March 2017

INDEPENDENT PRACTITIONER TODAY

Socking it to head injury

Protecting brains is part of the revolutionary work of The Concussion Clinic P26

‘Calamity’ looms for defence fees

By Robin Stride

The future of potentially thousands of consultants and GPs in private practice is under threat from an imminent shock rise in indemnity costs.

Defence subscriptions will go up dramatically due to Lord Chancellor Liz Truss changing the controversial formula courts use to adjust large compensation payments to take account of future investment returns.

Some reports have estimated the ‘discount rate’ switch, effective initially in England and Wales, could see some multi ­ million pound damages bills rocketing by 30%50%.

Private doctors’ new premiums were being assessed by indemnity providers as we went to press.

The industry hopes the fall­out will be a catalyst to introduce longawaited personal injury law reforms it has been urging to combat spiralling claims. Another lifeline could be a ‘discount rate’ revamp.

In a joint statement, Chancellor Philip Hammond and Association of British Insurers boss Huw Evans said: ‘The Government will progress urgently with a consultation on the framework for setting future rates, and bring forward any necessary legislation at an early stage.’

But this will come too late for many doctors awaiting quotes for their next annual defence subscription.

The Medical Defence Union (MDU) warned lowering the discount rate from 2.5% to ­ 0.75% would mean ‘a dramatic increase’

in the cost of indemnifying members.

It warned compensation award costs would go up immediately for known claims and also those arising from future incidents.

And it will apply retrospectively to claims for past negligent incidents where no claim has yet been made but will be at some future date.

Chief executive Dr Christine Tomkins said: ‘We need a longterm solution to the inflation­busting rises we are seeing in clinical negligence compensation payments. Personal injury law needs root and branch reform.

‘The impact on our members and the provision of healthcare is calamitous and a solution is needed urgently.’

➱ continued on page 9

CAP THAT! Consultant surgeons celebrated the 25th anniversary of the newly refurbished Knee Unit at HCA’s The Wellington Hospital, London, with model and former patient Jodie Kidd. From left: Mr Howard Ware, Mr Sam Oussedik, Mr Chinmay Gupte, Mr David Sweetnam, Mr Matthew Bartlett and Mr Rahul Patel. Full story next month

Doctors lag behind law on patient consent

‘Surprising numbers’ of independent practitioners are putting themselves at risk because they have not caught up with new duties for obtaining consent to treatment.

Solicitor Paul Sankey said doctors across the specialties seemed to have missed a law change two years ago.

The landmark Montgomery v Lanarkshire Health Board case redefined the legal doctor­patient relationship and placed a higher obligation on specialists to warn of treatment risks.

But Foot Anstey LLP partner Mr Sankey said: ‘Many seem to know little or nothing of the change. The continued use of standardised consent forms suggests practice has not sufficiently changed.

‘Standard forms are unlikely to record the sort of patient­centred advice and discussion the law expects.’

He warned: ‘Failing to comply with their legal duty means not only that doctors are failing their patients but are putting themselves at risk.

‘They can face months or years of anxiety over legal claims and having to look to their insurers to pay substantial damages. The award of damages in Montgomery v Lanarkshire Health Board was £5.25m.’ n Questions answered: page 12

did you know consent law has altered? a lawyer explains how doctors’ behaviour has to change after a leading law case P12

How we launched a subsidiary brand a clinic boss relates his experience of launching and publicising a venture P16

get brand protection

Legal experts show how to protect your brand with intellectual property law P21

make the most of your free time a good work-life balance can actually boost your career. But how’s it done? P24

create an income surge how to raise money quickly from your patients in an ethical fashion P32

Shedding light on perplexing pensions our regular accountant explains the changes to the way pensions are taxed P38

Paying the price of gilt

Doctors in private practice are set to take an unexpected extra hit on their already fast-escalating defence fees. Unlike NHS GPs, they won’t be cushioned.

Spiralling costs in recent years, coupled with constantly rising indemnity bills, have already made it impossible for some to practise.

Some have pulled out, while others have hastened their retire ment. Others have decided not to start.

Now the fall-out from the Lord Chancellor’s re-assessment of the discount rate (see page 1) is set to stir up a hornet’s nest as private doctors

begin to receive notice of their next indemnity bill.

Cue more retirements, expansion of groups and more private salaried service options.

Of course, claimants should get what they are entitled to in order to support their future needs.

But it is important the payout process is fair. Urgent reform of personal injury law has been required for years and now needs tackling alongside the payout system.

The discount rate relates to a three-year average of real returns on index-linked gilts – so bad they are not a logical home for victims’ payouts anyway.

tell US yoUr newS Editorial director Robin Stride at robin@ip-today.co.uk

New ISA rules help to soften pension cuts

By leslie Berry

Senior doctors should make the most of higher annual ISA allowances to combat a myriad of Government restrictions on their pensions’ savings in recent years, according to specialist financial planners Cavendish Medical.

Big cuts to once generous lifetime and annual allowance limits have caused significant headaches to independent practitioners looking to secure their own retirement.

And the new ‘tapered’ version of the annual allowance – the total amount their pension can increase by each year while still attracting income tax relief –means high-earning doctors could have an annual allowance of just £10,000.

Pension savings above individual allowances can also be subject to taxes of between 45% and 55%.

Now, with the ISA allowance rising in April from £15,240 to £20,000, doctors facing harsh tax penalties for overfunding pensions have an attractive option. The rise in the allowance is the largest in recent times and allows a family to shelter £40,000 a year from future taxation.

Cavendish Medical managing director Simon Bruce explained: ‘ISAs are particularly tax-efficient for higher-rate and additional rate taxpayers. Funds grow free from income tax and are not subject to capital gains tax on disposal.

inflation at 2.5%, could amass a total of £393,150 if 3% growth a year was achieved after costs. This equates to £239,317 in today’s terms or £480,134 at 5% annual growth after costs – worth around £293,011 in today’s terms.

If a spouse or partner’s allowances are consistently taken up, this figure doubles.

Mr Bruce added: ‘Having built up significant ISA pots, the savers could draw down on these taxfree, under present legislation, and enjoy an additional retirement income to the NHS pension.

‘It is particularly important not to let old investment ISAs languish unloved in a drawer at home. Older ISAs have higher charges and may reflect investment fashions of years gone by. Make sure these are reviewed and retained if still relevant or replaced if no longer suitable.

‘If considering a cash ISA, it is important to look at the detail –watch out for short-term bonus interest rates, limits on withdrawals and transfer penalties. And check your historical ISAs – it is quite possible that a cash ISA from a few years back is no longer attracting much interest at all.’

And he pointed out the cut in the Bank of England base rate to 0.25% has meant that cash ISA interest rates remain depressed.

Phone: 07909 997340 @robinstride

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Head of design: Jonathan Anstee chief sub-editor: Vincent Dawe Circulation figures verified by the Audit Bureau of Circulations

‘While there is the usual rush to use your ISA allowance before the end of the financial year, arranging your contributions should be part of a well-considered financial plan rather than an eleventhhour concern.’

Cavendish Medical figures show a saver maximising their individual investment ISA allowance annually for the next 20 years, allowing for

Cavendish Medical also warned savers to note the interest rate cuts being introduced in April across the whole range of doctorpopular National Savings & Investments products.

From May, NS&I will cut the premium bond prize fund it pays out each month by about £5m.

 For more information on how the Budget could affect you, visit our website www.independentpractitioner-today.co.uk  See page 38

Admin costs surge after CMA ruling

Consultants in the higher earnings bracket have been shocked to find their annual bill for room hire and secretarial services has come in as high as £40,000.

Professional business advisers say the expense is a direct result of the Competition and Markets Auth ority (CMA) ruling which put a stop to consultants receiving discounts for these services from private hospitals.

Last year’s accounts and latest tax bills have brought home to many doctors the true cost of running their private practice.

Independent Practitioner Today columnist Ray Stanbridge, of Stanbridge Associates, revealed the £40,000 rise in administrative costs which he said were as much as a third of some private consultants’ earnings.

He reported the rising costs were leading many consultants to investigate more cost-effective ways of running their practice.

Thomas Acworth, chief executive of PHF Services, an agency that looks after consultants’ private practices, said he anticipated a boom in the outsource secretarial services market.

He told Independent Practitioner Today :‘Consultants have been shocked to see how much they have been paying. Many consultants have found themselves paying anything up to 20-35% of their income on room hire and secretarial services, depending, of course, on their specialty.

‘But they could often cut their costs by 25% by outsourcing secretarial services. The CMA has provided an opportunity for this.

‘Private hospital groups have, in the past, been protecting consultants from paying and even knowing about the true costs.

‘Times are changing and technology is playing a huge part in maximising efficiency and cutting costs. The rise of private practice agencies is a sign of the changing market place consultants are now working in.’

 See Ray Stanbridge’s latest Profits Focus, page 49

By robin Stride

Consultants and Independent Practitioner Today have won their campaign to halt NHS England plans to force them to reveal private practice earnings.

They had labelled the proposals, issued last Autumn, pointless, unworkable and ludicrous.

We warned the idea did not add up, calling it ‘bonkers’ – and all the leading consultants’ bodies joined in the criticism.

Now NHS England has had a rethink, although concerns remain about possible attempts by trusts to control consultants’ activities.

A Federation of Independent Practitioners Organisation spokesman said it welcomed the fact that in the recent document Managing Conflicts of Interest in the NHS the original proposal for publication of private practice earnings by NHS consultants has been dropped.

‘This would have been of no benefit to the patients nor would it have provided any added or useful information on potential conflicts of interest,’ the spokesman added.

The document did not deviate from the current consultant NHS contractual situation in relation to

private practice apart from the fact NHS England was now stating that clinical staff should ‘seek prior approval of their organisation before taking up private practice’.

He continued: ‘This would appear to be a new condition, which, on the face of it, would seem to provide NHS trusts’ with the power to control a consultant’s activity in his/her free time.

‘If this is the intention, FIPO would strongly oppose this intrusion into the long-established rights of clinicians. Again, there is absolutely no benefit for patients and this might be yet another incentive for consultants to leave the NHS. This matter will need further clarification.’

Independent Doctors Federation specialists committee chairman

Dr Brian O’Connor said: ‘Provided doctors fulfil their contractual duties in the NHS, it really should not be the concern of the NHS as to the doctor’s non-NHS medical activities’.

Hospital Consultants and Specialists Association chief executive Eddie Saville said: ‘We’re pleased to see these guidelines adopting a common-sense approach towards private work following concerns raised by HCSA.

‘Many of our members were concerned at the disparity between the extreme level of detail expected of doctors in the original proposals compared to other parts of the NHS, where there are arguably far greater potential for conflicts of interest.

‘We have always felt that private work is fully covered by the terms of the 2003 Consultant Contract, which is clear on doctors’ responsibilities with regards the NHS and private sector.’

Fee publication dates extended Plans to reveal income ditched

Consultants have won more time to publish their fees following a Competition and Markets Authority (CMA) decision to extend its earlier timetable.

Under the new deadlines, from 31 December 2017 they must send pre-consultation letters outlining the fees and conditions to all patients considering treatment.

Further letters outlining fees for any additional tests, investigations or treatment must be sent out by 28 February 2018.

By 31 December 2018, consultants must regularly give the Private Healthcare Information Network (PHIN) information on their outpatient consultation fees (fixed fee or hourly rate) and their standard procedure fee for the 50 most frequent procedures, where applicable.

PHIN will be expected to publish consultants’ fees on its website by 30 April 2019.

It said the extension gave hospitals, consultants and itself suffi -

cient time to work together and ensure publication was both ‘fair and insightful for patients’.

While the explicit obligation falls on consultants, hospitals are required to maintain an audit of this process, it said.

PHIN chief executive Matt James welcomed the extension for publishing treatment fees.

He said: ‘Publishing prices for medical services is a complex undertaking, especially where it relates to insured patients.’

How we reported in october on nHS england’s plan to force consultants to reveal their earnings

By Edie Bourne

The head of the UK’s private hospitals trade body has called on the Government and employers to be more creative about the healthcare options available.

Employers should be willing to embrace and incentivise greater use of private medical insurance, says Fiona Booth, chief executive of the Association of Independent Healthcare Organisations (AIHO). Ms Booth was speaking as the

body published its response to the Government’s work, health and disability green paper Improving Lives.

She said the association backed the paper’s aims and the Government’s recognition of the positive impact that timely access to healthcare could have for employees, employers and the wider economy through increased workforce productivity.

‘The independent healthcare sector has a crucial role to play in

WHAT NEEdS To BE doNE To HElP

 Government and employers must be more creative about healthcare options available and embrace and incentivise more use of private medical insurance

 Government should encourage the public to use health insurance more effectively. A reformed and incentivised private medical insurance (PMI) market could support the NHS to manage demand and boost innovation,

ensuring patients have swift access to innovative treatment and care that enables them to return to work sooner.

‘Together with the Government, we can enable patients to access treatment through health insurance, and at independent hospitals or NHS private patient units, helping to reduce the everincreasing demand placed on NHS services.’

Ms Booth believed there was clear scope for an expanded role

efficiency and productivity by giving employees quicker access to care

 Policymakers should develop mechanisms to encourage people with PMI to use it, such as a more formalised GP referral system plus greater education for patients, GPs and support staff on PMI and the individual’s right to choose their provider

 The Government should consider specific

for the independent healthcare sector in supporting the work and health agenda.

She said AIHO looked forward to working with the Government, particularly with its Joint Health and Work Unit set up last Autumn, to help bring about reforms needed to create a healthy, productive workforce.

139 million sick days were taken in 2015 and the direct cost to businesses of sickness absence has been estimated at £9bn annually.

SEcTor TAkE THE STrAIN off THE NHS

incentives for small to medium-sized enterprises in particular to bring in PMI.

 The independent healthcare sector and Government must demonstrate to employers the returns gained by investing in workplace health

 Employers should be incentivised to make improvements in health and well-being through implementing workplace initiatives.

Call to use private care IT help for anaesthetists

Growth in bad online reviews harm doctors

Doctors’ stress levels are rising as they fall victim to a rise in patients using online ratings sites to give them negative reviews.

Medico ­ legal advisers have assisted a steady stream of doctors in the last year who have phoned up for help after becoming concerned about critical comments made by patients in online reviews.

The Medical Defence Union (MDU) has now issued advice for doctors distressed by negative online ratings.

It said this was a growing area although the number of doctors affected in the UK were small. But US research showed that over three­quarters of doctors are now being stressed by worries about online criticism.

The Harvard Medical School study, surveying 828 doctors and 494 patients from four hospitals across Massachusetts, found:  78% of doctors thought the pos­

sibility of bad online comments added to the stress of their job;

 46% said online rating websites could harm the doctor ­ patient relationship.

