uncompromising focus on patient safety, quality and clinical governance to secure the best outcomes for patients;
Making a positive difference to all colleagues – it talks of ‘colleagues’ rather than staff – instilling a culture of respect, inclusion and collaboration;
Making a positive difference to the environment, where it is committed to becoming net zero carbon by 2030, and to the communities it serves.
This ‘Purpose’ was initially coproduced in 2019 with consultants, patients and colleagues, and agreed by a vote of more than 200 attendees at an annual leadership conference.
It was then rolled out through a series of interactive workshops, with everyone attending a launch session. After an update to the wording last year, it is included in
all newstarter inductions, so joiners are immersed in it from day one.
Spire describes its ‘Purpose’ as sitting at the heart of its culture, driving what it does and inspiring its workforce to strive towards constant improvement. In its last staff survey, over 80% reported that this made them feel their job was important.
Patient satisfaction linked to self-pay growth
In patient surveys, 92% of patients say their care was outstanding, 94% say it was personalised and 85% say it made a positive difference. Spire says every patient deserves the same quality of care, regardless of whether they are NHS, insured or selfpay.
Patients say they choose Spire, knowing they will receive highquality care. 98% of the group’s Care Quality Commission(CQC) inspected hospitals and clinics are rated ‘Good’, ‘Outstanding’ or the equivalent by health inspectors in England, Wales and Scotland, ahead of the sector average of 89%.
95% of its sites are rated by the CQC as good or outstanding for
Spire describes its ‘Purpose’ as sitting at the heart of its culture, drivings what it does and inspiring its workforce to strive towards constant improvement
experience and boosting innovation.
With 19 robots assisting with knee and hip surgery, more are to be delivered across 2023. Spire Manchester is the biggest user of Mako robots in the country, across the NHS and independent sector, with more than 1,000 procedures having taken place to date.
being safe, against the average of 78%. For well led, it is at 97%, against the average of 86%.
Postpandemic waiting lists led to an explosion in demand from patients willing to self pay. As reported in the group’s interim results for the first half year of 2022, selfpay revenue was sharply up by 34% compared with H1 2021.
The 2021 figure was already 50% up on H1 2019, as the selfpay market expanded after the major peaks of the pandemic. Patients are increasingly booking with Spire for complex treatment, such as cancer and cardiac care, as well as diagnoses.
Spire is committed to developing skills and in 2021 launched a new nurse apprenticeship programme, currently training 200 people.
During the worst of the pandemic, it treated over 350,000 NHS patients between April 2020 and December 2021 and has continued to support NHS trusts to care for patients waiting the longest.
A digital transformation is meanwhile driving operational efficiency, automating manual processes, improving patient
Spire reports it reduced its emissions by 8% over 2021, building on the 33% reduction already achieved between 2015 and 2020. Its estate and engineering infrastructure continues to be upgraded, with the replacement of gas powered steam boilers with more efficient electrically powered equipment; installation of more efficient ventilation systems; investment in LED lighting and modern chillers with heat recovery systems.
The installation of photovoltaic solar panels is generating 24kw of free electricity, with more installations to follow. As well as establishing a network of Carbon Champions across all Spire hospitals and administration sites, it is expanding the use of electric vehicles across its fleet and installing charging points.
Its work with wider stakeholders includes:
Involving patients in decisionmaking about their care: 96% of patients say their experience of their care at Spire hospitals or clinics care was good or very good;
Patient groups helping the group develop services such as the design of a protocol to support patients and learn when things go wrong – something which is now adopted as national best practice by government;
Each hospital supporting local good causes; for instance, charity challenges across Spire have raised tens of thousands of pounds for food banks across the UK.
Next month: Spire’s Nursing Practice Award
Justin Ash, Spire Healthcare’s chief executive
ECONOMIC TURBULENCE , the pace of technological advances, globalisation and navigating the lingering shadow of a worldwide pandemic have all contributed to the complexity of the way the world does business in a postCovid landscape.
The increasing complexity of business following Covid has led to high levels of stress, and burnout among business leaders. Dr Robin Clark, medical director for Bupa Global and UK, discusses the findings of Bupa Global’s latest Executive Wellbeing Index
The latest Executive Wellbeing Index from premium international health insurer Bupa Global gives us an insight into the impact of this on the minds of industry leaders, innovators and entrepreneurs around the world.
It analysed research among more than 2,400 respondents across eight countries and regions, including the UK, US, France, United Arab Emirates, Egypt, Hong Kong and Singapore.1
Global trends and local impacts
The pandemic, turbulence in financial markets and world events have served as a stark reminder that we live in an increasingly interconnected world. Some events are universal and disruption in one part of the world can often reverberate across others.
Despite some regional variations in the way the pandemic and world events have impacted executives globally, the data shows that this demographic has much in common.
One of the stand-out findings of the Executive Wellbeing Index is the extent to which mental health challenges transcend geographic, socio-economic and cultural boundaries, with 89% of respondents reporting at least one symptom of poor mental health. Worryingly, this is up from 77% last year and 70% in 2020.
The most commonly reported symptoms were disturbed sleep (19%), mood swings (18%) and burnout (17%).
For context, the World Health Organization estimates that, globally, one-in-eight people is living with a diagnosable mental health
condition, 2 and in the UK that number is thought to be one in six.
This gap between diagnosed conditions and reported symptoms highlights the fact that mental well-being is a broad spectrum, and underlines the importance of looking out for signs that someone may be struggling.
Bosses pay more heed to workers’ burnout
Red flag
A worrying red flag highlighted by the survey is the increase in burnout. Managing through circumstances out of one’s control – a hallmark of the pandemic – is a recognised driver for burnout, particularly for senior leaders who are tasked with leading a business and making decisions that impact their employees.3
The persistence of sleep problems is also a concern. More than half (52%) of those surveyed reported getting less than seven hours at least twice a week and a quarter (27%) said this happens for more than half the week.
Research shows that just five nights of partial sleep deprivation reduces our ability to assess data and risks, and many of these sleepimpaired individuals are making decisions which have huge financial and human impacts.4
That the vast majority of those surveyed have experienced some symptoms of mental ill-health is a salient reminder that anyone can experience these challenges and the danger of making assumptions based on outward appearances.
On the plus side, a deeper dive into the data shows improvements across a number of symptoms of psychological distress.
In the previous year, 34% of this key demographic reported sleep problems compared to 19% this year, 24% were experiencing mood swings compared to 18%, and 37% complained of fatigue — more than twice the number (16%) in the latest dataset.
This is good news as, despite the overall upwards trend, it suggests a
significant fall in the number of business leaders experiencing multiple symptoms of poor mental health.
The overall increase in those reporting at least one mental health symptom may also reflect greater openness and honesty in our conversations and reduce the stigma around mental health.
Promoting a proactive approach
Another of the positives we see from this high-achieving, highly motivated demographic is that they are also very pro-active when it comes to looking after their mental well-being.
Almost all (97%) have taken steps to prevent or manage their psychological well-being in the past 12 months, with the most common self-help strategies being exercise (23%), spending more time in nature (21%) and talking to family and friends.
As we know well, physical exercise is hugely important for mental well-being. An American study based on data from 1.2m people showed that those who exercise regularly had fewer days of poor mental health than individuals with sedentary lifestyles.5
The fact that most have taken steps to support their mental wellbeing, primarily via lifestyle-based interventions, is also good news for mental health more broadly.
Not only for these individuals personally, but also because this degree of awareness at boardroom level is likely to shape decisions, openness and support within the organisations they lead and positively impact their employees too.
Prioritising health and well-being
New ways of working introduced in response to the pandemic have led to long-term changes in the way we do business – which, in turn, has changed, perhaps forever, our approach to balancing home-life and work-life.
There have been fundamental changes at a more personal level too, as many of us re-evaluated our lives and goals and recalibrated our priorities.