The MDU said options for dealing with criticism online include:

 Responding positively to the comment – asking the person to get in touch directly to raise concerns, while respecting patient confidentiality;

 Complaining to the website and/or asking for the offending information to be removed;

 Using the ‘right to be forgotten online’ to remove the page from search results.

But the MDU’s Dr Ellie Mein added: ‘You must not overlook patient confidentiality when engaging with unhappy patients via social media. Responding to critical comments or attempting to have them removed can be counterproductive and add fuel to the fire.’

Anaesthetists are being promised benefits from a new company just added to the portfolio of healthcare, technology and services company Clanwilliam Group.

Medical Business Systems (MBS), producers of practice management software for anaesthetists in Australia, said it was working on a system uniquely customised and focused on an

anaesthetists’ requirements in the UK and Ireland.

The company said it and the Group shared a common focus on delivering innovative services and software.

MBS’s three Platinum products for billing, diary and in ­ theatre are used by more than 1,000 anaesthetists to support their private practices.

Rise in alternative lending

Many small businesses are unaware of the forms of finance available to them as an alternative to high street banks, according to a survey.

High street banks are the first port of call for 39% of small to medium enterprises who are looking for additional funding, according to a survey by Close Brothers Asset Finance.

Chief executive Neil Davies said: ‘While high street banks are still understandably a popular choice for

many, there has been a strong rise in the role of alternative finance.’ Asset finance for new businesses grew for the sixth consecutive year last year, according to the Finance and Leasing Association.

Mr Davies said: ‘What we’re hearing from business owners is that one of the biggest appeals of asset finance is its flexibility and the fact it gives them access to the equipment they need without the cash flow disadvantage of buying it.’

Inspectors rate clinic outstanding

A consultant vascular surgeon’s entrepreneurial private clinic has received an ‘outstanding’ rating from the Care Quality Commission (CQC).

The watchdog said The Whiteley Clinic, Guildford, Surrey, founded by Prof Mark Whiteley, ( right ) deserved the accolade for:

 Inspirational leadership – the clinic’s culture was one of striving to provide the best quality care for patients with varicose veins, venous leg ulcers, venous eczema and phlebitis;

 Developing and researching its own clinical guidelines and protocols and sharing these with the national and international medical community;

 Competent staff who were supported to develop their skills further and taught others nationally and internationally. The clinic was involved in and continued to promote research into the management of venous conditions;

 Developing and promoting a charity for patients with venous leg ulcers and supportive fundraising.

Stiffer fines for clinics who fail to protect patient data

New data protection law coming into force in the UK in May 2018 will strengthen the information watchdog’s powers to fine errant companies.

The Information Commissioner’s Office (ICO) warned that fines of up to 4% of a company’s global turnover could be issued by it for a serious breach of data protection legislation.

Healthcare companies are already subject to hefty penalties and only last month one was fined £200,000 after audio recordings of

doctors’ outpatient letters due to be transcribed by a third party in India were found to be accessible online.

A spokesman for HCA’s Lister Fertility Clinic said it had apologised to the seven patients affected for any distress caused and it no longer worked with the company involved.

‘We take the protection of our patients’ confidential and sensitive information extremely seriously. However, on this occasion, we fell short of both the standards

of the ICO and the high standards we set for ourselves.’

He added that the clinic had put in place more rigorous checks and measures to ensure patients’ information remained safe.

The ICO discovered the Indian firm could not restrict access to the personal information because it stored audio files and transcripts using an unsecure server.

But it said the hospital group breached the Data Protection Act 1998 by failing to ensure its subcontractor acted responsibly.

Unit addresses its bad rating

England’s Chief Inspector of Hospitals has told BMI Healthcare it must improve patient safety at BMI Fawkham Manor Hospital in Dartford, Kent, which received an overall ‘inadequate’ rating after inspections last year.

The 30­bed hospital, with seven consulting rooms, was rated:

 ‘Inadequate’ for being safe and well led;

 ‘Required improvement’ for being effective and responsive;

 ‘Good’ for caring.

Responding on its website, the two­theatre hospital said patient care and safety was its absolute priority.

It stated that while disappointed with the inspectors’ findings, the hospital was pleased that the CQC also saw evidence of the staff’s commitment and their compassionate care.

It said it was working on a detailed action plan addressing all concerns raised by the CQC and that the commission had been

supportive of the prompt action taken and had placed no restrictions on the hospital.

The hospital’s management team had been ‘strengthened’ and it had spent over £0.25m on theatre enhancements.

More investment would address primary concerns about the Grade II listed building’s fabric.

It added: ‘We have invited the inspectors back and are confident that the improvements we are making will be evident.’

IVF patients look abroad

By olive carterton

Nearly 60% of more than 51,000 patients seeking fertility in the last year in the UK made inquiries for overseas clinics.

According to private healthcare search engine WhatClinic.com, the top five medical tourism hotspots for Brits seeking IVF treatment abroad were Spain, the Czech Republic, Turkey, Ireland and Greece – and prices range significantly.

It said the average price for IVF in the Czech Republic is £821, while in Spain it costs £3,360, on average.

WhatClinic’s Philip Boyle said: ‘Medical tour­

ism can often be driven by cost­conscious consumers. However, for some treatments, especially fertility, patients will travel further and pay more to find the very best, most experienced clinics.

‘Cost is very much balanced with expertise and number of successful outcomes in key treatments like IVF.’

The number­one fertility treatment in 2016 was intra ­ uterine insemination (IUI), with 7,459 patients who visited the site seeking it in the UK in the past 12 months.

The treatment cost £877, on average, in the UK.

In vitro fertilisation (IVF) came in as the sec­

ond most in ­ demand treatment and has an average price tag of £2,300. There were 5,562 visits to the clinic comparison site for this procedure across UK clinics in 2016.

At number three, fertility tests saw an increase of 7% in inquiries in the past six months and cost £310 on average.

Egg donation and egg freezing round up the top five treatments, at fourth and fifth spots on the list, with 2,659 and 2,898 patients searching on WhatClinic.com respectively.

Artificial insemination, at number six, saw the biggest overall increase in inquiries, up 46% in just the past six months, with an average price tag of £1,817.

Video consultation a hit with doctors

By charles King

Patients are being offered £24 oneoff appointments with GPs using a video portal from a new entrant into the UK telemedicine arena.

VideoDoc has been operating in Ireland since 2014, where it says its telemedicine consultation service is now used by half of the country’s GP practices.

Co-founder Mary O’Brien said it was initially assumed doctor applicants would be young and tech-savvy.

But 70% of doctors who applied to be on the company’s list were easing out of their own private practices.

They wanted to semi-retire or were working-mums trying to work around a busy childcare schedule.

She said: ‘One applicant told me the reason he liked the concept so

much was because it wouldn’t interfere with his midweek round of golf on a Wednesday afternoon.

‘However, what did become apparent was that older or more experienced GPs are simply much more confident in their own abilities and are able to diagnose someone through what they see or what the patient told them about their symptoms, rather than having to poke, prod or probe.’

The service is being targeted particularly at employed patients who might otherwise take time off work to see a doctor.

VideoDoc told Independent Practitioner Today it offered ‘a competitive package and lifestyle flexibility to doctors, who are able to see as many patients as they like in their own time, whether from the comfort of their consulting

room or their sitting room at home’.

It said: ‘Before the video consultation, patients fill out a form providing all of their local GP’s details and their own personal medical history.

‘While the consultation is taking place, the doctor is able to make a full record of what has taken place and been discussed –including recommendations for further investigation or referral –and will email, at the patient’s consent, over to their doctor.

‘If the patient doesn’t wish to share the medical notes made in the consultation, then they are stored on the VideoDoc app to be accessed at any time.’

The company hopes its technology will be bought and adopted by larger groups of healthcare providers such as consultants wanting to see more patients or

VideoDoc’s co-founder Mary o’Brien said the service was proving a boon to doctor mums trying to work round a busy childcare schedule

help others avoid having to travel for appointments.

Its UK service, running daily from 8am-10pm, allows users to consult with a GP face-to-face online via its website or on an app.

Corporate clients are being quoted £15 per employee for an annual subscription of unlimited GP appointments.

Doctors warned to keep registration active

Busy doctors are putting themselves at risk by mistakenly allowing their professional registration to lapse.

The problem is evidently getting worse, judging by a rise in the number of doctors who have been ringing their defence body for help after realising they have a problem.

But the MDDUS revealed lapsed doctors were nothing new. A spokesman said: ‘It is a recurring problem which affects a significant number of practitioners and practices.’

Doctors are also ringing up for advice after finding staff members, particularly nurses, have lapsed their registration too.

Forgetfulness is not always at the route of the problem. Many fees are now paid automatically and people may not routinely check that each one is up to date

with their current banking details.

The MDDUS said moving house was a common factor in these cases. It warned: ‘Members may neglect to provide a change of address when updating professional details for registration.

‘Professional bodies send out reminders, but if they go to the wrong address, they have no effect.

‘Use of electronic communication is not fool-proof either. If an email address is changed and your regulator is not informed, the same problem can occur.’

Illness occurring when registration is due can also lead to registration fees being overlooked, the union said.

And when the oversight is discovered, this can then compound their illness, especially if it is stress-related.

The MDDUS said doctors being

unusually busy, either at work or home, may also lead to a failure to keep on top of registration fees.

Doctors who have overlooked paying their fees can go through an administrative process to reregister, but this also takes time.

But, in some cases, the GMC may call the doctor to a hearing if the lapse has been long or inadequately explained.

Doctors are being advised to have a system in place to ensure necessary subscriptions with professional regulators and defence organisations are in place, for them and relevant staff.

The GMC and The Nursing and Midwifery Council (NMC) websites provide secure online portals where registrants can manage their registrations, pay fees, set up direct debits and update personal information.

The MDDUS warned that the

NMC now had a process where lapsed registration results in removal from the register.

‘A nurse must then go through a process of re-admission which can take up to six weeks. The disruption this can cause speaks for itself.’

action points

 check your current registration status and those of any employees now

 Update your regulator with any change of address, contact or banking details

 practices should have a robust system in place for keeping track of the registration status of all professional employees

Innovators reap rewards

By a staff reporter

Doctors and staff have been praised for their contribution to earning HCA’s London Bridge Hospital an outstanding rating by national regulators, the Care Quality Commission (CQC).

The rating was shared across the 124-bed, six-theatre hospital at London Bridge and centres at The Shard, 31 Old Broad Street and 120 Old Broad Street.

CQC inspectors found several examples of outstanding practice, including:

 An ‘excellent’ network of multidisciplinary teams (11 in total), including cardiac, breast, renal and gastro-intenstinal, bringing together teams including consultants, nurses, physiotherapists, nutritionists, oncology specialists and others to discuss the best way to treat a patient;

 A team of consultants who ensured they were available for their own patients as well as on an on-call basis;

 No waiting times for patients to be seen in a clinic or admitted to the hospital if a procedure was required;

 Highly-trained Resident Medical Officers with expertise in the specialist area they worked in;

 Across London Bridge Hospital, the CQC found staff that were ‘highly motivated individuals who aimed to deliver the highest quality care’.

The CQC remarked that it saw ‘innovative practice throughout the hospital, including new research taking place in operating

theatres, new infection prevention and control practices and safer medicines management through use of an electronic key system’.

The critical care unit was praised for active involvement ‘in national research programmes which resulted in developing innovative and new ways of working and improving standards of care for patients’.

The hospital was also found to have the latest equipment and facilities. This includes a hybrid catheterisation laboratory enabling consultants to image any part of the body that can be used when they perform complex medical procedures.

Janene Madden, chief executive of London Bridge Hospital, said the outstanding result reflected the high-quality and compassion-

the London Bridge Hospital with the shard behind

ate patient care delivered throughout the hospital. She said: ‘I am extremely proud of our dedicated team of doctors and staff who commit every day to going above and beyond.

‘It is great to see that the CQC has recognised London Bridge Hospital’s commitment to innovation. Whether this is through new technologies and state-ofthe-art facilities, contributions to national research or developing new ways of working, this is central in our drive to continually raise standards and improve care for patients.’

She paid tribute to John Reay, now president of operations at HCA UK, for the ‘outstanding’ leadership he gave during his tenure at London Bridge Hospital, which, she said, undoubtedly played a huge part in this achievement.

new centre to open soon at GUy’s

London Bridge Hospital will shortly open the latest development of its campus – London Bridge Hospital-private care at Guy’s.

the hospital in the top four floors of the new Guy’s cancer centre has been purpose-built to offer surgery and treatment in gynaecology, urology, breast, maxillo-facial and head and neck surgery, as well as reconstructive surgery.

CQC deputy chief inspector of hospitals Ellen Armistead said: ‘Leadership at both a local and senior level was visible and staff were overwhelmingly positive about the support they received from their managers.

‘They felt that they could raise issues in a timely manner and their concerns would be listened to and acted upon.

‘Staff were encouraged and motivated to take part in learning opportunities provided by the hospital. Learning included master’s degrees, specialist training in renal, intensive care and cardiac conditions.’

Ms Armistead praised several areas of outstanding practice which the inspectors noted at the hospital, including the electronic key for use when obtaining and dispensing medication.

This made medicines management safer, allowing staff to see which of them had accessed medicines cupboards, and reduced delays in patients receiving their medications.

CQC officials looked across the broad range of services offered at the hospital from the most complex care right through to outpatient and imaging services.

Core services reviewed were medical care, surgery, critical care, and outpatients, diagnostics and imaging.

London Bridge Hospital cares for patients across a range of specialties including cardiac care, liver treatment, gynaecology, oncology, neurology, orthopaedics and physiotherapy.

BMA meeting offers help for private doctors

Business tips and support are being offered to current and would-be private doctors at a special BMA event next month.

The association’s private practice conference on 5 April aims to help established independent practitioners maximise their business potential and guide new entrants on key issues to be aware of.

Those starting out will be able to network with experienced colleagues and there are parallel sessions for established specialists and those just starting in private practice or planning to set up.

Speakers include BMA private practice committee chairman Mr Derek Machin, Mr William Laing of LaingBuisson, speaking on the

state of private practice, and private GP Dr Ian Cole.

Dr Andrew Vallance-Owen, of Private Healthcare Information Network (PHIN), will advise on how to best engage with the body and will assess the workload implications.

Medico-legal adviser Dr Helen Hartley, of Medical Protection, will

discuss medical indemnity, barriers and risks in private practice.

Registration starts from 9.30am at BMA House, Tavistock Square, London, and a drinks reception from 4.30pm-6pm will offer informal networking.

Full programme and booking: www.bma.org.uk/privatepracticeconference

Cosmetic op drop is ‘not all bad news’

By a staff reporter

Business has not been so good for many plastic surgeons in the last year – but according to a prominent specialist, this could be seen as a good thing.

The income fall came as the number of Britons undergoing cosmetic surgery in 2016 dropped to the lowest in nearly a decade.

According to the British Association of Aesthetic Plastic Surgeons (BAAPS), a climate of global unrest and ‘bad news overload’ left patients prioritising stability and comfort over big life changes.

The association, representing the vast majority of NHS­trained consultant plastic surgeons in private practice, revealed the number of cosmetic operations last year fell 40% since reaching recordbreaking heights in 2015.

Following years of relatively consistent growth, cosmetic surgical procedure totals for women and men combined dipped below 31,000 – with 2016’s totals 5% down on those in 2007.

BAAPS president Mr Simon Withey said the downturn could be seen as positive because the public was being more thoughtful about the serious impact of surgical procedures.

He said: ‘The 2016 BAAPS audit demonstrates that, at the very least, patients seem to be getting the message that cosmetic surgery is not a “quick fix” but a serious commitment and are, as a result, carefully evaluating risks as well as benefits surgery may offer.

‘If it means people are taking their time to be truly sure a procedure is the right investment for them, then this can only be a good thing.’

Male procedure numbers were fewer than in 2005 (2,440 in 2005, 2,409 in 2016), but while men’s

ops were 48% less than the previous year, they still accounted for the same proportion of all patients, roughly 1% of the total number, as they have done historically.

Former BAAPS president Mr Rajiv Grover, who compiled the audit, said: ‘In a climate of global fragility, the public are less likely to spend on significant alterations and become more fiscally conservative; by and large, opting for less costly non­surgical procedures such as chemical peels and microdermabrasion, rather than committing to more permanent changes.

‘The background of negative news and economic uncertainty seems to have re­invigorated the famous British ‘stiff upper lip’ –achieved, however, through dermal fillers and wrinkle ­ relaxing injections, rather than surgery.’

Abdominoplasty surgery stayed popular for both genders, increasing to 6th place in 2016 from 8th place in 2015.

Despite nearly 50% fewer men undergoing surgery than in 2015, BAAPS saw a 47% increase in male abdominoplasty surgery.

It said this could possibly be attributed to the fact that there is no adequate non­surgical option for the removal of excess skin.

Women’s cosmetic surgery dropped 39% from 2015, and while breast augmentation continues to remain the most popular procedure for women, with almost 8,000 undergoing surgery, overall numbers sagged by 20%.

Many surgeons reported that the oversized styles of the past have made way for smaller sizes, resulting in more natural enhancement.

Anecdotally, it is non ­ surgical treatment such as facial injectables that have remained on a steady rise.

figures in full

men and women comBined

The top surgical procedures for men and women in 2016 (total 30,750 –a fall of 39.9% from 2015).

in order of populariTy:

 Breast augmentation 7,769 – down 20% from previous year

–

–

– down 14%

– down 56%

 otoplasty 987 – down 9%

 Browlift 607 – down 71%

women only

The top surgical procedures for women in 2016 (28,341 total – a fall of 39.1% from 2015). women had 92% of all cosmetic procedures in 2015.

in order of populariTy:

 Breast augmentation: 7,732 – down 20% from previous year

 Blepharoplasty (eyelid surgery) 3,584 – down 55%

 Breast reduction: 3,566 – down 38%

 face/neck lift 3,328 – down 53%

 liposuction 2,879 – down 42%

 abdominoplasty: 2,591 – down 6%

 rhinoplasty 2,174 – down 14%

 fat transfer 1,359 – down 56%

 otoplasty (ear correction) 566 – down 9%

 Brow lifts 562 – down 71%

men only

The top surgical procedures for men in 2016 (2,409 total – a fall of 47.8% from 2015). men had 8% of all cosmetic procedures in 2016.

in order of populariTy:

 rhinoplasty 529 – down 35% from previous year

 otoplasty (ear correction) 421 – down 19%

 liposuction 339 – down 42%

 Blepharoplasty (eyelid surgery) 321 – down 67%

 Breast reduction: 320 – down 59%

 abdominoplasty 172 – up 47%

 face/neck lift 125 – down 66%

 fat transfer 100 – down 61%

 Brow lifts 45 – down 72%

 Breast augmentation: 37 – static

Conflicts set to rise over car licences

By leslie Berry

Doctors could increasingly be thrown into conflict with patients as the population gets older and patients seek to hang on to their car driving licences.

Medical defence experts believe more doctors may encounter difficulties and face having to breach patient confidentiality as a result.

New GMC guidance, highlighted in Independent Practitioner Today last month, gives doctors updated guidance on a range of confidentiality issues and DVLA disclosures are one of the big topics.

The new guidance, which comes into effect from 25 April, provides enhanced guidance for doctors on how to deal with such patients.

No doctor wants to find themselves in the position of having to act against their patient’s wishes and breach their confidentiality.

But there are situations where information may have to be disclosed in order to protect the public interest, even when consent has been refused by the patient.

One such scenario is when a patient has a medical condition that may compromise their fitness to drive, yet they continue to do so against their doctor’s advice.

Dr Barry Parker, a medical adviser at the defence body MDDUS, said the union had

encountered cases where patients disagreed with the advice of their doctor and considered they were still competent to drive.

And some seek to cope with the condition by offering to restrict driving in some way.

But he warned that with some patients willing to accept any risk to themselves in driving, the risk inevitably extends to other members of the public.

‘Doctors may find themselves in the difficult position of having to act against their patient’s wishes and to breach their confidentiality in such circumstances.

‘The decision on whether or not a patient may drive with a temporary or permanent medical condition or treatment is a matter of clinical judgement, bearing in mind the detailed guidance provided by the DVLA and the new GMC guidance.’

Some conditions, such as a

clearly documented loss of visual acuity, may be relatively straightforward. But Dr Parker said others, such as alcohol misuse or fainting episodes, might be more difficult to assess.

So it was important to record as precisely as possible the history provided and any examination findings, together with the reasons for the decision on fitness to drive.

He advised: ‘If a patient continues to drive when they may not be fit to do so, then every reasonable effort should be made to persuade them to stop. Discussing the matter with relatives, friends or carers could be helpful, but only if the patient consents to this approach.

‘Should all attempts fail to persuade the patient to stop driving, or the doctor discovers that the patient is continuing to drive against advice and poses a safety risk to the public, then this should be disclosed to a medical adviser at the DVLA.

‘This should be done in confidence and include all relevant medical information that relates to the patient’s fitness to drive.’

Dr Parker said before taking this step it was important that the doctor tried to inform the patient of the decision to disclose personal information to the DVLA and perhaps further discuss the matter.

Big hikes in defence subs likely

➱ continued from front page

At the Medical Protection Society, chief executive Simon Kayll also expressed extreme concern at such a significant cut in the discount rate.

He said: ‘This decision will increase the cost of settling future loss claims against our members at a time when the cost of clinical negligence is already at a worryingly high level.

‘This increase in costs will need to be reflected in subscription

rates, and we know this will be very troubling news for our members. We will determine what this means for them as a matter of urgency.’

He added: ‘The need for a package of legal reforms to tackle the spiralling cost of clinical negligence is becoming ever more pressing.’

The Medical and Dental Defence Union of Scotland warned bigger pay ­ outs would also lead to

System for reviewing deaths is ‘good as NHS’

Private hospitals’ processes into investigating and reviewing patients’ deaths have been highlighted following a CQC report exploring the way NHS trusts handle such events in England.

The Association of Independent Healthcare Organisations (AIHO) said the independent sector has robust and comparable processes to investigate and learn from adverse events and is subject to the same requirements to report ‘never events’, serious incidents and deaths to the CQC.

Commenting on the CQC report entitled Learning, Candour and Accountability, AIHO said:

 The independent sector is required to report patient deaths to coroners in accordance with coroners’ guidance and each hospital must respond to coroner reports on preventing future deaths.

 Each hospital reports on unexplained deaths through their clinical governance structure, often with the support of their Medical Advisory Committee;

 The independent sector participates in the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

 The sector has been working with the National Reporting and Learning System to enable it to report incidents the same way that NHS hospitals do. A pilot is nearing completion and this work will begin to roll out across the sector.

significant new costs for the NHS.

Chief executive Chris Kenny said everybody agreed medical accident victims should be properly and promptly compensated. But the increase in claims awarded showed this was already happening.

Radical proposals for a better system for setting the rate were needed without delay and should be brought in rapidly with timetabled proposals to address the wider issue of tort reform.

leT us know your sTory

share your experience of what has and has not worked in your private practice. even if it’s bad news, let us know and we can spread the word to prevent other independent practitioners falling into the same pitfalls. contact editorial director robin stride at robin@ip-today.co.uk

dr Barry parker: adviser at the mddus

You can now prove cosmetic expertise

By Mr Stephen Cannon Vice-president

of the Royal College of Surgeons and chairman of the Cosmetic Surgery Interspecialty Committee

Once viewed as the domain of only Hollywood ‘A’-listers and the celebrities adorning Britain’s glossy magazines, cosmetic surgery is now a booming industry in the UK.

i n 2015, more than 51,000 Britons took the decision to have cosmetic surgery and this number is expected to increase in the future. with sophisticated and expensive advertising campaigns promising the world, it’s not hard to see why so many are enticed to go ‘under the knife’.

Unfortunately, alongside these glossy adverts, horror stories of ‘cosmetic surgery gone wrong’ also abound in the media.

The vast majority of surgeons performing cosmetic surgery in the private sector are meeting the highest standards of patient care, but we need to make sure this is the case in every hospital and clinic around the country.

Problems within the cosmetic surgery industry exist for a variety

of reasons. The law currently allows any doctor – surgeon or otherwise – to perform cosmetic surgery in the private sector.

c osmetic surgery is not a defined surgical specialty and, historically, there have not been common standards available to the surgeons who perform it.

There are also concerns about ‘fly-in fly-out’ doctors, who regularly visit the UK to offer cheap treatments before going back to their home countries.

inadequate indemnity very often, these doctors will not have adequate indemnity insurance and the distance will make it difficult for patients to track them down should the patient be unhappy with the outcome of their surgery or suffer complications.

it’s vital the public and employers are able to distinguish highly qualified, experienced individuals from those who are working without adequate insurance nor the necessary specialist training.

For this reason, the Royal college of Surgeons (R c S) has just launched a new system of certification for doctors who perform cosmetic surgery.

Surgeons will be able to certify in one or more groups of closely related procedures. it is envisaged that the scheme will make the cosmetic surgery industry safer for patients and enhance the reputation of the profession.

The RcS is urging all surgeons who perform cosmetic surgery procedures to apply for certification.

To receive cosmetic surgery certification, surgeons will have to prove that they have the necessary clinical and professional

Independent Practitioner

Today reported last month on the launch of the royal college’s scheme (right)

skills required to provide such surgery.

They will also be required to attend an RcS accredited professional behaviours masterclass.

Professional and ethical aspects of practice – including the relationship with the patient – are the most common reasons for unsatisfactory outcomes in cosmetic surgery.

Therefore, demonstration of knowledge and skills in this area is an integral part of the certification process. Later this year, the RcS will launch an online portal which will allow patients to search for certified surgeons in their areas.

c ertification marks the next stage in work by the R c S and specialty associations to improve patient care and safety for cosmetic surgery following Sir Bruce

Keogh’s 2013 review of the regulation of cosmetic interventions.

The review followed the ‘P i P i mplant Scare’ in which around 300,000 woman across e urope were thought that have received implants made from an unauthorised silicone filler, which had double the rupture rate of other implants.

no protection

At the time, Keogh found that cosmetic surgery procedures, despite having potential major and irreversible impacts on a patient’s wellbeing, were largely unregulated. He wrote that ‘a person having a nonsurgical cosmetic intervention has no more protection and redress than someone buying a ballpoint pen or a toothbrush.’

The review set out three key

areas for the industry to improve on, including:

 High-quality care with safe products and skilled practitioners;

 An empowered public informed of the pros and cons of cosmetic surgery;

 Accessible redress and resolution in case things go wrong. i n response, the Government tasked the RcS with setting up a c osmetic Surgery i nterspecialty c ommittee ( c S ic ) to make cosmetic surgery safer for patients.

The committee, made up of representatives from varying relevant specialty associations and professional associations and societies, has helped to set standards for the training and practice of cosmetic surgery, develop patient information and support the launch of the RcS’s certification system. ensuring those who are considering cosmetic surgery can access authoritative and independent information is vital to improving

By certifying with the RCS, surgeons will demonstrate their expertise, reassure their patients and play their part in raising standards in cosmetic surgery

the reputation of the industry and patient safety.

That is why, in October last year, the R c S launched online patient resources urging people to ‘think carefully before cosmetic surgery’. The resource offers advice on how to choose the right surgeon and hospital, as well as explaining the risks of undergoing surgery and possible complications to consider.

The web pages include a section on questions to ask a surgeon before an operation, a downloadable check list, and three short animation films.

with a clear set of common standards now available, a big step has been taken in helping improve patient safety for cosmetic surgery procedures.

By certifying with the RcS, surgeons will demonstrate their expertise, reassure their patients and play their part in raising standards in cosmetic surgery.

Consent to treatment

So, did you know the law has changed?

In March 2015, the case of Montgomery v Lanarkshire Health Board [2015] UKSC 11 redefined the legal relationship between doctors and patients.

Many doctors were concerned at its implications. Some feared it placed too high an obligation on them in warning patients of the risks of treatment. Others thought the decision simply brought the law into line with current practice. Two years on, we asked solicitor Paul Sankey to review its impact

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call:

What was the decision about?

Mrs Nadine Montgomery gave birth to her first child, Sam, in October 1999 at a hospital in Lanarkshire.

There were three factors that increased the risk of injury to both mother and child at delivery:

 She was diabetic;

 She was also short, at around five foot tall;

 Her baby was known to be large – estimated (and, in fact, underestimated) at 3.8 kilos.

The risk of shoulder dystocia was around 9­10%, much higher than average. Shoulder dystocia increased the risks of injury to her.

For instance, there was a risk of postpartum haemorrhage of 11% and of a fourth ­ degree perineal tear of 3.8%.

The risk of a brachial plexus injury to the baby was 0.2% and a 0.1% risk of prolonged hypoxia causing cerebral palsy or death.

She was a highly intelligent woman. She had a degree in molecular biology and was capable of understanding these risks.

Mrs Montgomery’s obstetrician did not advise her of these risks or invite her to consider a caesarean section. Her reasoning was that, while the risk of shoulder dystocia was high, the risk of serious injury was so small.