As a result of what has been called ‘The Great Resignation’, it’s estimated that around 75.5m people globally quit their jobs last year
– the equivalent of the entire population of Canada.6
Studies show that productivity declines when we work more than 50 hours a week. This is why it is essential that work-life balance is created from the top down, with leaders using the tools at their disposal to support their mental wellbeing, and role-modelling this for their people.7
Interestingly, although older executives are marginally more likely to be considering a significant career change – 55% of over45s – this shift in outlook spans the generations.
The Index found that 48% of executives under 34 were also considering a major change to their work life, such as moving to parttime hours, consultancy, freelance working, moving to another company or stopping working entirely.
Unpredictable landscape
Senior leaders under immense pressure are now weighing up whether their ways of working are sustainable for their long-term mental health.
This has been exacerbated further by recent global events, increasing pressure on leaders to navigate an unpredictable economic landscape to meet their business targets, while also feeling greater responsibility to provide stability for their workforce.
Our latest Index data shows that some organisations are already responding to this shift in expectations from their workforce. Globally, almost half (48%) say their company plans to improve employee benefits packages in the next 12 months.
Wellness initiatives, which may have been seen as ‘soft benefits’ in the past, are now a high priority. When asked to rate what matters most to senior leaders, 31% said wellness packages such as health insurance and gym memberships.
Increasingly, it seems that companies are making substantial cuts to spending that is not considered essential, with 18% of board directors saying their organisations no longer offer corporate hospitality and two-in-five companies (41%) also intend to cut back on business travel.
However, the Index data suggests these cutbacks are part of a wider shift in priorities, as 14% of
As a result of what has been called ‘The Great Resignation’, it’s estimated that around 75.5m people globally quit their jobs last year – the equivalent of the entire population of Canada
services, it is essential that we – as well as employers – take early action.
Where people present with any of these symptoms, we need to make sure they are signposted to support and coping strategies that can help ease this burden before it is too late.
It is encouraging that senior business leaders are so motivated to improve their mental health and well-being, despite the many challenges they face.
those surveyed said these savings are being redirected to support health and well-being initiatives for their people
Overall, 47% said their company plans to make employee mental health and well-being the organisation’s top priority in the coming year and a similar number (49%) would like to see this happen.
Preventative health and support for healthy lifestyles are also a key focus, with 45% of those surveyed confirming their company plans to do more in the coming year.
As part of this, demand for private health insurance is high. Seven in ten (69%) of this demographic are considering paying for cover themselves in the coming 12 months.
And their priorities in terms of what’s covered are regular health checks (26%), physical and mental support for their whole family (25%) and advice on preventing issues by maintaining good physical and mental health (25%).
Conclusion
The need for preventative care and mental health support at work has never been greater – at every level – if businesses are to retain the very best talent and steer the global economy back on track.
And, naturally, executives are looking for organisations that value a healthy and happy workforce.
These findings suggest that there are huge numbers of people living with symptoms of poor mental health who have not crossed the threshold of distress that would lead to diagnosis.
To prevent this reaching crisis point, both for the individuals and already stretched mental health
As they make changes to improve their long-term mental health, this will influence company policies and benefit their employees. We need to find ways to support and encourage this proactive behaviour change, as it is key to improving the health of the population.
As clinicians, we need to demonstrate the quality and value that the private sector offers patients to encourage the continuation of the increased demand for private cover.
And insurers need to deliver new and innovative products to help people take a pro-active and preventative approach to their health, with the aim of keeping them well rather than reacting when stress leads to illness.
References
1. The Bupa Global Executive Wellbeing Index 2022 analyses research conducted between 3 August and 7 September 2022 among 2,439 adults with £1m+ in annual salary and investable assets.
2. Mental disorders, World Health Organization, 8 June 2022.
3. Understanding the burnout experience: recent research and its implications for psychiatry, World Psychiatry, June 2016.
4. Effects of Total and Partial Sleep Deprivation on Reflection Impulsivity and Risk-Taking in Deliberative Decision-Making, Nature and Science of Sleep, May 2020.
5. Association between physical exercise and mental health in 1.2 million individuals in the US between 2011 and 2015: a cross-sectional study, Lancet Psychiatry, September 2018.
6. New Research on The Real Cause Of The Great Resignation, Forbes.com, January 2022.
7. The Productivity of Working Hours, The Institute for the Study of Labor, John Pencavel, April 2014.
Bid to tackle racism
A new resource to help doctors suffering from racism in their working lives is proving popular as an educational tool too. Agnes Rose reports
‘WE ALL HAVE A RESPONSIBILITY TO ACT’
PROF COLIN MELVILLE, GMC medical director and director of education and standards:
‘Everyone has the right to come to work without fear of experiencing racism, but as we know only too well, and as the BMA’s recent survey underlines, this is a very real challenge that we must work together on across our healthcare system.
‘We are clear: there is zero tolerance for racism of any kind and we all have a responsibility to act when we witness it.
‘We understand speaking up in the moment or acting upon racist behaviour in the workplace can be challenging or daunting, so it’s important for support and guidance to be readily available and easily accessible.
‘Equally, we must encourage working cultures where doctors feel supported and empowered to speak up, if discrimination of any kind does take place.’
DOCTORS WHO witness racism at work, or face it personally, are taking advantage of a useful newly launched resource to support them.
In a dedicated area on its website the GMC has brought together current guidance that gives advice on how to tackle discrimination, whether personally or as a bystander.
A council spokesperson told Independent Practitioner Today : ‘Since launching in November, our ethical hub page focusing on racism in the workplace has been viewed over 5,000 times.
‘The page brings together cur-
rent GMC guidance and is focused on supporting those who experience discrimination, as well as signposting to further support.
‘Our early feedback shows users are visiting the page when seeking support for personal experiences of racism and for use as a teaching aid.’
Inclusive cultures
The GMC’s hub also highlights expectations of employers and medical leaders to foster inclusive cultures, where people feel supported to challenge racism, and it signposts to how and where a concern or issue can be raised.
Tackling discrimination and inequality is seen by the regulation body as an urgent priority in healthcare.
According to a recent survey by the BMA, 76% of more than 2,000 respondents had experienced racism in their workplace on at least one occasion in the last two years.
The doctors’ union found:
Racism is widespread within the medical workforce;
Overseas qualified doctors experience racism more often than doctors trained in the UK;
Experiences of racism are significantly under-reported;
Reporting experiences of racism results in backlash;
Racism has an impact on career progression for many doctors;
Experiences of racism are affecting doctors’ confidence and mental and physical well-being;
Many doctors are considering leaving or have left their jobs because of racial discrimination.
The GMC has committed to working with organisations to drive forward change, setting targets on tackling inequality.
As well as collating guidance and signposting to further support, the GMC hub looks at real-life examples where doctors have experienced racism, from explicit discrimination to micro-aggressions that often continue unchallenged.
A locum doctor anonymously shared comments received from colleagues which left them feeling they ‘had to work harder to prove themselves’ than their white counterparts, including: ‘I can’t pronounce your surname, can I just use your first name?’ and ‘Oh, not a foreign doctor again.’
Another doctor shared their experience of a patient’s carer asking to see another doctor as they ‘did not appear British’.
The GMC says experiences highlight not just the impact of racism on those who suffer it, but the essential role of employers and witnesses in challenging racist behaviour, including:
Expectations of those in senior positions in tackling and rooting out discrimination where it arises;
Duties of conduct towards colleagues and patients;
Resources for employers on creating inclusive non-discriminatory environments.
The section is the latest of 12 areas in an ‘ethical hub’ which brings together resources on how to apply GMC guidance in practice. The hub focuses on areas doctors often query or find most challenging and aims to help address important ethical issues.
The new hub is available on the GMC website. For advice on speaking up on discrimination, visit the GMC’s dedicated webpage.