In the obstetrician’s words: ‘If you were to mention shoulder dystocia to every [diabetic] patient, if you were to mention to any mother who faces labour that

there is a very small risk of the baby dying in labour, then everyone would ask for a caesarean section, and it’s not in the maternal interests for women to have caesarean sections.’

This rather revealing comment highlighted the key issue in the case: was it for the doctor to decide what was in the maternal interests or for the mother herself?

Unfortunately, the risk of shoulder dystocia materialised. The baby suffered prolonged hypoxia and was born with severe disabilities.

Mrs Montgomery sought damages against the health board responsible for her management.

THE NEW LAW SAYS: ‘The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments’

She alleged that she had been inadequately advised, not given informed consent to vaginal delivery and would have elected for caesarean section had she known of the risks.

In the lower court and on appeal, her claim failed. However, the Supreme Court found in her favour. It held that the failure to warn of the risks of vaginal delivery was negligent and that, with adequate advice, she would have elected for a caesarean.

How did the law change?

Until Montgomery, the courts applied the ‘Bolam test’ to a doctor’s duty to advise – following the case of Bolam v Friern Hospital

Was it for the doctor to decide what was in the maternal interests or for the mother herself?

Management Committee [1957] 1 WLR 582.

That test is whether a doctor acted in accordance with a practice accepted as proper by a responsible body of medical practitioners skilled in that particular art.

The test recognises that there are different schools of thought and different practices within the medical profession. The courts will not sit in judgment over different approaches provided they are rightly accepted as ‘responsible’, ‘reasonable’ or ‘respectable’ and capable of logical analysis (Bolitho v City and Hackney Health Authority [1997] 4 All ER 771).

The Bolam test had been applied

not just to diagnosis and treatment but to advice. It let the medical profession set the standard of what advice was acceptable. So long as a responsible body of similar doctors would have given the same advice, that advice was acceptable.

Mrs Montgomery’s claim failed in the lower courts because there was a responsible body of obstetricians who would not have warned of shoulder dystocia or invited her to consider caesarean section.

The Supreme Court rejected the Bolam test’s application to a doctor’s duty to advise. But it still applies to diagnosis and treatment.

The new test focuses on what a

particular patient would want to know rather than what doctors in general would normally advise. It replaced a clinician ­ centred test with a patient­centred one.

What is my duty?

The Supreme Court set out what might be regarded as two principles.

The first is that an adult of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo, and her consent must be obtained before treatment. There is nothing particularly new here. It is for doctors to advise and patients to decide.

The second is more significant and sets out the nature of the duty to advise. This is where the law has changed. The wording is complex but it is worth quoting in full:

‘The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.

‘The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.’

In short, the duty is to make sure a patient knows the material risks of the recommended treatment. It is then to make sure a patient can consider alternatives and knows the risks of those alternatives.

It is not enough, therefore, only to discuss the treatment a doctor recommends. Patient autonomy entails understanding the options and being able to make a choice.

How do I know what is ‘material’?

The duty is to advise patients of material risks. This begs the question as to what is material. The starting point is that advice is specific to the particular patient.

The Supreme Court’s definition starts by referring to : ‘…the circumstances of the particular case’. The same standardised advice will not do for all patients. The risks may in percentage terms be the

same, but advice must be tailored to the individual.

The wording goes on to consider whether ‘a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.’

There are two parts to this

The first is where ‘a reasonable person in the patient’s position would be likely to attach significance to the risk’.

At first sight, this seems convoluted. The key is again to consider the patient as an individual rather than as one of a group. What is material to one patient may not be material to another.

Consider two patients undergoing knee surgery. One may be elderly and in a wheelchair because of hip dysfunction. The other may be young and playing professional football.

Clearly, the potential risks and benefits of surgery will be very different to each. The benefits of successful treatment are much greater to the one than the other, although so are the risks.

The two could be considered at opposite ends of a spectrum and the example is perhaps rather extreme. However, consider two patients with no particular risk factors considering whether to deliver vaginally or by caesarean section.

One has experienced the grief of her sister­in­law’s stillbirth following complications of a vaginal delivery. She is therefore very aware not only of what can go wrong but the impact of it.

She is anxious about the risk even though it is remote. The other is less worried. She regards these risks as something that happens to other people and the risk to her seems small.

The first woman is much more likely to attach significance to the risks of vaginal delivery than the second. In fact, this issue arose in one of the cases decided in the wake of Montgomery.

However, note that the test is not that this particular patient would be likely to attach significance to the risk, but that a reasonable person in the patient’s position would do so.

The new test focuses on what a particular patient would want to know rather than what doctors in general would normally advise

What seems like a complicating qualification, probably removes a degree of subjectivity. People are complex. There comes a point at which doctors cannot be expected to understand the idiosyncrasies of a particular patient. The test is therefore qualified to introduce an element of reasonableness into the equation.

The second part of the definition is where a doctor is or should reasonably be aware that a particular patient would attach significance to the risk.

This covers a patient who has told their doctor about particular concerns or those concerns have been recorded in the medical records. They may be unusual. They may be unreasonable. But they are important to the patient and the doctor knows about them.

The key is understanding the particular patient and being able to have a tailored discussion. You can only know what is material to a patient by spending enough time with them and engaging in dialogue with them.

Dialogue should reveal what is important to them. This might concern their work, leisure, family circumstances, interests or anxieties.

In private practice, this may be easier than in the NHS, where time is more constrained. The reaction of many is that this is precisely what they have been doing. Certainly, the Supreme Court thought that what it was doing was to bring the law into line with existing practice.

Do I have to advise of every risk, however small?

The duty is to advise of material risks. What is material cannot be reduced to a matter of percentages. The Supreme Court pointed out that the significance of a risk is likely to reflect factors other than its size.

These may include the nature of the risk, the effect its occurrence would have on the life of a patient, the importance to the patient of the benefits sought to be achieved by treatment, alternatives available and the risks of those alternatives.

The risk of shoulder dystocia in Montgomery was 9­10%. The risk of serious hypoxia was 0.1%.

It is not enough only to discuss the treatment a doctor recommends. Patient autonomy entails understanding the options and being able to make a choice

Interestingly, in two subsequent cases, the courts have said that a risk of 0.1% was too low to be material when the risk was, as in Montgomery, serious hypoxia during delivery.

In A v East Kent Hospitals NHS Foundation Trust [2015] EWHC, a risk of 1:1,000 was described as ‘theoretical, negligible or background’.

In Tasmin v Bart’s Health NHS Trust [2015] EWHC 3135, the judge, perhaps mindful of the Supreme Court’s comments in Montgomery, preferred to formulate it as being ‘too low to be material’.

Those decisions may be regarded as a step back from Montgomery. However, they do not necessarily mean that the courts will take the same view in every case.

There may be people for whom a 0.1% risk of serious injury is a material risk because of their particular circumstances. An example is the woman in labour whose relative had a stillborn baby.

Is there a risk of giving too much information?

A patient needs to be able to make an informed decision. To do so, she will need to understand the seriousness of her condition, the anticipated benefits and risks of treatment and of any alternative treatments.

The decision will only be informed if she can understand the advice. Blinding a patient with science or providing so much information that she cannot take it in isn’t helpful. As the Supreme Court said: ‘The doctor’s duty is not…fulfilled by bombarding the patient with technical information she cannot reasonably be expected to grasp…’

So there is a risk of providing too much information. How much a patient will need to know – and is capable of grasping – will vary from person to person.

should I still use consent forms?

A consent form alone is unlikely to provide evidence of the sort of process the Supreme Court considers necessary.

It is unlikely to record the rationale for one form of treatment as opposed to another and may be geared towards generic

risks rather than material ones. It is also unlikely to provide evidence that a patient has understood the significance of a risk.

For instance, ‘nerve injury – 1%’ gives no indication of the severity of injury or its impact on a patient.

A 1% risk of numbness is quite a different matter to a 1% risk of permanent intrusive pain.

It is much better to record not just advice but the fact of discussion in either a clinical record or a letter. The record should set out not just the advice given but also the patient’s concerns, priorities and reasons for agreeing a particular treatment.

What should my advice cover?

This depends on the condition, the nature of treatment and the patient’s concerns. However, the Royal College of Surgeons has recently produced useful guidance in line with Montgomery.

The check list comprises:

 Diagnosis;

 Prognosis;

 Options – including no treatment;

 Purpose and benefits of treatment;

 Prospects of success;

 Potential follow­up treatment;

 Material risks of the various options;

 Advice on lifestyle that may moderate the disease process;

 The clinicians involved in treatment;

 The costs and potential future costs of treatment – for private patients.

There are other guidelines. For instance, the Association of Anaesthetists of Great Britain and Ireland has recently produced new guidelines. Interestingly, the Royal College of Obstetricians and Gynaecologists has not.*

What if I think my patient is making the wrong decision?

Provided the decision is within a range of reasonable decisions, your patient has understood the issues and you are prepared to give the treatment, then the ultimate decision is your patient’s.

As the Supreme Court said: ‘An adult person of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo…’

What about patients without capacity?

The decision in Montgomery applies to patients who have capacity. However, similar principles will apply to advice given to people making decisions on behalf of patients without capacity.

are there any exceptions?

The Supreme Court identified three exceptions, but said they were to be treated with caution:

1. The patient who does not want to know;

2. The therapeutic exception –where disclosure may be seriously detrimental to the patient’s health;

3. Necessity – for example, the unconscious patient.

are we at greater risk of claims?

The decided cases raising issues of consent since Montgomery suggest probably not.

It is not obvious the decisions would have been different under the old law. More than half the cases concern birth injuries and it may well be that obstetrics will be the area of medicine most affected by the decision in Montgomery. Cases based on consent remain very difficult for claimants. They have the burden not just of proving that the advice they were given was inadequate, but that, putting aside hindsight, with different advice they would have made a different decision. In many cases, that is a difficult task. 

Paul Sankey (right) is a partner at solicitors Foot Anstey LLP, Bristol

✱ Consent is an area that the RCOG is addressing at the moment. Its document, Obtaining Valid Consent, was published two months before the Montgomery ruling.

The college says pregnancy and childbirth represent significant consent challenges, but if a doctor provides all options regarding treatments proposed – including no treatment, documents these discussions, obtains consent as per the GMC’s Good Medical Practice (2013) , and takes into account our document, Obtaining Valid Consent, then consent will be valid.

An RCOG spokesman said the college had begun a project to enhance and update its information tools to further aid patients to make decisions and to document that they have been fully involved in their decision-making.

‘After much internal discussion, we have realised that to get this right in women’s health, and especially maternity, this involves much more than re-doing our consent documents – it’s all about the communication with our patients,’ the spokesman added.

‘As part of this process, we will be involving our Women’s Network to get their input.’

pRomoTing A nEw SERvicE

How we launched a subsidiary brand

London Medical’s chief operating officer

David Briggs describes his experiences to date in marketing its diabetes practice under a new identity, focusing on its expert consultants

David Briggs (left) and London Medical’s founder, Dr Ralph Abraham at the launch

A key strand of our strategy is to raise the profile of our most important asset, our consultants

I re C en TLy HAD the opportunity to launch our diabetes practice under its own identity – The London Diabetes Centre (LDC).

The launch marked a major milestone in our 25-year history. In a sense, it was also a case of coming full circle – a return to the original vision of our founder Dr ralph Abraham.

His vision was to bring together a select group of specialists with related expertise under one roof to provide joined-up thinking on patient care in a place where these specialist consultants could thrive.

Having it both ways

London Medical is first and foremost a multidisciplinary outpatient clinic with a wide range of different specialist areas such as ophthalmology and cardiology that are vitally important to us.

In launching a sub-brand for diabetes, there is the combined ‘defensive’ challenge of not losing the positioning of our key offer ing in our marketing, not confus ing existing patients, and equally not alienating existing consult ants operating outside the field of diabetes.

But the truth is, by raising awareness of The LDC, everyone wins. Firstly, it enables our con sultants to both practise in their chosen fields, such as cardiology or ophthalmology, and partici pate in the upside of an estab lished and expanding workflow in diabetes, the area of special interest for many of them.

Secondly, by remaining an inte gral part of London Medical, the new venture benefits from ready access to the myriad expertise of the wider group, making for a symbiotic set-up – all in one con venient location.

How do we bring this story to market? More specifically, how do we increase visibility for The LDC’s team of consultants who are the core of its proposition?

Six wAyS To SUppoRT ExpERT poSiTioning

1

Start with the clinic’s new brand identity

Personally, I have spent too much time attempting to define brands; that is, trying to pin down the key attributes that differentiate one clinic or service from another.

It is very easy to tie yourself in knots and spend lots of money on branding agencies to reflect what you probably already know.

Having said that, it is important to have the answer to the brand question, as this will be a crucial starting point for selling the idea to all your stakeholders. In our case, this is our staff, our consultants and our patients.

One good way of approaching this was to ask our patients why they kept coming back to the clinic.

This will give a quick, clear indication of what other people – who also happen to be your most important audience group – think is your point of difference.

Be open to surprises. It may be different to what you first thought.

For us, it became clear that what makes The LDC unique is its deep interconnectivity between the various specialties within a single

2Apply the principles of thought leadership marketing

As London Medical has been around for 25 years and has succeeded mainly on word of mouth and by attracting consultants at the top of their clinical field, we have never really invested significantly in marketing before.

But when it came to marketing a brand new sub-brand, this required more of a deliberate strategy.

A key strand of our strategy is to raise the profile of our most important asset, our consultants. Many of them are leading specialists who publish research and books regularly and whom we are lucky to have. If we can use both social media and professional platforms to allow our consultants to lead the agenda and conversation in their respective fields, both they and The LDC will benefit. We have invested in media

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of The London Diabetes Centre

training for our consultants and promoted them to the media so that they can be called upon to provide expert commentary, which would then be inserted into the news cycle.

3

Turn traffic into leads using digital and social media

e xtending the presence of The LDC started with creating a new website that is user-friendly for patients, easy to navigate, branded to the new identity and, most crucially, featured our consultant profiles prominently.

Other steps you should take to boost your online marketing are:

 Take the time for search-engine optimisation. your site should be thoroughly optimised to appear high up – the first page or two, as users rarely click-through past the third – in search engine results in order to generate traffic.

 Invest in digital advertising –pay-per-click or PPC. We spent a small amount of money on this, to last until our organic search gathered momentum.

 The analytics are gold. We track website activity to ensure that we are moving in the right direction and that we are promoting what people are actually interested in.

The object of social networking is to build awareness, relationships and, ultimately, referrals. Currently, The LDC’s social media channels include Twitter and LinkedIn. At this early stage, we are using the London Medical Facebook page to promote The LDC.

Will this result in more patients? I don’t know, but I do know that more people are seeing

us, which we expect to result in more referrals, but it is certainly a long game that we are in. I expect that, in the future, for word of mouth, read social media.