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THE VIEWS OF PRIVATE HEALTHCARE MANAGERS
Optimism is in the air
The private providers’ trade body has been taking the temperature of the independent healthcare sector. David Hare (right) reports
AFTER A BUSY 2022, the Independent Healthcare Providers Network (IHPN) was pleased to take the opportunity to pause and look at how independent providers themselves view the current healthcare landscape.
This culminated in the publication of our third annual IHPN Industry Barometer: State of the Sector report.
The barometer provides a snapshot of how senior leaders across the independent healthcare sector feel about all their key markets and the issues affecting their business,
and which we hope will make interesting reading for those working within the sector.
Overall, there’s no doubt that the health service is under significant pressure, with rising demand from patients across all parts of the system.
Economic downturn
In addition, we are facing an economic downturn and cost of living crisis which is impacting all healthcare providers’ ability to run their organisations and recruit and retain staff, not to mention the
inflationary pressures showing up in the energy and labour markets.
But while this may paint a gloomy picture, it’s clear that independent providers are overall feeling positive about the prospects in all their key markets, with growth expected particularly in both domestic and international self-pay.
Almost nine-in-ten providers (88%) are ‘positive’ or ‘very positive’ about the private self-pay market – unsurprising given the backdrop of rising NHS backlogs leading to more people paying privately for their care.
In addition, over half (55%) also feel ‘positively’ or ‘very positively’ about the market for insured patients, with the same number positive about the international self-pay market – a marked increase from 20% last year now that Covid travel restrictions are thankfully a thing of the past.
Of course, coupled with this, the sector is not immune from the wider economic challenges facing businesses all across the country, notably rising inflation and low economic growth.
More than half of respondents
(54%) reported this being felt most in pressure on wages, followed by prices for services not keeping up with inflation (42%).
Interestingly – and encouragingly – no respondents felt the impact was being seen in declining consumer confidence, suggesting demand for private healthcare will continue to grow.
Workforce shortages
As Independent Practitioner Today readers will be aware, workforce shortages and the difficulties around both recruiting and retaining staff loom large in the sector. When asked about the biggest challenges facing the independent sector, the overwhelming majority (80%) of the respondents to the barometer cited access to skilled workforce and shortages.
And this is not just seen as an operational issue but a safety and quality one too. Almost nine-inten providers (88%) told us that workforce recruitment, training and development was the biggest challenge in relation to quality and safety in their organisation.
But as clinicians working in the sector will know, the independent health sector is working hard to ‘grow its own’ workforce, with the survey demonstrating the wide variety of ways that our members are bolstering their numbers.
This may be through apprenticeships, training and development, more employee support and well-being, overseas recruitment or changes to contract/benefit packages.
And for our part, IHPN is continuing to do all it can to support members on a range of workforce
issues. This includes looking at innovative new ways we can help the sector to access specialist clinical staff, including nurses, anaesthetists and radiographers.
Brexit has, of course, impacted on the ability to recruit highly skilled workers from overseas and, in the last year, the IHPN has welcomed the opportunity to continue the work with Talent Beyond Boundaries.
This refugee organisation specialises in placing clinicians in the UK. Around 100 refugees have been placed among IHPN members since this activity began.
Workforce plan
And in addition to our on-going work with Health Education England to support doctors in training, we will also be working with colleagues in the NHS and Government to ensure the sector is fully factored into the ‘comprehensive workforce plan’ for the health service that was announced by the Chancellor last autumn.
As I’ve mentioned in previous columns, the healthcare regulatory landscape is changing dramatically, and in terms of the forthcoming changes to the Care Quality Commission’s (CQC’s) operating model, the jury is definitely still out in the sector.
Indeed, equal numbers of members feel the new CQC assessment and inspection framework is both an ‘opportunity’ and a ‘challenge’.
To support members to navigate this new word, IHPN has set up a new member reference group to discuss the CQC’s new regulatory approach to help ensure the independent sector is fully factored into the regulator’s plans.
So while it is a nuanced picture in some areas, this year’s Industry Barometer overall shows the real sense of optimism within the independent healthcare sector, with demand for the high-quality services it provides expected to rise significantly in the coming year – particularly among private patients.
We hope Independent Practitioner Today readers enjoyed these insights and will look with interest at what this year’s will hold.
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The IHPN published its third annual Industry Barometer in December
Beware the risk of remote reporting
Outsourced remote radiology reporting has increased in recent years along with an increased ability for radiologists to report from home. But while this can speed up the delivery of reports, there are some risks both for the hospital and the private teleradiologist. Dr Emma Green (below) explains how some of these risks may be mitigated
UK NHS TRUSTS are allowed to procure the reporting services of compliant private teleradiology suppliers covering a range of reports including backlog, urgent and second opinion referrals. Due to Covid-19, radiology is not new to remote working. However, outsourced remote radiology reporting has been increasing in hospitals over recent years and can offer completion of reports 24/7, allowing for a greater volume of imaging to be undertaken.
A 2018 Care Quality Commission report1 indicated that 76% of hospitals trusts in England were outsourcing radiology at this time. A subsequent 2021 report from the Royal College of Radiology (RCR)2 showed that UK outsourcing of radiology reporting in 2020 had increased to a cost of £128m compared to £81m in 2018.
With the full impact of Covid-19 not reflected in this report, it is likely that outsourcing will have increased further although the 2021 report3 does not include the outsourcing costs in isolation, so there is currently no comparable data.
With recognised shortages in the NHS consultant workforce for radiology and the increasing use of radiology for diagnostic purposes, it is unsurprising that trusts are increasingly outsourcing this work to meet the demand for reporting.
There are, however, some medicolegal risks both for the trust and for the teleradiologist and we have noticed a trend in associated claims.
In 2019 and 2020, these claims featured in the top 25 UK claims
ERRORS LEADING TO CLAIMS
Some recent claim examples include:
Failure to diagnose slipped upper femoral epiphysis when remote reporting with specific criticism of failure to request alternative views.
Failure to diagnose metastatic cancer due to insufficient information provided on imaging request resulting in the report being focused elsewhere. This was picked up in a discrepancy meeting.
Criticism of reporting language used to describe compression of all nerve roots of the cauda equina. ‘Severe spinal canal stenosis’ may not be understandable to the referring clinician or recognised as a potential emergency.
While it is recognised that cauda equina syndrome is a clinical not radiological diagnosis, this should raise awareness to radiologists of how their report may be interpreted by others.
by cost and we anticipate this trend will continue.
A 2020 report published by Getting It Right First Time4 and a 2021 report by the Parliamentary and Health Service Ombudsman5 highlight a number of areas where it was recognised that outsourced remote reporting might contribute to systemic problems. It is important to also highlight that, while there is an accepted reporting error rate for radiologists between 3-5% for plain film radiographs and higher for cross-sectional imaging, 6 this has been shown to increase with off-site reporting to between 8.7%-12.7%.7 This shows the importance of ensuring there is a robust system to allow for learning from errors.
Some of the problematic areas identified by the reports above and seen in cases managed by Medical Protection include:
IT systems
Many systems do not allow image sharing between hospital trusts. This can result in previous imaging being unavailable and leaves the reporting radiologist exposed to potential risk. It can also result in further imaging being suggested, which may be unnecessary.
Communication
Radiology request forms are only as good as the level of detail included on the form. If important clinical detail is not included and face-toface communication cannot occur, the reporting radiologist may be clinically disadvantaged.
Remote reporting can also result in the loss of the communication with other healthcare profession-
when it may not be possible to tailor a report to the professional background of the requesting clinician.
So use plain English, avoid acronyms, abbreviations, colloquialisms and explain any medical terminology which is unusual, localised or subject to interpretation.
This is where the lack of knowledge of the status of the referrer should be taken into account to provide a clear report.
This should include access to and participation in REALMS meetings and relevant continuing professional development.