But we are not there yet and our patients still come to us, in the main, through personal, face-toface recommendation.

4

Have a content strategy

It’s easy to forget that digital and social media is only a means to an end. To drive a truly integrated online presence, you need a content strategy that would help project the consultants’ voice.

At its most practical level, content is the updated information you are able to publish online. Search engines promote websites with the most ‘relevant’ and current content above others, so this is an ongoing job.

Make no mistake, it is a significant challenge, as, ideally, you would like original content – this includes re-tweeting other people’s content or stories promoting them rather than you – and we actively elicit this from our consultants.

It has really been a case of engaging consultants with a view to capturing their thinking. I have found the best approach is to sit down with them and interview them.

This often yields gems we can expand into an article, a thought piece or use as a shorter but timely blog post commenting on a development in their field. On the whole, consultants will not have time to craft pithy content every week, so you need to do it for them.

5

in a multichannel world, ‘traditional’ still matters I think we made early mistakes in thinking that marketing meant digital when, in fact, there needs to be a mix, and the right blend is determined by who your target audience is.

It is worth making sure you know the answer to this question early on in the journey.

In my experience, our patients rely on word of mouth and certain on print media, of which newspapers still figure. And their preferred method of communication is the telephone rather than online.

We have learnt to be mindful of the need to nurture the audience we already have, as differentiated from those we are trying to reach; and to resist the temptation to over-invest in online techniques and forget the marketing mix.

Medical care remains deeply personal and what the majority of our patients value is personal service, fast access and someone on the end of the phone line when they call.

6

Ditto for offline engagement platforms

Where we have enjoyed considerable success in positioning our experts is in our events for patients. We held a patient-targeted ‘Insights Day’ as part of The LDC’s launch activities in October and again in January.

e ach event was attended by around 50 patients and prospective patients, who got to attend information sessions led by our consultants, met them face to face afterwards and asked questions, heard other patients’ stories and experienced the latest technology available in diabetes management.

We had a great response and gained new patients from this platform, which is now a regular activity for us.

I invite you to think of marketing as a revenue centre, even if our accountants treat it as an expense.

r educing marketing often reduces business and revenue. A properly designed and executed marketing plan with expert positioning as a key component will put you on the path to the return on investment you seek. 

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Get brand protection

A business’s brand and the goodwill associated with it are valuable assets worthy of protection. This is as true for a business offering healthcare services as it is for any high-street seller of goods.

This is because building up a brand and reputation takes a substantial investment of time, effort and resources. But how can a practice protect its hard-earned intellectual property?

Gill Hall and Nabil Asaad (pictured below) discuss the key intellectual property rights

that are relevant to an independent practice and advise how best to protect your hard-earned brand

INTELLECTUAL PROPERTY covers a range of rights, some that apply automatically and some requiring registration for a fee. Some obvious examples are brand names and logos – for example, ‘CocaCola’ or the Nike ‘Swoosh’.

Protecting a brand name or logo as a registered trade mark gives a monopoly right to use that trade mark throughout the territory(ies) covered by the registration in respect of the goods/services for which the mark is registered.

So, if someone else wishes to use your trademark in those territories and for those goods or services, then they will need your consent. Businesses will often protect their key brands as registered trade marks, since these give strong protection for a relatively small financial outlay.

‘passing off’

Goodwill in a business is protected in the UK by the law of ‘passing off’. Other countries may have similar passing off laws or may alternatively afford similar protection under the law of unfair competition.

Broadly speaking, passing off is intended to prohibit a third party from taking unfair advantage of another business’s reputation; for example, by claiming that it is associated with a business of good repute when, in fact, it is not.

Protection against passing off is available without the need for any formal registration. But the consequence of the lack of registration is that a business will need to be able to prove that it has goodwill and that the other party has made a misrepresentation that damaged its business.

Bringing a passing off claim can therefore be difficult, time-consuming and expensive. But if the aggrieved business also has a registered trade mark that has been infringed by the outside party, then taking action under trade mark law is usually more straightforward.

➲So here is our first key message: Protect your practice goodwill by registering your brands as trademarks.

protecting confidence Confidential information and ‘trade secrets’ can be protected by a duty of confidentiality.

This duty can be imposed under a contract, such as a non-disclosure agreement or by what is known as ‘an equitable duty of confidence’.

The latter does not require a formal contract or registration, but only attaches to information which the law regards as having

‘the necessary quality of confidence’.

Classes of confidential information that might be highly valuable to your business could include:

 Business know-how and ways of working, particularly those which give you the edge over your competitors;

 Inventions and technical specifications that are not protected by other rights such as a patent;

 Lists of clients and potential clients that include information about those individuals’ requirements or when they might require your services in the future.

Personal data and sensitive personal data, such as patient records, belong to the individual whose data it is.

These are subject to protection under the Data Protection Act, so should not properly be regarded as an asset of the business.

That said, information provided

by clients and which the practice is legitimately entitled to retain for its own use could form part of the practice’s confidential information.

Also, if time and effort has been expended to include such information in a database for business use, then the database itself might be subject to legal protection.

Even if a non-disclosure agreement is in place, the other party might be careless or might intentionally misuse the confidential information and, once your confidential information enters the public domain, there may be very little that you can do about it.

You should also take practical steps to ensure that access to confidential information is only given to those who genuinely need such access.

All employment contracts and contracts with third-party providers should include appropriate confidentiality provisions.

➲The golden rule and our second key message is: Do not let confidential information leave the business unless absolutely necessary

copyright protection

Practice literature, promotional materials, software and website content will usually be subject to copyright protection. Where such materials have been produced by employees in the course of their duties, then copyright will automatically vest in the employer.

Where such materials are commissioned from outside parties such as graphic designers or website designers, then copyright will belong to the outside party –for instance, the designer – unless it is formally assigned to you, even if they have been paid in full for their work.

➲ So here is another key message: Ensure that you secure the future ownership of

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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.

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any commissioned content at the time the outside party is commissioned . If this is not addressed, then the third party could be free to sell the same materials to others, including to your competitors.

Due diligence

It is a good idea to undertake some basic due diligence on any outside parties whom you commission to prepare materials for you. If a designer copies materials from others or incorporates, for example, a stock photograph or clip art in the materials without the proper usage rights, then you could find yourself liable to the rights’ holder for infringement of those rights and then having to attempt to claim your losses back from the party you commissioned.

A website domain name itself cuts across a number of the above rights. Attempting to register a domain name that includes a

third party’s registered trade mark can lead to a dispute.

Ultimately, the third party could secure control of the domain or perhaps make a complaint that leads to the domain being put out of action for a period of time while the dispute is on-going.

Conversely, owning a trade mark does not automatically entitle the trade mark owner to regis-

ter that trade mark as an internet domain. In particular, if a third party already holds the registration, then it is not automatically obliged to transfer it to the trade mark owner.

➲Our final key message is this: Select a brand name which is not already in use or registered by a third party in the territories in which you will operate or for the domain name(s) you wish to secure

You can then register the domain name(s) and trade mark at the same time, having done as much as possible to avoid a third party claiming that the registrations infringe their rights.

Some basic internet searching followed by an early ‘freedom to operate’ search from a professional service provider and registration without delay can prevent a costly and time-consuming dispute at a later date.

If you develop new products,

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then these may be protectable as patents – for new inventions – or as designs, which protect the ‘look and feel’ of the product. These are worth considering in more detail, since the licensing of such rights might open up additional revenue streams from a much wider customer base than the immediate client base of your practice.

Intellectual property rights can be highly valuable business assets. Formulating strategies at the earliest possible stage for their protection and exploitation can put you on the right path to avoiding costly pitfalls and gaining the best commercial position in respect of your hard-earned IP. 

Gill Hall is a partner and Nabil Asaad a solicitor at Hempsons Solicitors. Gill Hall: Phone: 0191 230 6056. Email: g.hall@hempsons.co.uk Nabil Asaad: Phone: 01423 724102. Email: n.asaad@hempsons.co.uk

Kay,

Moneypenny

Receptionist.

Making the most of your free time

A good work-life balance can actually boost your career and well-being. But how do you set about achieving it? Jane Braithwaite gives some advice on taking time out

Last month, I wrote about time management and how to utilise time more efficiently.

We need to do this to achieve our ultimate goal: creating ‘quality time’ for ourselves, for enhanced enjoyment of life.

h appiness is described as a mental or emotional state of wellbeing, defined by positive or pleasant emotions; these range from contentment to intense joy. When was the last time you felt pure joy?

Creating a good work/life balance is to create a balance between work, career, and ambition. t his includes considering

our lifestyle, health, pleasure and leisure, family, and spiritual development. that’s what I will focus on here.

While researching the statistics of the general UK population relating to work/life balance, I found some interesting information from the o rganisation for Economic Co-operation and Development (oECD).

Quality of life

t he o ECD was created in 1961 and represents 35 countries. It helps governments design better policies for better lives for their citizens and produces a bi-annual

How indEpEndEnt practitionErs can crEatE quality

timE and makE tHE most of it

 Define quality time for you personally. i believe it should consist of several activities that appeal to you specifically. it should ideally include exercise in the fresh air, free time and time spent socialising with friends and family.

 Structure your free time. are you happier at your job or during your spare time? research has shown that many people feel happier at work. one explanation for this is that leisure time without structure can feel boring. the secret to this is to plan. arrange an activity in advance for sunday afternoon. waking up on a sunday morning with nothing planned sounds dreamy, but can actually feel uncomfortable and tedious.

 Free time. Having made the point about structuring your time, it’s also important to allow yourself some free time. time to have a nap, watch tV and lounge around. this type of free time allows you to relax in an entirely different way.

 Family and friends. take stock of who your favourite people are and make a conscious effort to meet up with them. arrange to participate in activities together. what do you all enjoy? whether theatre, music, parties, or champagne – plan to indulge in these activities together.

 Exercise is important for all of us, but it can be hard to stick to a routine – unless we find something enjoyable. physical activity can sound exhausting, but it’s very energising, particularly if taken in the fresh air. Get together with family or friends for a long walk or cycle ride. if you really want to work on your fitness, but have little time, investigate Hit training. short bursts of exercise can be squeezed in at the start or end of the working day, or even in in your lunch break. look at www.thelibrarygym.com for those who need a personal trainer to motivate them. the good news is the training sessions are only 15 minutes long.

 Hobbies. allocate time to indulge your passions and hobbies. if you have let these go over the years, try to revitalise previous interests, or perhaps start afresh with something new. if you love the idea of playing a musical instrument, take a look at ‘Get playing’ on the BBc music website. they have created a virtual orchestra of 1,200 people of varying musical ability, playing every type of music. it’s fabulous.

 Your Inspiration folder. create two folders, one physical and one online. file cuttings from magazines and newspapers of appealing activities. store reviews of enticing restaurants and seductive holidays. spend some time occasionally glancing through these ideas and investigate further. if you spot something interesting while you’re out and about, take a quick photo to remind you to follow up later.

 Reflect. look back on your favourite holidays, days out and activities over the last few months. which ones do you remember with pleasure? make a mental note to repeat these or investigate similar activities. then plan them for the future.

Exercise is important for all of us, but it can be hard to stick to a routine –unless we find something enjoyable

report called the Better Life index, which reports on each member country’s performance against issues that shape the quality of our lives.

the report is based on 11 topics that the o ECD has identified as essential to well-being in terms of material living conditions (housing, income, jobs), and quality of life (community, education, environment, governance, health, life satisfaction, safety, and work-life balance).

If you visit the oECD website, you can create your own profile based on the conditions that are most important to you.

If work-life balance is your top priority, based on the 2015 report criteria, you should head to the netherlands. the UK scores well on safety and health, but less well on work-life balance.

t he phrase ‘work-life balance’ was first implemented widely in the UK in the 1970s and, in 2017, is still widely recognised as an ideal we all strive for. m any people report feeling stuck on the treadmill of working life, feeling trapped, getting little exercise, and following a poor diet.

If this is the case for so many of us, how do we break the trend? the key seems to be to prioritise quality time for ourselves. on the left, I have compiled my top tips on how independent practitioners can create quality time and make the most of it. 

Jane Braithwaite (right) is managing director of Designated Medical

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pRivATE spoRTs sERvicE

Socking it to head

Protecting brains is the business of The Concussion Clinic at The Manchester Institute of Health and Performance, operated by HCA Healthcare. Mr John Leach (right) describes the unit’s revolutionary work

The managemen T of head injury in sport is undergoing a revolution.

Previously, a knock to the head may have been shrugged off or even glorified. These days, there is increasing recognition that concussion is a form of traumatic brain injury that can have significant implications for a player or athlete.

Specialist medical assessment for prolonged concussion symptoms or multiple concussion episodes has historically been somewhat disorganised.

The Concussion Clinic at The manchester Institute of health and Performance brings together a multidisciplinary team of experts who provide structured assessment of amateur and professional players with concussion injuries from a wide variety of sports.

The service consists of two consultant neurosurgeons – myself and mr hiren Patel – and a sports and exercise medicine consultant Dr John Rogers.

Collectively, we believe that the best way to manage and rehabilitate a concussion is through an individualised treatment plan based on the patient’s specific needs and goals for recovery.

concussion in sport

The incidence of concussion is highest in horse racing and contact sports such as rugby and boxing.

Precise figures vary, but the occurrence of concussion is increasing, probably due to heightened awareness of the importance of appropriate management of concussion symptoms.

Increasing player size, speed and therefore force of impact have also been cited as possible areas of concern for increased concussion episodes.

The 2014­15 Professional Rugby Injury Surveillance Report for the e nglish Rugby Union Premiership reports that concussion was the most common match injury for the fourth year running, affecting 17% of players last season, and that concussion episodes have more than doubled recently – 54 episodes in 2012­13 versus 110 in 2014­15.

International guidelines on recognition and management of concussion have been published: The Zurich Consensus Statement of Concussion in Sport 2012. The Rugby Football Union and League have invested in education regarding concussion recognition (‘Don’t be a headcase’) and management (‘Recognise, Remove, Recover, Return’).

Being ‘concussion aware’, removal from field of play, sideline head injury assessment ( h I a ), physical and cognitive rest and ‘graded return to play’ have all now entered the fabric of rugby life.

For professional players, baseline Cogsport and SCaT­ 3 concussion assessment protocols assess and record acute symptoms and provide some measures of physical, emotional and cognitive well­being.

symptoms

Common concussion signs such as headache, dizziness, foggy thinking and visual disturbance usually resolve within two to

three days. Research on cognitive impairment suggests that deficits usually resolve slightly slower than symptoms, over a time period of three to seven days.

approximately 85% of athletes are able to successfully return to full training around one week following injury.

Successful concussion education programmes mean that professional clubs are now confident to manage simple concussion effectively without specialist advice. But what about the remaining 15%?

Some athletes experience prolonged symptoms following a concussion or suffer multiple concussion episodes and it is these injuries that The Concussion Clinic seeks to address.

some facts we know:

 Players who suffer multiple concussions within one season are more likely than their peers to suffer further concussions in the next season;

 Prolonged symptoms require a prolonged period of physical and cognitive rest;

 Repeat concussion episodes are likely to result in more severe symptoms, particularly if they occur in quick succession;

 a small minority of athletes exposed to repeated head injury may experience early cognitive decline later in life.

This condition – chronic traumatic encephalopathy (CTe) – is a specific tau­protein­mediated neuro ­ cognitive disorder that was first recognised in boxers in the 1920s, but is now recognised

to be associated with repetitive brain injury of any kind.

The discovery of CT e in US national Football League players has been highlighted in Will Smith’s recent film Concussion. although rare, the severe implications for quality and length of life have made CTe a current hot topic in sports­related concussion.

For every known fact on concussion there are at least as many unanswered questions:

 Does the current six ­ day ‘graded Return To Play’ protocol adequately protect athletes from further injury?

 When is it safe for an athlete to return to play after resolution of prolonged (>1 week) concussion symptoms?

 Why do some athletes seem more vulnerable to concussion than others? Individual brain factors, physicality, technique and training may play a role.

 Which athletes suffering concussion are most at risk of late cognitive decline?

head injury

 a re there cognitive assessments which may highlight potential concerns early enough to protect an athlete from the onset of later permanent cognitive problems?

The concussion clinic

A t The Concussion Clinic, we enter into a partnership with our athletes. We educate them about current medical evidence and the limitations of existing research presently available on concussion in sport.

With their agreement, we are building up a database of clinical, neuropsychological and eye movement data to enable longitudinal assessment and help answer some of the questions posed above.

Our patients include players from rugby’s Super League, aviva Premiership, g uinness Pro12, soccer’s Premier League and Champion ship, professional and amateur boxers, taekwondo as well as social athletes.

We are currently the only private concussion service to offer

patients the Saccadometer test which measures rapid eye movements called saccades.

Saccadic latency is not subject to voluntary control and is measured in milliseconds, allowing a direct assessment of frontal eye field brain function.

In acute injury, saccadic latency can vary from baseline and then be seen to return to normal during recovery. These measurements can provide further reassurance about clinical recovery from concussion.

Our over­riding mission at The Concussion Clinic is to protect the brains of our patients.

a lthough our tests occasionally suggest that further cognitive and physical rest is required, just as often we are able to provide reassurance to a worried athlete who has sustained traumatic brain injury and enable them to return to training and play with confidence. 

Mr John Leach is a consultant neurosurgeon at The Manchester Institute of Health and Performance and has an interest in sports injuries including concussion and spinal disorders. His NHS practice is at Salford Royal Hospital, where he manages neurotrauma, including brain and spinal injuries

AccoUNTANT’s cLiNic: FiLiNG yoUR AccoUNTs

Timing is everything

The paperwork around filing year-end accounts isn’t everyone’s idea of fun

– although the resulting profit calculations hopefully will be. Susan Hutter (right) gives her tips

Meeting the deadlines

Independent practitioners who trade as a limited company have to file their year-end accounts within nine months of that year end.

A popular year-end date for companies is 31 December. So accounts for the year to 31 December 2016 will have to be filed by 30 September 2017 and the corporation tax must be paid on 1 October 2017.

The sooner you know the tax liability, the better it is, so you can save up for it. It will also help you with your personal tax planning. Remember, any dividends and salaries you draw from the company will have to be included on the personal tax return.

Therefore, all dividends and salaries drawn in the year to 5 April 2017 will form part of your income for the tax year 2016-17. The sooner the accounts are prepared for that year, the sooner you will be able to see what your income tax bill is for 2018.

You don’t want to be in the position of not having enough money to pay your tax – either company or personal – on the due date.

Trading as a limited-liability partnership (LLP)

The filing dates will be the same as a company – nine months after the year end. However, the tax is a liability of the individual members of the LLP.

Once again, the sooner you get the accounts prepared, the better, as the personal tax bill can be worked out. For self-employed/ sole traders, the practice accounts will form the basis of your income for your personal tax liability calculations.

General book-keeping and accounting

It is advisable that your accounting records are updated regularly so you can send them immediately to your accountant.

Post all the entries for invoices raised and monies received as soon as possible after the yearend.

At that point, print out a report of money owed to the practice and this will ensure you have an accurate picture and do not muddy the waters with any invoices after the year-end.

However, you will probably need a few months after the yearend date before you can finalise

the accounts, just in case there are any unrecoverable debts.

Pensions

For doctors wanting to carry out personal pension planning, the timing of the payment into the pension plan is crucial.

If you trade as a limited company, in order to get tax relief in the financial year, the payment has to be made by the year-end date.

To plan how much the firm can afford to pay into your pension, you will need to have a look at the trading results a couple of months before the year-end and, at this point, you will need to take advice.

The sooner you know the tax liability, the better it is, so you can save up for it

Consultants who are LLPs and sole traders will need to pay in any pension in the same year for it to be tax-deductible. However, there are complex rules on how much you can pay into the pension (see page 38).

The maximum not only depends on your current tax year’s annual allowance but also any unpaid premiums in previous years where you have not used up your allowance and your income.  Next month: How to manage cash flow effectively

Susan Hutter is a specialist medical accountant and a partner at Shelley Stock Hutter

REviEwing YoUR FinAnciAl mAnAgEmEnT

Spring-cleaning your finances

With spring in the air and the financial tax year-end pending, it is a good time for private doctors to give their practice a spring-clean for financial health. Gary Nials (right) suggests suitable areas

Busy doctors involved in private practice are often so focused on providing a high standard of medical care for their patients that they lose sight of the most fundamental aspects of running their practice and forget the fact that it is a business.

Even now, many independent practitioners obviously still do not like to think of their private work as a business enterprise. But, in reality, for anyone employing people and running a practice with a reasonable-sized turnover, that is exactly what it is.

It is normal for any going concern to regularly review the processes and procedures used to operate the business to ensure

for treatment

that it incorporates best working practices. If you also take into account all of the changes that are taking place in the market, it would make sense to review how your private practice is operating to decide if you need to make any changes – especially if it has grown over the last few years. of course, every practice operates its business based on its own preferences. But I have identified below the key areas that most practices should look at in any review.

Secretarial support

If this key area is not resourced correctly and kept in line with the growth of the practice, it will undoubtedly cost the practice money in lost opportunities. We visit many different practices on a regular basis and still come across many where the secretary is struggling to cope. this is particularly true where the secretary has more than one consultant to look after or where the consultant’s practice has grown so fast over the last few years that it has outstripped the capacity of the secretarial support. t he main areas of concern is communication, such as phone calls and emails.

Phone calls

A practice has a plethora of calls from many sources. on top of all the calls it receives from private medical insurers (PMIs) in relation to finance queries, the largest increase is typically due to the amount of phone calls coming in during the day from either existing patients or new patients wishing to book appointments.

c ombined with this is the amount of outgoing calls the secretary has to make to the insurers, including calls to obtain authorisation for the treatment. t hese have also increased, as these calls have become more complex.

Emails

Another issue will be the number of emails that a practice receives on a daily basis.

this puts pressure on the secretary, because when people send emails, they expect a rapid response.

If they do not get one, they might perceive that as poor service and send another email chasing a response, which just adds to the amount of emails received. this could also mean the practice is missing out on lost opportunities, with potential patients going elsewhere due to poor communication via missed phone calls or slow responses to emails. s o unless these issues are addressed, the problem will only intensify.

Becoming ‘fee assured’

Back in January 2012, Bupa was the first PMI to introduce the fee assured format with the ‘open referral’ system, causing a major change in what consultants would be paid. t his made consultants agree with Bupa rates to ensure getting Bupa patients. other PMIs have since followed suit, including AXA and more recently Aviva.

In recent months, we have had a number of clients asking us whether they should become fee assured on a purely commercial basis and this is something a practice needs to consider.

t his is obviously going to be specific to each practice, so an analysis needs to be done to identify what the best commercial decision is and if there is any action that the consultant needs

to take to mitigate any subsequent changes in business volumes.

Self-pay

due to all of the recent changes in the market, including an increase in co-share insurance policies –where the patient pays a percentage of any invoice – it is not unusual for a practice to have a substantial element of the billing to go to the patient.

Again, this is something that is going to be specific to each practice, so an analysis needs to be done to identify if there is any action that needs to be taken to make sure the practice is getting its fair share of the self-pay market as well as managing the collection process effectively.

importance of invoicing

A point to note here is that costs are increasing – or certainly not decreasing – while private medical insurance payments are going down.

this is also more and more the case now with embassies in London, which leaves the self-pay market increasingly important to many private practices.

It is therefore crucial to get paid what you are owed.

so the practice’s focus must be on:

 Making sure that invoices are raised in a timely manner;

 Ensuring that every procedure is billed correctly;

 Invoicing with correct coding rules for each private health insurer;

 c ollecting the money in a timely fashion to avoid bad debts. over the years, many practices may have managed to exist without paying too much attention to the finance side of the practice and, as they have grown their businesses, this may have masked any inefficiency that existed. times have changed.

It is down to each practice to carry out their own practice health check and to decide in what priority to tackle these areas. of course, one thing to consider is outsourcing the billing and collection to a professional billing agency which can assist across many areas in multiple ways. 

Gary

Nials is

managing director at Medical Billing and Collection

how To boosT REvEnUE

Create an income

Surgeon Mr Dev Lall gives advice on

surge

If there is one thing we could all do with at times, it is a sudden and rapid increase in our income.

Obviously, a regular and prolonged increase in our income is even better, but now and then it’s a windfall we need.

Maybe the tax deadline is approaching and you haven’t kept quite enough cash by, or perhaps you need extra cash for some other reason. But is it possible to raise extra income quickly from our private practices? And if so, how?

from the outset, let me say that what I’m going to consider here is gaining extra income through generating extra business –patients – for your practice, not through loans, mortgages, outside investment or anything like that.

Because although sometimes that’s what you need to do, it’s far more fun to generate the cash organically through growing your practice, and it hones the skills you need to run a successful private practice in the first place.

the second thing is that the ease with which you will be able to create the income surge you want will depend upon several factors. these include:

 the amount of money you need

– relative to the income generated by your ‘average’ patient;

 the speed with which you need to generate the cash. You can only do so much, after all;

 Your specialty (more later);

 Your location: affluent vs less affluent;

 how long you have been established in private practice – the longer, the better;

 What systems and processes you already have in place to generate patients;

 the records you’ve kept about past patients. Again, more on this later.

All these variables matter, but, in my experience, the most important aspect of all is you.

Are you willing to get stuff ➱ p34

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done? to do what it takes in the requisite time-scale to make it happen? We all move fast when it comes to dealing with sick patients, but I’m always surprised how slowly people move when it comes to fixing a sick – that is to say, underperforming – private practice.

The low-hanging fruit the easiest way to grow any practice, both in the long and short term, is to do more of what you already know works.

So if you hold GP educational meetings and after each of those meetings you notice an uptick in patient numbers, simply hold another meeting. Don’t overthink it – just choose a topic relevant to your audience, fix a date in the near future (a few weeks perhaps) then get the word out.

Write and call local GPs to get as many people to attend as possible. from your own experience, it

has worked in the past to generate patients, so it is highly likely to work again.

Similarly, if you’re an ophthalmologist and hold meetings for optometrists in your region and experience tells you this generates patients each time, hold another.

have you had some recent publicity in the local newspaper that brought in patients? then write a press release and send it to the reporter you spoke to last time.

If they don’t run with it, then approach other newspapers, including free papers, that are circulated in your region.

If none of them accept it, then re-write the piece and try again. free Pr is not difficult as long as you adhere to the golden rule of making it interesting and relevant to the audience. And if that fails, send it in as a paid-for article or ‘advertorial’ and get it published that way.

the mistake so many consult-

ants make when it comes to marketing their practice is that they try one approach, get a good result then say: ‘Great! Now what should we do?’ t he answer is almost always: ‘Do it again!’

Give them what they want If there’s one thing patients always want, it is more of you. So give it to them.

t he obvious example here is patients with chronic conditions or cancer. Nationally, there are guidelines on the duration and intensity of follow-up for certain conditions – for example, breast cancer – and we’re all well-aware of the relentless pressure we face to discharge patients from followup in the NhS.

And our patients hate it. Say you’ve been following up your patient with breast cancer for the last five or ten years and you decide she can now be safely discharged. So many patients resist

it, don’t they? After all, she’s got to know you over the years, she trusts you and she is reassured when you assess her each year. these restrictions on follow-up are not present when it comes to private patients – as long as you adhere to good clinical practice, of course. You can follow them up for as long as you like.

Sure, their insurance may not cover them and, yes, you might feel that further reviews are unnecessary. But there’s no reason you can’t offer them a follow-up appointment as long as you explain that you are happy to discharge them but are willing to offer them a further review if they wish.

A surprisingly large number of patients will take you up on that, even if it means they have to pay for the appointment themselves. this is very smart and successful as an on-going strategy, but what if you want that income surge?

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easy. Simply extract from your database of previous patients those with a condition you know either merits review or that patients like to be followed up for. Write them a letter inviting them for outpatient review and have it sent out to all those patients on your list.

Sure, not all recipients will want to come back and be seen again, but you will be surprised how many will – so give it a go.

Pivot around complications

Nobody likes complications in their patients, but perform enough of any procedure and they are unavoidable – even in the best of hands. But rather than wait for them to appear, why not look for them?

Crazy? Nope. for example, we know that a significant proportion of patients following cataract surgery develop posterior capsule opacification causing their vision to deteriorate again.

But rather than waiting for them to present, why not search for them? Write a letter inviting your patients who have had cataract surgery to return for a checkup and send it to patients who had their procedure more than, say, two years ago.

A significant proportion will reattend your clinic for review and a further number of those will require treatment. t here are many similar examples from other specialties too.

Don’t miss a trick

Another example in the easily missed category is if you are doing Google AdWords or f acebook advertising. People frequently run campaigns, get a positive return on investment then sit back and let the campaign run, quietly bringing them patients and making them money.

But don’t forget that once you’ve created a campaign that is successful like this – i.e. making you money – the next step is to increase your ad spend.

So if you spend £500 per month on ‘clicks’ which generate £5,000 in income for you, if you spend £1,000 on ‘clicks’, that will generate £10,000 for you. t here’s no need to be scared of spending more, as you know the numbers work in your favour.