➲ Quality assurance should also include discrepancy reporting in line with RCR standards with at least 5% of reports being reviewed.
als either through the traditional multidisciplinary team or passing ‘corridor consultations’. This can result in lost opportunity to seek further clinical correlation or secondary reviews of reports. Similarly, receiving clinicians are unable in most cases to contact the reporting radiologist or do not have the same working relationship as those co-located in the hospital environment.
This can result in reports being interpreted incorrectly, especially when the report contains ambiguity, lacks suggested further management or an unexpected finding is not reported in a way which highlights potential serious pathology. So how can private teleradiologists supplying reports to NHS trusts through third party suppliers reduce their risk?
Firstly, while remote reporting may be undertaken for NHS trusts, the work will require separate, individual indemnity for radiologists. Those undertaking remote reporting should ensure they are aware of the indemnity requirements and contact their medical defence organisation if they are unsure.
While many of the problems cannot be solved by individual clinicians alone, those involved in remote radiology reporting should adhere to the RCR reporting standards.8
Some of the key areas that can assist teleradiologists in reducing risk include:
➲ Ensuring report wording is unambiguous. This is especially important for those reporting for a company and not directly alongside the referring clinician
➲ When reporting images, the report should consider pertinent previous radiology, clinical information and lab/histopathology reports. This can be a barrier for those reporting remotely for a third-party without access to patient records.
The report should therefore consider whether knowledge of results would change the report and whether the information needs to be obtained.
➲ When imaging reports identify unexpected significant clinical findings or life-threatening emergencies, reporters should comply with local reporting mechanisms.
This is a key area which can result in claims or potential criticism and we have seen claims relating to delayed diagnosis of cauda equina as a result of poor reporting pathways.
Teleradiologists should ensure, if they are providing their service to a company, that they are satisfied there are robust reporting mechanisms and be aware of the referral pathway before undertaking the work.
If a clinician cannot satisfy themselves that the pathway is adequate, the risk of a claim increases and it is likely that some responsibility will be attributable to the radiologist as well as the organisation.
➲ Those reporting for external organisations or taking on additional reporting workload should consider the increased risk of errors associated with working above contracted hours as well as the increased risk associated with reporting during night hours.9
➲ Clinicians should ensure they are satisfied that the remote radiology companies to which they are contracted facilitate a service which is subject to quality assurance.
This ensures that colleagues undertaking remote reporting are subject to the same scrutiny and can learn from the peer reviews undertaken of their work.
Medical Protection recognises the important role that teleradiology plays in the evolving picture of medical practice, especially since Covid-19.
But, with rising numbers of claims, those providing this service should familiarise themselves with the expected standards, consider ways to ensure that reports are easily understood, and ensure all relevant information and unexpected findings which require action are clearly communicated to the provider.
Dr Emma Green is a medico-legal consultant at Medical Protection
References
1. Care Quality Commission: 2018; Radiology Review; A national review of radiology reporting within the NHS in England.
2. Royal College Radiologists: 2020: Clinical radiology UK workforce census 2020 report.
3. Royal College Radiologists: 2021: Clinical radiology census report.
4. Getting It Right First Time 2020: Radiology GIRFT Program National Speciality Report.
5. Parliamentary and Health Service Ombudsman: 2021: Unlocking Solutions in Imaging: working together to learn from failings in the NHS.
6. Maskell G. Error in radiology-where are we now? Br J Radiol. 20199.
7. Howlett D et al. The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit. Clin Radiol: 2017 Jan; 72(1): 41-51.
8. Royal College Radiologists: 2018: Standards for interpretation and reporting of imaging investigations: second edition.
9. Patel A et al. Radiologists Make More Errors Interpreting Off-Hours Body CT Studies during Overnight Assignments as Compared with Daytime Assignments. Radiology 2020; 297: 374-79
Business cycles of a private practice
In the first of a two articles, medical billing and collection expert Simon Brignall examines the life cycle of a private practice during a consultant’s career. Here he provides some useful advice for consultants starting out on the independent journey
WE ARE all subject to the impact of time, and businesses are no different.
Every business goes through four phases of its life cycle: start-up, growth, maturity and renewal/ rebirth or decline.
Private practice is, in fact, similar to any other small business, so understanding what phase you are in can make a huge difference to the strategic planning and operations of your practice.
As part of my role, I often meet consultants whose practices are at each of these various stages and so I thought it would be beneficial to discuss the challenges they face and how these can be overcome.
Starting out
One of the most common things I hear from consultants when they start out in private practice is that they suddenly feel that they are on their own.
There can be a sense that they are no longer part of a team and that they are left to fend for themselves. They feel colleagues who they went to for medical advice may be reluctant to assist them.
There can be a lot to consider when you are setting up your private practice and so here is a short check list of subjects to tackle to make sure everything is covered: Accountant – to advise on being a sole trader/limited company/ LLP;
Bank accounts;
Private Medical Insurer (PMI) recognition;
Staffing/administration;
Infrastructure;
Marketing and digital footprint;
Medical indemnity.
Accountant
It is always advisable to sit down with an accountant to discuss your plans, as they will be able to provide you with their professional opinion
Private practice is similar to any other small business, so understanding what phase you are in can make a huge difference to the strategic planning and operations of your practice
about what corporate structure would be beneficial for you.
At Civica Medical Billing and Collection, we have practices of many types, including sole traders, limited companies and limited liability partnerships.
Your personal circumstances will dictate which is best for you and your accountant will also advise you of the reporting requirements for each option.
Bank accounts
I would recommend having a dedicated bank account for your practice’s funds, as it makes the reconciliation task easier and means you are less likely to have errors.
If you are setting up your own company , then this will require a dedicated company bank account. Please note we have noticed the banks have been taking longer to do this since the pandemic, so ensure you prioritise this task.
Private medical insurer (PMI) recognition
Depending on your specialty, it is likely that private medical insured patients will make up a significant cohort of your patient demographic. So you can see why gaining recognition is important and needs to be actioned as soon as practical.
Note that the PMIs will require your bank details as part of this
process – which is why it is important to ensure you have reviewed the points on accountants and bank accounts.
The Private Practice Register (PPR), available from Healthcode, enables you to get set up with multiple insurance companies in one go.
Here is a short list of the major UK PMIs you need to be set up with.
My advice to any new consultants starting private practice is to ensure they focus on growing their practice and treating patients. It is important they ensure the billing and collection is quick, accurate and efficient and that they offer the full array of payment options patients expect.
As new consultants face an array of fixed costs such as their medical indemnity premium, medical secretary fees and possibly practice management software, this means there is a distinct advantage in choosing to outsource their billing.
This is because most billing com-
panies’ fees are calculated against money received and often billed in arrears. That can be a welcome relief to the practice cash flow at this time and ensures some of your costs are aligned to your income.
Splitting the medical billing from the many other tasks your medical secretary carries out is also beneficial.
Choosing to separate the billing process from the patient’s clinical journey allows your medical secretary to maintain a warm and engaging relationship with the patient because they are no longer required to make those difficult segues into conversations about money.
And by removing the burden of the billing process, this allows your secretary to respond to any new inquiries or patient queries more effectively, which, in turn, boosts revenue.
Recruiting for a medical PA to carry out the remaining tasks is often easier, as many medical secretaries do not enjoy the billing and chasing tasks and you will also have the capacity of the billing company on tap to accommodate the practice as it grows.
Infrastructure
One of the first things consultants should do when commencing private practice is to ensure they have the appropriate infrastructure.
A vital element of this involves having a robust auditable system to facilitate the financial processes of the practice. This should include the ability to:
Raise invoices and take 24/7 payments;
Reconcile payments;
Employ a robust chase process, including the ability to follow up on outstanding invoices using a range of communication methods.
We use our own proprietary software so that even practices we partner with who rely on manual systems now have the infrastructure and functionality of a modern practice.
Effectively, they have the revenue management side of a practice management solution alongside the latest payment pathways. Whatever system you adopt, you need to ensure the billing for the practice is auditable and accurate so that figures can be easily generated for your accountant
Marketing and digital footprint
It is important to review your presence online and ensure that whatever you find puts you in the best light.
Even if you do not have a website, you will find that you are probably on multiple sites, which may include the hospitals you work and your Bupa profile.
Make sure the information displayed is up to date and ensure you have a professional profile picture. Many studies show patients are more likely to engage when there is a picture of a person they can relate to.
Where possible, and this especially includes on your website, remember your audience is prospective patients not your colleagues.
Tailor your messaging to your patients’ needs rather than attempt to impress your colleagues by detailing your CV or a list of your accomplishments.
Medical indemnity
You will require medical indemnity cover for your practice activity, and this can be sourced either from the commercial insurance market or one of the medical defence organisations (MDOs). They will offer cover based on ‘losses occurring’ indemnity or ‘claims made’ insurance policies and contractual and discretionary indemnity.
It is important you understand these terms and assess which option is best for you.
Starting out can often be the most daunting phase of the practice life cycle, as everything is new.
Often the best option is to reach out to experts such as a medical billing company, who can not only provide valuable assistance in this key role but can often assist with introductions to key providers in other areas.
In next month’s article, I will cover the remaining business cycles of a private practice
Simon Brignall (left) is director of Business Development at Civica Medical
Billing and Collection
Don’t get your pocket picked
Costs really do matter. Dr Benjamin Holdsworth
(right) gives the lowdown on the high charges that can impact your investment
returns
HOPEFULLY, THE IDEA that ‘costs matter’ when investing will not come as a surprise to you. It is remarkable, though, how relaxed some investors are about letting others dip their hands in their pockets to extract high fees.
The problem has two root causes. The first is that, in most walks of life, paying higher costs should help you to secure the best lawyer, architect or builder, yet when it comes to investing, this relationship is less black and white.
When investing, you may pay your financial adviser to undertake work on your behalf much as you would with the professionals noted above.
They will make recommendations, ensure tax efficiency of the products selected and provide guidance as to how your assets might be best structured to help meet your objectives.
And, of course, they will meet with you to monitor progress on an ongoing basis. But when they ultimately decide on a suitable portfolio for you and make investment selections, the cost for those funds and investments is an important factor to consider.
This does not mean that cheap investments are always the best, but higher fund charges do not automatically mean better results.
Impact of compounding
The second is that costs of, say, 2% a year do not sound very much, but unfortunately they are when compounded over time. In fact, the exponential impact of compounding can work both for and against us.
Imagine three different portfolios that deliver returns of 1%, 3% and 5% per year after inflation, but before other costs, over a period of 30 years: £100,000 invested in each would result in a growth of purchasing power to around £135,000, £240,000 and £430,000 respectively.
Seemingly small differences in the compound rates of return, turn into large differences in terms of financial outcomes. That is one of the great positives of a disciplined and patient approach to investing – small returns turn into big numbers, given time.
On the other side of the coin, costs – when compounded over
time – eat away at these market returns to a far greater degree than many investors imagine.
For example, take two managers who deliver 3% gross – before fees – above inflation, where Manager A has costs of 0.25% and Manager B has costs of 1%.
Here costs matter a great deal; over a 30-year period, an investor in Manager B’s fund is over £40,000 worse off than an investor with Manager A’s fund.
Severe deductions
Unfortunately, investors fail to consider the severe deductions from long-term wealth of the costs they suffer.
A pound of costs saved is no different to a pound of market performance in monetary terms, yet it is far more valuable due to its consistency over time and the fact that it is achieved without taking any more risk.
Minimising costs in an invest -
ment programme can have significant benefits, through the effects of compounding, over time.
Legendary investment guru Jack Bogle said: ‘In investing, you get what you don’t pay for.’ Multiple research sources identify the fact that low costs drive higher performance outcomes.
Performance advantage
The use of low-cost products to implement an investment strategy provides a meaningful performance advantage over higher-cost alternatives.
It would be worthwhile paying higher fees to invest in a fund managed by a uniquely talented manager who can deliver returns above the market after all costs.
But only if we can be certain that their performance is due to skill and not luck – you need around 20 years of track record to split one from the other – and if we are confident that they will consistently
Legendary investment guru Jack Bogle said: ‘In investing, you get what you don’t pay for.’ Multiple research sources identify the fact that low costs drive higher performance outcomes
risk you are willing and able to take, and the purpose for which you are investing.
Good advice is worth paying for – but keeping investment costs to an appropriate level while doing so is a key part of our investment selection process.
Dr Benjamin Holdsworth is a director of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS
deliver market-beating returns into the future.
Regrettably, those are big ‘ifs’ with little supporting data. In the absence of that level of certainty, focusing on managing investment costs as tightly as possible makes good sense.
Cavendish Medical believes that the priority is to have a well-diversified portfolio that matches the
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.
Free legal advice for Independent Practitioner Today readers
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
Are you using the right
Doctors’ accountants have regularly reported in Independent Practitioner Today about the main types of business structures for your practice and the key differences between them. Now solicitor Kirsty Odell gives a legal viewpoint
ANYTOWN PRIVATE MEDICAL QUARTER
MANY BUSINESSES are now choosing to operate as corporate vehicles instead of as sole traders or partnerships – but why is that?
What are the differences between these structures and what is the right structure for your business?
Let’s consider some of the main business structures used to operate private medical practices.
➤ SOLE TRADER
An individual who runs a business alone has full autonomy and owns all of its assets personally. The individual has complete power in
TRADER
terms of running the business and making all the decisions – there is no distinction between management and ownership.
There are no particular requirements for setting up a business in this way and this keeps the set-up and operational administrative costs low. A sole trader doesn’t need any other documentation to govern how it is run.
There also aren’t any filing requirements in the same way that there is for some of the other structures mentioned below.
But the biggest risk is that a sole
trader is personally liable for all the business’s liabilities. This means, for example, that any debts, claims or expenses of the business will have to be paid by them personally. Any personal assets that they own, such as their residential home, are at risk if the business cannot meet its liabilities and creditors then demand payment.
➤ PARTNERSHIP
A general partnership is where two or more people carry on a business together, with a common view to make a profit. The default provi -
sion is that the partnership is governed by the Partnership Act 1890, which is very basic and does not provide certainty and stability.
Therefore, every partnership should have a partnership agreement – and ensure that it is kept up to date – to govern the relationship between the partners.
Without this, the decision-making and limitations on partners, the ability to expel partners and the terms of retirement do not exist, so can only occur with every partners’ agreement at the time.
The partnership may be termiSOLE
right business structure?
nated by any partner. Any of these may lead to catastrophic consequences on the business.
A partnership is made up of the collective group of individuals, so it does not have its own legal status.
This means that where contracts are entered into, they are not entered into with the ‘partnership’ but with the partners as individuals, even though it is under the trading name of the partnership.
So it is those individuals that are liable for the debts and other obligations of the partnership. The liability will be joint and several and you, as a partner, may therefore end up responsible for acts or omissions of your partners.
Having a partnership agreement
can minimise the risk of this to some extent through the contractual obligations it creates, but ultimately there is unlimited liability for the partners in this business structure.
As with a sole trader, there are minimal formation formalities and filing requirements, although a partnership agreement is something that any prudent person would insist on.
➤ LIMITED LIABILITY COMPANY
A company is a trading vehicle and is separate from the individuals involved in the business. There are different types of corporate structures, but the most common for the operation of a
medical practice is a limited liability company.
This could be either a company limited by shares or one limited by guarantee. For the purpose of this article, we will look at limited liability companies generally and not the detailed differences between those types.
As the name suggests, these companies benefit from limited liability. This means that, aside from any other arrangements that the individuals enter into personally, the company pays its own debts and other obligations.
Every partnership should have a partnership agreement – and ensure that it is kept up to date –to govern the relationship between the partners
For a company limited by shares, a member would only be liable to lose what they paid for their shares and liable to pay the amount which is unpaid for their shares, ➱ continued on page 42
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which could be a nominal value of as little as 1p per share.