Yet another reason why you must know your numbers.

Give them a reason why

If you’re marketing and promoting your practice, you will probably recognise that there is often a lag period between the time when patients encounter your marketing and when they finally decide to book that appointment. And that delay can be weeks or even months. So how can you reduce this lag time?

t he trick is to give patients a reason why. You should explain to the patient exactly why they should act now to be seen rather than putting it off.

that could be a clinical reason – the risk that their symptoms could be due to a serious cause –or to avoid complications; for example, incarcerated/strangulated hernia. Alternatively, you could give them an incentive to act now rather than later.

With incentives, you do need to tread very carefully. Special offers, discounts, BOGOfs (buy one, get one free) all work, but can land you in hot water. You have likely seen criticism of these practices in relation to cosmetic surgery.

Yet there are other less dubious approaches you can take to spur patients into action.

Make a time-limited offer of a free initial consultation, perhaps. hold an open evening for patients with particular conditions and symptoms at your clinic. hold a patients’ educational meeting in the same way as you might hold a GP meeting (see page 18).

Stress in your marketing that successful practices such as yours also have waiting lists to be seen, so come in over the holiday period when your practice is quieter and they can be seen with no delay at all. You’ve just got to think a little laterally.

Yes, it is entirely possible to generate an income surge in your practice, and there are many other ways than the five strategies I’ve touched upon here.

Better yet, it can be surprisingly easy to do. the question as always is: are you willing to give it a go? 

Mr Dev Lall is a surgeon specialising in helping colleagues grow their private practices. He can be contacted at dev@privatepracticeexpert.co.uk

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GETTING THE BEST OUT OF YOUR PPU

Separate the teams

Philip Housden (right) reviews the interface between the PPU and the rest of the NHS trust, and how getting this right can drive growth in financial surpluses from the trust’s investment in the PPU

Most typically, at least in nonmetropolitan NH s trusts, the private patient service really means the ward.

However, many trusts will also have a private patient office housing the administrative team. Where possible, the two will be colocated, enabling substantial benefits from liaison between the ward clinical team and administration colleagues, and, of course, much better value from the investment that has been made in those staff.

the primary purpose of the ppU and private patient team is to deliver financial and other benefits that contribute positively to the trust in support of NHs core services.

this may seem obvious, but not all ppUs appear to have been set the clear objective of taking actions to maximise the return on that investment.

For instance, the ppU team should be considered supernumerary to the trust staff establishment, although employed on trust contracts.

Why? s o that the revenues the ppU brings into the trust are considered to be those used to pay for the staff. i t then follows that the resources are not a drain on the trust – quite the converse.

a further behavioural change comes when it is no longer assumed that the ppU staff team can just pick up NHs demand pressures for free.

this taps into the understandable

human trait that something paid for has value and is valued. a ll too often, a good service or one enjoyed for free is not valued as highly. it works both ways, of course. the trading account for the ppU should understand the cost of estate facilities and other corporate overheads. Why? so that the full costs of service are understood and a gross and net margin and return on investment are identified.

the above sounds dry, but it is the consequences of understanding the above that then shifts thinking towards innovative and exciting opportunities.

staff working in a ‘trading’ situation with fluctuating activity and non-guaranteed revenue streams find that this focuses the mind, but in a good way.

Closer links the vast majority of staff, clinical and non-clinical, do appreciate when there is a closer link between what they do, how they do it, the quality and reputation of that work and the resulting success of their team.

therefore, as in a private hospital, and also most other walks of life, ‘busy’ becomes ‘good’. a ppU is in the privileged position of being able to ‘keep score’ and share how the team is doing

tHe story so far

If you missed last month’s article in this series, I explored the issues that PPU teams need to take into account when considering existing tariffs with private medical insurers and also when setting local prices for self-pay patients.

the first step should be internal analysis of what are the clinical specialties and procedures where the NHs PPU has a relative position of strength in the market.

It may well be the case that the NHs trust’s wider tariff rates have, over the years, fallen behind those achieved by the local independent sector chain competitor.

But, seeking simplified acrossthe-board uplifts in an era of very low inflation will only entrench this position – whereas focusing efforts on strengthening prices for the PPUs service’s ‘hot spots’ will be a better route to achieving improved profitability.

regarding income, costs and surpluses. that’s why they can and should be fun places to work within a trust.

turning to the built environment and capacity, the same applies. pp Us are likely to push hard at capacity, at maximising the flexibility of rooms and all the square meterage of space they have access to in order to be able to say ‘yes’ to all referrals.

Unused space

this means looking at use of space not just within the pp U, but unused space elsewhere in the trust; for example, during evenings and weekends.

perhaps your ppU has exported the trust’s private patient branding to one or more corners of the building well away from the private ward base?

it may only take the use of a key colour, improved signage, or the adding of some personality to a space to turn it into a private patient facility after-hours, even when that same space has been used for the NHs from 9 to 5. o n the private patient ward itself, the same thinking extends

to actions aimed at growing the market. ppU private patient bed occupancy will inevitably vary: by time of day, day of the week and by month and season.

Unused bedrooms must earn their keep and many trusts have successfully integrated the amenity bed approach into their business model.

amenity beds have been around for many years, most noticeably giving mums the opportunity to book a single room when giving birth, but also for side rooms on general NH s wards, when those rooms are not required for clinical priorities.

Re-launching the amenity bed product through the pp U, though, gives a great opportunity to think carefully about the services offered, the price point and how to engage with the rest of the trust.

this really can be a win-win, as patients taking an amenity bed will release an NH s bed when they move to the ppU, while the ppU is then maximising revenues from the staff team and the physical space it has.

prices vary, but typically £250£300 a night will be the cost for an ensuite room with the hotel and privacy comforts it brings.

it is perfectly possible for trusts to aim to build the amenity bed revenues from scratch to well into six figures quite quickly.

When set against multi-million trust deficits, that may not seem much, but it should be remembered that this is real cash.

t he evidence is that amenity patients are satisfied with their experience and can then become advocates for the services of the ppU, both private and NHs amenity, to their friends and family.

However, when multiplied across the whole NHs, the amenity bed contribution which is already significant, could be so much more, if embraced in every trust.

 Next month: Lessons learned from the past year in the PPU world and suggestions for how the NHS should be revitalising PPU services across the country

Philip Housden is a director of Housden Group, a management consultancy specialising in commercial support in the healthcare sector

PROBLEMS WITH THE TAX MAN?

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Perplexing pensions

Your pension questions, especially about the erosion of your benefits due to tax changes, are keeping accountants busy. Ian Tongue (right) explores the impact of major changes to the taxing of your pension and shows what to consider now

T HIN k OF your pension as a bucket. HM Revenue and Customs (HMRC) does not want you to fill it too fast because you get tax relief on the flow in. And when it gets full, the taxman wants some of the tax relief back.

This seems unfair, particularly as previous governments encouraged pension saving. But the rules changed due to the soaring cost of giving tax relief on pension contributions, and the economic climate. This was in addition to the shake-up of public sector pensions following the Hutton report.

The changes can be autonomous, as you could face a charge for your pot being too large (breaching the Lifetime Allowance), filling up too quickly (excess pension growth) or both.

Doctors should now consider:

 Is my annual pension growth within the acceptable limits?

 Has my pension grown larger than the Lifetime Allowance?

 Am I eligible for any pension protection?

 If I have pension protection, am I still eligible to retain it?

Annual pension growth

The current limit for pension growth to enjoy tax relief is £40,000 – the Annual Allowance. If you are in the NHS, it is extremely unlikely you will be physically paying anything like that figure into your pension, because an employee’s maximum contribution is 14.5% of earnings. However, your physical contributions into the pension are disre-

garded because the NHS scheme is a defined-benefit scheme.

In plain English, this means your end pension is not directly related to what you put in the pot. Another formula calculates the benefits. Outside the public sector it has become uncommon for defined-benefit schemes to exist or accept new members. Most have huge black funding holes, as the amount being paid out exceeds contributions in and returns on scheme investments.

So, an alternative way of measuring your NHS pension growth is adopted. This ignores the amount paid and values the capital increase of your pension from one tax year to the next.

There are different formula depending on whether you are a

1995, 2008 or 2015 NHS Pension Scheme member.

For those in the 1995 or 2008 scheme, annual pension growth is significantly affected by any form of superannuable pay rise, such as a clinical excellence award or pay increment. This is because your years of service and annual superannuable pay determine your pension growth.

Inflation also plays a role, as the point where HMRC calculates inflation is a year out of sync to the NHS Pension Scheme, which can lead to some unexpected figures.

For consultants in the new 2015 scheme, the pension accrual each year is 1/54th of earnings. So pension growth is more even and predictable with less of a spike effect when a pay rise is received.

AFTER YOUR MONEY:

Whichever way you turn, the taxman will try to catch you

Take a simple example: a consultant with a £95,000 superannuable salary under the 2015 NHS Pension Scheme would accrue £1,759 of pension for that year, which, using a complicated HMRC formula, is a deemed growth figure of just over £28,000. For comparison, he would have paid around £13,000 in contributions before tax relief. This example also ignores the effect of inflation and any growth from previous NHS Pension Scheme membership, such as growth from a previous pension pot before becoming a 2015 scheme member. It is important to note that any other pensions need to be taken into account when calculating pension growth.

Tapering of Annual Allowance

From 6 April 2016, the standard £40,000 Annual Allowance is reduced on a sliding scale for those earning over £150,000. On reaching £210,000, the limit is just £10,000 annually.

‘Earnings’ for the purposes of this restriction is not the figure you earn for tax. It is usually substantially higher, as your’s and your employer’s pension contributions are added back, among other adjustments.

Be sure to liaise with your accountant to see how this complicated area may affect you. If you have a medium to large private practice, it is likely your pension Annual Allowance will be restricted to as little as £10,000.

As my previous example shows, a £95,000 salary under the 2015 scheme resulted in growth of circa £28,000 – which is an excess of £18,000.

Where there is excess growth, you can go back three years to see if you have not used up your allowances, which can be used to extinguish the excess growth. Where the excess is not extinguished, a tax charge at your marginal rate of tax arises.

With the above example for a 45% taxpayer, the tax charge would be £8,100. This could hit a consultant each and every year.

So discussing your private practice trading structure with your accountant is essential to exploit any tax planning opportunities that may exist, as the potential tax savings are substantial.

Choosing ‘Scheme Pays’

A system is in place to allow the NHS Pension Scheme to pay tax due (in excess of £2,000) on excess growth and this effectively forms an interest-bearing loan that is deducted from your benefits on retirement.

This system is well established and you have around 16 months from the tax year in question to make the election. For the year ended 5 April 2016, you have until 31 July 2017 to make the election.

A significant issue has arisen here, as the current stance of NHS Pensions is that it will only accept a ‘Scheme Pays’ election on the excess over £40,000, which is the standard Annual Allowance.

Therefore, if you had a reduced (tapered) Annual Allowance, any tax on up to £32,000 – £14,400 for an additional-rate taxpayer –would have to be paid personally.

As this is still a relatively new area, there is hope that NHS Pensions reconsiders its position on this matter; otherwise many members simply will not be able to afford continued membership.

The Lifetime Allowance

This is more straightforward than the Annual Allowance and is put-

ting a ceiling level on the size of a pension pot before a tax charge arises: currently £1m.

Unlike the Annual Allowance, this tax charge is worked out and payable only when you take your benefits. But you can measure yourself against the limit by obtaining a pension forecast or referring to your total reward statement.

Often there is a misconception that your pension stops growing when you reach this level. But this is rarely the case.

To put matters into context, if you retired and had a pension £100,000 in excess of the Lifetime Allowance, then you would have a tax charge of £25,000 deducted from your pot.

However, this figure is divided by 20 and deducted from your gross pension and therefore in real terms it costs you £750 a year from your pocket.

Usually the extra pension you receive per year from having the £100,000 extra pot is greater than that figure and this highlights how an incorrect decision could be made here.

As always, having an independent financial adviser review your circumstances and formulate a retirement plan is essential.

The perfect storm?

For those facing both an Annual Allowance charge and a Lifetime Allowance charge, your pension growth per year is clearly compromised.

Often, one way to look at it is to imagine a graph with a positive gradient. These tax charges will certainly reduce the gradient of the line, but it is usually still moving in an upward trajectory.

So the decision on whether to continue is frequently a value-formoney decision and a financial adviser should be able to assist you in assessing your position.

Pension protection

There have been a number of pension protections over the years, mostly in response to falling levels of Lifetime Allowance, but the ones being discussed the most at present are Individual Protection 2014 and Individual Protection 2016.

These forms of protection provide a tailored Lifetime Allowance

depending on the value of your pension and, crucially, allow you to continue to contribute to the NHS Pension Scheme. This is in contrast to Fixed Protection 2014 and Fixed Protection 2016 which effectively prevented you contributing any further.

For those with pensions with a value of at least £1.25m as at 5 April 2014, you can apply for Individual Protection 2014. But you must do this by 5 April 2017 and therefore time is limited.

For those with pensions with a value of at least £1m as at 5 April 2016, you can apply for Individual Protection 2016. Unlike Individual Protection 2014, there is no time limit to apply for this protection.

The process for each is the same with NHS Pensions, providing you with a capital value of your pension at the requested date and a subsequent application is made to HMRC.

It is important to ask your independent financial adviser for their advice in relation to holding pension protection and often you can hold more than one type, which can act as a ‘belt and braces’ approach.

Loss of pension protection

For several types of pension protection, your eligibility to retain the protection must be considered on an ongoing basis.

There are too many scenarios to discuss within this article, but one area that has caught out both consultants and GPs is where they hold ‘Enhanced Protection’ and have been transferred into the 2015 NHS Pension Scheme. If this sounds like you, contact your independent financial adviser or accountant to discuss the next steps.

The tax changes around pensions are complex and can seem illogical in parts, but they are here to stay. It is important that you are aware of at least the basics and liaise with your accountant and independent financial adviser on a regular basis to ensure your retirement plan is on course.

 Next month: Digital tax is on the horizon. Which independent practitioners will be affected and what should you do?

Ian Tongue is a partner with Sandison Easson chartered accountants

Private medical insurance

work in Private Practice is big business, so let Code Buster! keeP you in the know every month, the clinical coding and schedule development group (ccsd) reviews its 2,000-plus procedure codes, and more than 3,000-plus diagnostic codes, that form the basis of private medical insurance. it is crucial for independent practitioners and their practices to know these codes, so they bill correctly. if they don’t, then it could cost them money

No puzzle to getting paid quicker

CODE BUSTER!