Unlike a sole trader or partnership model, a company is its own legal entity. This means it enters into contracts in its own name, and can make claims in its own name and be sued in its name.
There tends to be separation between owners and managers of companies, although, for smaller businesses, they might be the same individuals acting in both capacities.
The owners are ‘members’ –shareholders in a company limited by shares – of the company, but they delegate day-to-day management of the company to ‘directors’. The members still have certain statutory rights with respect to the company.
Directors are subject to certain statutory duties, such as to promote the success of the company; to exercise reasonable care, skill and diligence and to avoid conflicts of interest.
A director may have personal liability to the extent that they don’t act appropriately. This is particularly the case if they are found to be trading wrongfully or fraudulently or when insolvent.
It is important that a company has a clear and sound governance structure, and its constitution, the Articles of Association, do need to be filed at Companies House. They are published for anyone to read.
If there are certain matters between the members that they don’t want to be publicly available, then they may also have a shareholders agreement, which isn’t filed. This is also a contract between the members.
WHEN ALTERING YOUR ENTITY
What to consider if you are looking at transferring your business to a new entity:
CONTRACTS – These may need to be assigned or new contracts entered into with the correct contracting party
EMPLOYEES – A consultation process may be required in some circumstances to comply with the statutory transfer of staff that will take place
SELF-EMPLOYED INDIVIDUALS – They will not be transferred via the same statutory process as employees and you will therefore need to agree new contracts with any associates/other self-employed individuals
CARE QUALITY COMMISSION – A new registration is likely to be required for any new business structure
PREMISES – Will the ownership of any property need to be changed or any leases need to be assigned?
FINANCE – You will need to consider any existing finance arrangements in place and whether changes to those are required.
Whatever you decide, specialist advisers will be able to guide you through the process.
Each structure has its advantages and disadvantages, and it is important to understand those fully before changing from one to another.
It is also important to review from time to time whether the structure you have at the moment is the most appropriate one considering the business, the risks and the opportunities you have.
While the biggest benefit of a company like this is the limited liability status, it does come with extra administration and running costs.
The company will be registered at Companies House. Various changes that occur in the company have to be notified to Companies House, such as changes in the share capital or of directors or of the Articles of Association.
Additionally, the accounts of the company will need to be made publicly available and filed annually at Companies House.
➤ LIMITED LIABILITY PARTNERSHIP (LLP)
An LLP may be viewed as a hybrid between a limited company and a general partnership.
It has the benefit of being a separate legal entity and limited liability – so, unlike with a general partnership, it is able to enter into contract in its own name, rather than the individual partners.
It is also the entity that is liable for its own debts and obligations.
There is a statutory procedure that is needed to set up an LLP and there are some ongoing administration costs and filing obligations.
For example, the accounts of an LLP will be publicly available at Companies House.
While there is no statutory requirement for an LLP to have an LLP agreement, it is again something that is strongly advised. This will ensure that proper governance processes are in place, as opposed to relying on the basic statutory requirements under the Limited Liability Partnerships Act 2000.
Like a partnership, it does not have the same separation between owners and managers as a limited liability company does.
Unlike a sole trader or partnership model, a company is its own legal entity. This means it enters into contracts in its own name, and can make claims in its own name and be sued in its name
Planning a move
It is important to note that if you are looking into changing your current business structure, then this should be done properly and there may be tax and accountancy implications of the proposed change.
Obtaining proper advice first may save you from a financial shock and also ensure you are trading from one entity and not two, resulting in having to register both entities with regulators like the Care Quality Commission.
The business and assets may need to be transferred from one entity to another and a proper process should be followed for this to ensure that title to the assets legally transfer.
Check out the box above to see some other things doctors should consider if looking at transferring their business to a new entity.
Kirsty Odell (right) is an associate at specialist healthcare law firm
Hempsons
Ten ways to save tax in year ahead
As we all breathe a sigh of relief after our 2021-22 tax returns have been submitted, it is worth looking ahead to see how you can save tax. Specialist medical accountant Alec James gives ten tips to boost your finances before the end of the tax year
WITH THE tax year shortly drawing to a close, whether you have self-employed income or trade via a limited company, now is a good time to review your position for both the current tax year and the tax year ahead.
The combined impact of lowering the threshold of 45% additional rate for the personal income tax rate and increased corporation tax rates from April 2023 means that careful planning should be done now to help mitigate the impact of this.
Below are ten top tips to consider before the end of the tax year:
1 Allowance tapering
By now, most doctors are familiar with the tapering of the personal allowance and pensions
savings annual allowances. With these in mind, it is worthwhile reviewing your estimated taxable earnings position, particularly in relation to the pension savings annual allowance.
➱ continued on page 44
The impact of having adjusted income being in excess of £200,000 can cause significant tax implications.
A review of this may mean that you consider your trading structure, dividends or even scaling back on income to avoid exceeding a threshold.
If you operate your private practice as a sole trader, then you may wish to contemplate accelerating capital expenditure in order to retain an allowance.
2 Trading status
While you are reviewing your projected profits from your private work, it is worth assessing the way you are trading.
For example, if you are selfemployed and you are likely to be tapered on your annual allowance, it may be beneficial to form a partnership or limited company.
Likewise, it may be that a limited company is no longer beneficial to you and you consider becoming a sole trader or partnership.
These discussions should always be held with a specialist medical accountant, as there is not a ‘one size fits all’ solution.
3
Dividend planning
Extractions of company profits paid to shareholders are called dividends. Dividends are taxed based on the date they are declared rather than the date they are paid.
You should consider your plans for any dividend you may wish to declare before 5 April 2023 so that they are included within the 202223 tax year.
It is important to remember that the dividend tax rates are reducing from 6 April 2023 but the tax-free dividend level is also reducing. Careful planning should be made with an accountant to discuss any potential extractions from the company.
If you have a company with ordinary shares, it may be worthwhile changing the ownership of the company or restructuring the shares issued to allow for variable dividends which may allow you to pay tax-efficient dividends.
4
Increase in corporation tax rates
From 1 April 2023, the corporation tax rates are changing.
Smaller companies with profits less than £50,000 will remain unchanged, but those with profits of more than this will see an increase in corporation tax.
Any company with profits in excess of £250,000 will pay corporation tax at the highest rate of 25%. Those that fall in between the two rates, as many private practice companies do, will see the impact of marginal rates.
The effective impact of this is that the profits between £50,001 and £250,000 are taxed at an effective rate of 26.5%.
One may assume that it would therefore be logical to have multiple small companies which each have profits of less than £50,000. However, there are rules in place to prevent this.
Any companies which are similarly owned are deemed to be ‘associated’ for corporation tax purposes. This means that the limits are spread among the number of associated companies. For example, if three companies were associated for corporation tax purposes, you would find that the lower rate band of £50,000 would become £16,666 for each company.
With this in mind, if you have multiple companies, it may be worth considering if this is the best trading structure for you.
It may also be worth considering changing the year-end of the company in order to ‘lock in’ the lower rates of corporation tax. Discussions like this should always be done with an accountant.
5 Capital expenditure
For those with limited companies, until 31 March 2023, certain capital expenditure currently qualifies for tax relief on 130% of
the costs incurred and it is called ‘super allowance’. This means that effectively you are obtaining tax relief at 25%.
On the face of things, it may seem logical to accelerate tax relief forward until 31 March 2023 to make the most of the additional allowance.
But if your company is going to pay tax at the marginal rate, then it may be beneficial to consider delaying the expenditure until after 31 March 2023, as you could then save corporation tax at 26.5%.
There were initially plans to reduce the Annual Investment Allowance from £1m down to £200,000 from 1 April 2023; however, this was scrapped in the Chancellor’s Autumn Statement.
6
Rewarding your employees
If your private practice employs staff, whether this is a secretary, personal assistant or a family member, you may consider rewarding the employees. These would be tax-deductible, which helps save tax for you.
Certain rewards are not subject to tax implications for your employees. This would include staff entertaining and trivial benefits such as small gifts. But there are limits to the amounts you can spend in order for them to be exempt from tax.
Bonuses and pay rises would be subject to the usual tax and national insurance deductions.
You may also wish to consider making an additional pension contribution on behalf of your employee. This is likely to be exempt from tax for them, but you or your company will be able to claim tax relief on the payment.
You may also wish to consider making an additional pension contribution on behalf of your employees. This is likely be exempt from tax for them, but you or your company will be able to claim tax relief on the payment
7 Review your pricing structures
Inflation rates are currently higher than they have been for many years. The insurance market forms a substantial part of the private medical sector and they have tariff rates for procedures. It is difficult to negotiate these.
However, with high waiting lists within the NHS, many Independent Practitioner Today readers are seeing self-paying patients. The selfpay market usually has higher rates and pricing is set by you. With this is mind, you should review the fees you charge to ensure you are at least keeping up pace with inflation.
It may be tempting to discuss pricing with colleagues – however, you should be very careful if you do so. The watchdog, the Competition and Markets Authority (CMA), has been interested in the medical sector for some time and has punished businesses where it believes uncompetitive practices have been taking place.
8
Crystalise capital gains
Many companies now hold investment portfolios as a way of keeping funds retained in the companies in line with inflation. If you have a large portfolio, it may be worth discussing selling your investment portfolio and repurchasing prior to 31 March 2023 in order to ensure the gains are taxed at 19% rather than likely paying corporation tax at 25%. Such decisions should be discussed with both your independent financial adviser or portfolio manager, and an accountant, as it may be necessary to take certain steps to ensure this is taxed correctly.
9
Salary sacrifice schemes
Electric cars have been very popular over the last few years, particularly since the benefit-inkind rates on them have been low.
Many doctors will have chosen to make use of the NHS fleet scheme to obtain tax and superannuation relief on the lease payment of an electric car.
As the deduction is made against your pensionable pay, the commencement and cessation of using the NHS fleet scheme has an impact on your pension growth for tax purposes.
When you cease to use the scheme, this can cause a significant increase in growth leading to tax charges, particularly if you have been part of the 1995/2008 pension scheme.
HM Revenue and Customs (HMRC) allows for inflationary increases to your pension pot which is based on the Consumer Price Index (CPI).
There are ongoing consultations taking place surrounding the CPI rates used. The outcomes of the consultations may give rise to planning in respect of the return of an NHS fleet scheme vehicle.
10 Pension savings annual allowance
Many doctors have received the dreaded brown envelopes from NHS Pensions this year showing their growth figures for 2021-22.
If you have not already done so, you should ensure this has been reviewed by a specialist medical accountant to see that you do not have any hidden tax liabilities in relation to your pension savings.
It may be that if you have growth in excess of £40,000, then an amended tax return needs to be submitted on your behalf.
The date for 2020-21 ‘scheme pays’ election applications closes on 31 March 2023. You should ensure that if you have opted for a
It may be that if you have growth in excess of £40,000, then an amended tax return needs to be submitted on your behalf
‘scheme pays’ election for this year, then this has been accepted by NHS Pensions.
You can request confirmation that the election from NHS Pensions has been accepted. Applications made after 31 March 2023 may not be accepted.
The next few months are likely to be extremely busy for doctors, but making time to ensure you are ready for the next tax year could save you a significant amount of tax.
Next month: Make the most of a new opportunity in private practice following Prime Minister Rishi Sunak’s ‘five pledges’, which includes a promise to tackle inflation
Alec James (right) is a partner at Sandison Easson & Co, specialist medical accountants
So what should you do with your records following retirement? Dr Kathryn Leask provides the answer
Keeping records after retirement
Dilemma 1 How long do I retain records?
QI was a consultant orthopaedic surgeon and have had an extensive medico legal practice. But now I have retired from my private practice and have now decided to bring my medicolegal practice to an end, too.
Please could you advise me what my responsibilities are with regards to retention of the records I keep?
AAlthough the records relate to private medico-legal work, for the purposes of record retention, the GMC explains in its Confidentiality (2017) guidance:
‘Paragraph 130: The UK health departments publish guidance on how long health records should be kept and how they should be disposed of. You should follow the guidance, even if you do not work in the NHS.’
In terms of current guidance for the retention of records, NHSX published updated guidance on this topic: Records Management Code of Practice 2020 . The minimum retention periods start at Appendix two on page 50 of the guidance, which is a ‘Health records retention schedule’.
Although the NHSX guidance refers to NHS records, the same minimum retention periods can be applied to private records.
Retain
for ten
years
The guidance advises that litigation records are retained for tenyears. When acting as an expert witness, the instructing solicitor should advise the expert witness when the case has concluded.
It is common for instructing solicitors to ask that the bundle you are sent is destroyed at the end of the case, but, of course, that may mean you are unable to provide a response to a complaint or claim, should one arise later.
These are very much minimum retention periods and you might choose to retain your records for
longer in a particularly serious or contentious case.
Bearing in mind that concerns or allegations can arise many years after the events in question, it can make it much harder to mount an effective defence if there are no existing records; for example, if a claim was made against you.
The retention period for children’s records is much longer: typically to the child’s 25th birthday. There is a slight anomaly for a child who is 17 at the point treatment commences and their records would be kept until their 26th birthday.
Your advantages of retaining records from a medico-legal point of view need to be balanced by the requirements of the General Data Protection Regulation (GDPR) Article 5(1)(e), which says you should not retain records for longer than necessary.
There are also practical implications to consider when retaining medical records. Records should be stored securely to mitigate against breaches of personal data and confidential information.
The GMC also states in its Confidentiality guidance:
‘Paragraph129: You must make sure any other records you are responsible for, including financial, management or human resources records or records relating to complaints, are kept securely and are clear, accurate and up to date.’
The GMC does not define what ‘secure’ is, but a locked metal filing cabinet secured to a wall in a locked room or building is common practice.
Any digitised copies should be stored in accordance with British Standard BS10008:2014. This guarantees the integrity of the records and ensures they meet the requirements of the Civil Evidence Act 1995.
This means that the records could be used as primary evidence to defend a claim against the doctor.
If scanned records are not stored according to this standard, then they can only be adduced as secondary evidence and will carry less weight in court proceedings.
Staying registered at GMC when work stops
A consultant’s retirement throws up another question this month for Dr Kathryn Leask (right) about what indemnity and GMC registration provision they may need
Dilemma 2
Do I require GMC registration?
QI am a consultant cardiologist and have recently retired from my NHS and private practice.
I have continued to do some medicolegal work as an expert, but would now like to bring this to an end.
Can you tell me what to do if I am contacted by a solicitor in relation to a preexisting case or a patient I have seen previously? What indemnity and GMC registration do I need now?
AIn terms of follow-up work, for an MDU member whose work is confined to medico-legal work only, we recognise that they may be asked to clarify the content of a report or be called as a witness to attend court.
Providing they are not adding to, or providing a new view on any previous report, then this would not be considered ‘new’ work.
If you were to engage in any new work, whether that be a slight alteration or change to an existing report, then you would require active MDU membership. You would also require GMC registration and a licence to practise (LTP) and the appropriate indemnity in place.
With regards to having a LTP, you may wish to seek advice from the solicitors’ firm that you take instructions from to establish whether they would expect you –
undertaking your proposed follow up work – to remain registered with the GMC and/or with an LTP. In general terms, some experts who have relinquished their LTP continue to undertake medicolegal work, but there are caveats to this.
Firstly, the correct MDU subscription would still be required and there are limits to the extent of work that can be undertaken.
Limit your practice
MDU members without a LTP would need to limit their practice to reporting on matters of breach of duty and causation relating to another medical professional’s examination, condition, diagnosis or treatment, and/or opinions on clinical or medical issues without reference to an individual patient.
If a member intends to take on medico-legal work that involves providing opinions on current conditions or prognosis, they would need to retain their LTP and retain the appropriate MDU membership.
If you are intending to apply to give up your GMC registration entirely, this would only be an appropriate step once you had ceased all professional activity. The GMC requires an application to be made to give up registration and the full details regarding this process can be found at https:// tinyurl.com/3u8ce3cd.
Doctors can apply to give up their registration up to three months in advance and as part of that process, are required to declare whether they have provided medical services within the last five years.
This is known as a ‘provision of medical services statement’ and accounts for the most recent three months of medical services provided. The statement requires completion by the doctor and any ‘individuals, bodies or organisations to whom you have provided medical services to even if you were self-employed’.
If you intend to apply to give up your GMC registration in the future, then it is important to let the membership team of your defence organisation know so that your records can be updated and reviewed accordingly.
You should keep them updated with regards to the type of work you are doing and your GMC status.
Dr Kathryn Leask is a medico-legal adviser at the Medical Defence Union
DOCTOR ON THE ROAD: MAZDA CX-60
A premium SUV with affordable price tag
Independent Practitioner Today’s motoring correspondent Dr Tony Rimmer (right) gets behind the wheel of a premium SUV that undercuts its rivals by £10-£15k
WE LIVE in a competitive world and, for any business to survive, it needs to be open to new practices and innovations. For car makers, this means looking at market sectors that are new to the brand and then offer their own special attributes as enhancements.
Mazda is a company that is well known for producing cars with sharp dynamics that appeal to keen drivers. The brilliant MX-5 is a class-leading sports car and Mazda’s small hatchbacks and SUVs also share this sporting DNA. So, it seems like a brave move for the Japanese company to move out of its comfort zone and build a premium SUV to compete with the likes of Lexus, Volvo and BMW.
This market sector is all about high quality, versatility and comfort and all the current favourites are plug-in hybrids for optimum economy, which also boosts their green credentials. Can Mazda compete without previous hybridbuilding experience?
On paper, the CX-60 seems to
have everything needed to take up the challenge. The plug-in hybrid powertrain consists of a 150bhp 2.5litre petrol engine and a 173bhp electric motor, which is supplied by a 17.8kWh battery.
This provides a claimed 39 miles of electric-only driving when fully charged. There are three trim levels available and all come with leather seats, alloy wheels and a large 12.3inch driver’s digital display.
My test car was the entry-level Exclusive Line and was not lacking in any of the essentials expected from a car at this premium level.
Smart styling
From the outside, this Mazda is a big car. It hides its bulk with smart styling and you get the usual commanding view from the driver’s seat. Inside, there is plenty of room for five and generous luggage space in the rear.
There is an under-floor area, so charging cables can be stored out of the way. Also, there is even a three-pin plug socket in the boot should you need it.
Passengers should have no problems with head and leg room and the perceived luxury from the quality trim materials and finish is certainly on a level with premium rivals.
The little Mazda MX-5 is one of my favourite cars to satisfy keen drivers, so I took the CX-60 out on a mixture of challenging local roads to see if it could live up to the brand’s reputation.
Well, any car weighing two tons is not going to be sprightly, but this large SUV does pretty well to avoid excessive body roll and has reasonable feedback through the steering.
However, this is no sports car and isn’t as much fun as perhaps
any Mazda should be. The ride is a little harsh over rough surfaces, too, which doesn’t help comfort levels.
Power is adequate and you can’t complain about the performance, but the transition from petrol power to electric and vice versa needs some work to make it smoother and a bit quieter.
Lexus, using all the years of sister brand Toyota’s development of similar systems, is the leader in this field. The CX-60 is Mazda’s first offering with this technology and I am sure that it will catch up given time.
Real-world economy
I fully charged the battery on my home wall-charger and found that the electric driving was hushed and smooth. However, it doesn’t take much extra pressure on the accelerator to wake up the petrol engine, which spoils the economy and quiet progress, but this is an issue with other hybrids I have driven.
As far as real-world economy is concerned, expect about 45mpg, which will improve only if you charge regularly and do lots of short journeys.
The transition from petrol power to electric and vice versa needs some work to make it smoother and quieter
I had my test car during a particularly cold and icy spell and there is one really useful feature that is shared with most plug-in hybrids and all-electric cars.
The Mazda App allows you to remotely pre-heat the car’s interior before you set off, so you jump into a fully defrosted and warm car before you begin your journey – a most welcome accessory for those chilly starts.
Overall, the CX-60 is a fine entry into the premium plug-in hybrid SUV market, but it has some refinement issues that need ironing out. Knowing Mazda, I am sure that this will happen in due course.
Also, the Mazda holds an important trump card. At £43,950, it undercuts its direct rivals by £10k to £15k. That is a significant saving and particularly relevant in these fiscally challenging times.
If you are in the market for a Lexus NX 450h+, a BMW X3, an Audi Q5 or a Volvo XC60 Recharge, then it certainly is worth including the Mazda CX-60 for your consideration.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
CX-60 phev exclusive line
Body: Five-seat SUV, four-wheel drive
Engine: 2.5litre four-cylinder petrol + single electric motor
Power: 150bhp + 173bhp. Total: 323bhp
Torque: 500Nm
Top speed: 124mph
Acceleration: 0-62mph in 5.8 seconds
Claimed economy: Combined – up to 188.3mpg
CO2 emissions: Between 33 and 154g/km
On-the-road price: £43,950
Due to smart styling, you get a commanding view from the driver’s seat. Inside, there is plenty of room for five and generous luggage space in the rear
MAZDA
HERE’S WHAT’S COMING IN OUR MARCH ISSUE
Coming in our March issue, published on 7 March:
The responsibilities of practitioners in dealing with personal data.
Henry Forrester, a solicitor in the corporate and commercial healthcare team of the specialist healthcare firm Hempsons, highlights data protection considerations and presents a toolkit for private doctors
How we did it: King Edward’s VII’s hospital, London – winners of the LaingBuisson hospital of the year award
At the last estimate, the cost of meeting future negligence liabilities for the NHS in England stood at a staggering £128bn, a figure which has increased more than six-fold in the last decade. And it’s bad news for independent practitioners that this means less cash for patient care, warns Dr Michael Devlin, the MDU’s head of professional standards
Getting positive feedback: Marketing expert Catherine Harriss shows what private doctors need to know about getting and using testimonials from patients
The importance of not reacting to market falls. A specialist financial adviser with Cavendish Medical says being an investor is never easy because, as humans, we tend to live in the moment responding to our emotions, the environment around us and the circumstances we find ourselves in...
Demonstrate your skills by becoming a Certified Expert Witness.
Simon Berney-Edwards, chief executive of the Expert Witness Institute. outlines its new certification scheme, why it is important, and how you can apply for the gold standard certification process
INDEPENDENT PRACTITIONER
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A specialist medical accountant has some wise words about collaborating to practice in a group
In the second part of our series on the business cycles of a private practice, Simon Brignall of Civica Medical Billing and Collection looks at growth, maturity and renewal and rebirth or decline
Peter Byloos, chief executive of Optegra, reveals his plans for the company
Problems can arise when transitioning patients between private and public care. Sarah Baggot identifies some of the common issues and explains how risks can be reduced for both the patient and the doctor
Our Troubleshooter Jane Braithwaite spells out ten musts for building and maintaining a successful consultants’ group
A consultant asks for advice after receiving a Subject Access Request (SAR) asking for information about a patient. Our Business Dilemmas series, by Dr Kathryn Leask of the MDU, also answers a consultant cardiologist’s query about whether to remain registered with the GMC after relinquishing his licence to practise.
Our motoring correspondent Dr Tony Rimmer tests the new electric MG4 and finds it an interesting and good-value entrant into the market
What was making the news in private practice a decade ago
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