Changes to note this month

Specialties recently affected include: spine, spinal cord and peripheral nerves (Code A & V); breast (Code B); eye and orbital contents (Code C); ear, nose and throat (Code D & E); abdomen –excluding urinary and reproductive organs (Code G); vascular system (Code L); urinary system and male reproductive organs (Code M); female reproductive organs (Code Q); skin and subcutaneous tissue (Code S); bones, joints and connective tissue/tendon muscle (Code T & W).

there are Five new proCedure Codes

L8881 – Endovenous mechanochemical ablation for varicose veins – bilateral;

W5920 – Fusion of first metatarsophalangeal joint and bones grafting +/- internal fixation (as sole procedures);

G387 – Laparoscopic removal of gastric band;

E2501 – Fibre optic examination of the pharynx +/- biopsy/removal of foreign body;

B2919 – Mastectomy and immediate reconstruction of breast using fixed prosthesis and acellular dermal matrix (ADM) – bilateral.

there are Five narrative Changes

D1720, D1710, M4780, C7940, B2918 and two re-instatement of codes: C7923 – Intravitreal injection of pharmaceutical for neovascular age-related macular degeneration; C7924 – Intravitreal injection of pharmaceutical for central retinal vein occlusion.

there are 81 unaCCeptaBle CoMBinations (also known as unBundling)

V2562 add with V2543; E1480 add with E1260; A7352 add with W0300, W0310; S0520 add with S3622, S3623 , S3624, S3625; T6822 add with T6722; E5480 add with T0320; W0890 add with W9040, W9030; T6450 add with T6520, T6580, T6782, T6800, T7050, T7230, W9040, W9030; T7915 add with A7350, T7910, W8700, W9030, W9111, W9112 ; W4900 add with A7350, W8700, W9030, W9111, W9112; W8192 add with A7350, W9030; W9111 add with W9030; W9112 add with W9030; W5550 add with W0850, W8700, W9030; W7860 add with A7350, T8050, W8700, W9030; W8880 add with A7350, T8050, W8700, W9030; W1648 add with T6213, W0850, W1647, W8700, W9040, W9030; W8800 add with A7350, W8700, W9040, W9030; W0632 add with A7350, W8520, W9020, W9030, W9040; W8520 add with A7350, W9030; W8630 add with A7350, W9030; W8840 add with A7350, W9030; W8850 add with A7350, W9030; W0860 add with W8700, W9040; W0861 add with W8700, W9040; Q1800 remove with Q0230

ThERE ARE AlSO FOUR nEw DIAGnOSTIC TEST CODES

4300U – Leukotriene E4 – urine; 4301B – Prostaglandin D2 – serum; 4302U – Prostaglandin – urine; 4303B – Lactose intolerance gene.

Of special note this month: codes C7923 and C7924 (ophthalmology) have been re-in stated. These were de-activated back in August 2013. But this will have been contested since, resulting in its re-activation. The narrative for code B2918 has also been changed to make this unilateral, with the new code B2919 activated for the same procedure but bilateral. Remember, however, that codes are not mandatory by insurers. In other words, the inclusion of procedure codes within the CCSD Schedule does not indicate the automatic agreement of individual insurers to provide benefit for this procedure.

You need to contact each insurer directly to find out whether benefit is provided. 

Code Buster data is provided B y Medi C al Billing and ColleCtion. For Full details, go to the Clini C al Coding sChedule developMent we B site at www. CC sd. org.uk

UndERsTAnding sTocks & shAREs

The world really

Is your portfolio benefiting from the decline in sterling?

Simon Bruce (below) explains why your investments should have a global outlook

is your oyster

The uncerTainTy which continues to surround Brexit – hard or soft, sooner or later – is still having a pronounced impact on sterling.

While the media hype focuses on the increased cost of your summer holiday and the rising fuel prices, there is another side to the story.

investors holding globally-diversified portfolios have enjoyed a boost to their returns. This is because many FTSe 100 companies generate a large proportion of their income from overseas markets.

c ompanies such as h SBc and GlaxoSmithKline earn much of their revenue in dollars and are seeing a substantial rise to their share prices.

a round three-quarters of the earnings of FTSe firms come from outside the u K. i f the pound is weak, these profits are worth more when converted back into pounds from dollars or euros.

The weak pound can be good news for investors. Both u K oil companies royal Dutch Shell and BP made quarterly payouts in December that were 20% higher than a year ago.

Together, the firms gave a c hristmas bonus worth almost £500m to u K shareholders because of the practice of setting dividends in dollars and paying them in sterling.

in fact, ordinary dividends paid by FTS e 100 and FTS e 250 firms increased by around 16% year on year in the last quarter of 2016, with technology, telecoms, oil and gas firms leading the field.

On the flip side, if your investments have been in mainly domestic portfolios, you will have lost out significantly over the last few years. you are far from alone.

Data from the i nternational Monetary Fund confirms that uK investors typically allocate only 50% of their total equity allocation outside of the uK – despite

UK stocks have not actually done too poorly recently; it is more that the rest of the world has performed better

the country making up only 7% of world market capitalisation. i nvestors can also suffer from ‘home bias’ – preferring to invest in domestic holdings that they know and recognise at the expense of foreign securities.

not all due to Brexit uK stocks have not actually done too poorly recently; it is more that the rest of the world has performed better. i n 2016, performance index MSci uK was up by 17%. The global index MS ci World (excluding uK) fared better, rising 26% in the same period.

The decline in prices is not just recent and although the eu referendum has substantially affected the situation, it is not entirely to blame. u K equities have underperformed over the last two years, with non-uK stocks up by 45% to British stocks’ 18%.

Some forecasters suggest that the pound will reach parity with the dollar and euro by the end of the year. however, it is fair to say that currency predictions, like those involving the markets, should be taken with a pinch of salt. in 1984, currency fluctuations added 22% to the annual return on non-uK equities, only for the same stocks to lose 17% in 1985.

Today’s situation is very different and the weak pound is likely to stay until there is a clear path forward, particularly in relation to the country’s future trade agreements. a t c avendish, we have been running global portfolios, where

u K equities account for only a small percentage of a client’s holdings, since 2008.

Portfolios are created with full knowledge that major events will occur and that only robust, welldiversified investment plans will stay the course.

a s a result, clients are not dependent on u K equities and have enjoyed higher returns on their investments since the Brexit vote, despite the volatility in the value of the pound.

at times when the economy is facing challenges, it can serve to highlight areas of an investor’s portfolio which are unevenly weighted or that contain higher-than-appropriate risky or illiquid assets.

highly diversified

n o one knows what the future holds and owning a highly-diversified portfolio is the key tool to make sure that we are prepared for whatever the markets throw at us.

There will always be one or two parts of the portfolio that are doing well, but one or two that are not. The patient and disciplined investor knows that there is little point in knee-jerk responses and that this is simply the way that markets are.

i f your portfolio is well-structured and well-diversified, you should not need to change your game plan due to market or currency volatility.

i f you are not confident that your investment plan is up to the challenge – or you are spending too much time and money changing the direction of your investments – seek expert help without delay. Once your portfolio has been properly designed, you should be able to leave it alone and do something more meaningful with your time. 

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

The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.

Levels, bases of and reliefs from taxation may be subject to change and their value depends on the individual circumstances of the investor. The value of investments and the income from them can fluctuate and investors may get back less than the amount invested.

Handling unusual requests

Patients’ more unusual requests to their private doctor are discussed here by Dr Nicola Lennard (right)

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Dilemma 1 Patient wants to donate her body

QOne of my elderly private patients has had high blood pressure for many years and her heart is now failing. The patient knows she has a limited life expectancy and is determined to die at home. She has also asked me to help her donate her body to medical science. How should I respond?

AMany medical schools rely on body donations to help train their students and do research. In the first instance, your patient should be directed to their local medical school, which will be able to give her the necessary information to make an informed decision and provide the appropriate consent form. You can find a list of contact details for the medical schools on the Human Tissue Authority’s

For more information please contact:

South East

James Gransby FCA

E: james.gransby@mhllp.co.uk

T: +44 (0)1622 754033

M: +44 (0)7712321899

East Midlands General email: healthcare@mhllp.co.uk www.macintyrehudson.co.uk

Robert Nelson DChA FCA

E: robert.nelson@mhllp.co.uk

T: +44 (0)1162 894289

M: +44 (0)7814009160

website (www.hta.gov.uk/donating­your­body) along with some useful guidance.

You should prepare the patient for the fact that not all bodies can be accepted for donation even if appropriate consent is in place.

Such decisions cannot be always made until the time of death, as certain medical conditions or circumstances of death may preclude donation. For example, requirement by the coroner for a postmortem examination to be performed.

Under the Human Tissue Act 2004 in England, Wales and Northern Ireland – and the Human Tissue (Scotland) Act 2006 in Scotland – appropriate consent for anatomical examination must be in writing and signed by the donor in the presence of a least one witness.

The consent can be signed by a representative at the direction of the donor and in the donor’s presence, but, again, this will require the signature of at least one witness.

You should prepare the patient for the fact that not all bodies can be accepted for donation even if appropriate consent is in place

If your patient wishes to go ahead, she should inform her family, executors and GP so that timely action can be taken when she dies.

As the patient wishes to die at home, arrangements will need to be made with an undertaker for the body to be held in a chapel of rest until the decision has been made.

Suitable preservation

The relevant medical school should be contacted as soon as possible after her death so the body can be preserved in a timely fashion. Depending on how the body is kept after death, it must be received by the medical school within three to five days to allow suitable preservation.

If you plan to attend the patient at her death, bear in mind that her body cannot be lawfully stored for anatomical examination until there is a signed Medical Certificate of Cause of Death.

Once this certificate is available, the medical school can take the body and begin the process of timely preservation, but the body cannot be used for anatomical examination until the person’s death has been registered.

If you sign the patient’s death certificate, the medical school might contact you to ascertain the suitability of the body for anatomical examination.

Dilemma 2

She doesn’t want her husband told

QA woman in her 30s recently attended my clinic for a termination. I explained it was my usual practice to write to her GP so her medical records could be updated, but, to my surprise, she

became distressed and begged me not to.

She said she was worried about her husband accessing her medical records and finding out. What should I do?

AGood communication between specialists and GPs is part of good medical practice and can help ensure continuity of care.

In this situation, this information could be important if the patient experiences any complications at a later date or has difficulty in conceiving. However, the patient’s consent is necessary.

It is a good idea to explain this to the patient and explore why she is so concerned that her husband will be able to access her medical records.

You could try explaining that her GP has a legal and ethical duty of confidentiality not to disclose her medical records to family members without her explicit consent.

It might also reassure her if you emphasise to her GP in writing that she doesn’t want the details of her termination to be disclosed.

Ultimately, if a patient objects to you writing to her GP, her wishes should be respected, but it’s a good idea to record this discussion in your notes.

If you do not inform the patient’s GP, you will be responsible for her care. Ensure that she is clear about the symptoms which might suggest infection or that the procedure has failed. She should know how to contact you or another named suitably ­ qualified person if she experiences complications. You should also provide her with enough written information so that another doctor can take over her care in an emergency. 

Dr Nicola Lennard is a medico-legal adviser at the MDU

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DocToR on ThE RoAD: REnAUlT ScEnic

Take a scenic route

The new Scenic is well worth a look for the independent practitioner who needs a good-looking family car that is cheap to run, feels modern and scores highly for practicality, says our motoring correspondent Dr Tony Rimmer (right)

Uncertainty can certainly put a bit of a damper on things and independent practitioners are naturally concerned about the on-going effects of various forms of increasing regulation and rules. there are also many issues surrounding other external financial challenges threatening profitable private practice.

the full-blown effects of Brexit are still an unknown and global political changes are similarly unsettling.

Fortunately, car makers are very aware that, because of this, we may have become a little more conservative in our purchasing habits.

i n response, they have been releasing some very interesting

and excellent-value products over recent months.

this is particularly true in the MPV sector, where practicality is of primary importance. One such maker is renault and it has just launched its latest version of the Scenic.

Family friendly

the new Scenic is the fourth generation of r enault’s compact MPV which has, since 1996, been setting the standard for roomy and family-friendly cars with the exterior dimensions of a fivedoor hatchback. i t is based on the floorpan of the new Megane and shares chassis design with the nissan Qashqai and renault’s own Kadjar cross-

RenaulT scenic dynamic s nav dci 160 automatic

Body: Five-door hatchback engine: 1.6 litre four-cylinder turbo diesel Power: 160bhp

Torque: 360nm

Top speed: 115mph

acceleration: 0-62mph in 10.7 secs

claimed economy: up to 62.8mpg

On-the-road price: £29,145

over. t his, like sharing clinic space and equipment, allows them to cut costs. the Scenic seats five in comfort and a seven-seater version, the Grand Scenic, is also available for those with larger family needs.

there are four trim levels available from the baseline expression+ model, through Dynamique nav, Dynamique S nav versions to the top-of-the-range Signature n av model that has a leather interior, full LeD headlights, electric seats and the bigger 8.7” touchscreen for the tomtom satnav and infotainment system.

Power comes from a choice of two petrol and three diesel engines of varying power output and the gearbox can either be a six-speed manual or six-speed automatic.

i n mid-2017, a Hybrid a ssist version will be available. t his clever tech incorporates a 10kW electric motor in the gearbox which aides the internal combustion engine and reduces fuel consumption and cO2 emissions by 8-10%.

Distinctive swoops

i spent a day sampling several different versions of the new Scenic, assessing all the new interior features and driving them on a variety of roads around the beautiful cotswolds.

t he first thing to note is how good-looking the new car is. r enault has done a great job to make a very functional family vehicle look smart and stylish. the standard across-the-range 20” alloy wheels help, but the body itself has enough distinctive swoops and curves to turn heads. t he shape of the bigger Grand Scenic is not so gentle on the eye, but sometimes function wins over form.

Renault has done a great job to make a very functional family vehicle look smart and stylish

the interior has a really up-todate and modern feel. t he portrait-style infotainment screen is clear, easy to use and gives a premium feel to the dashboard.

Passengers have plenty of room to stretch out in the back and, to satisfy modern teenagers, two USB ports sit in the rear central console. Storage space is impressive too.

Hidden underfloor compartments and good-sized door bins are just ready to hold the paraphernalia of modern family life. they are also great for storing sensitive clinical notes so that they are out of view in a locked car.

the flat-floored boot is a really well proportioned space even when the rear seats slide to their rearmost position – another really useful feature.

Serious mistake

Family MPVs are not designed to be drivers’ cars and, i have to say, the new Scenic is no exception. the electrically assisted steering is well weighted but a little inert. the chassis is well-tuned to keep body roll under control and handling through the twisty bits is perfectly acceptable, if not exciting.

What is a bit of a surprise, though, is the poor ride quality. i think renault has made a serious cost-cutting mistake by only offering large 20” wheels on all models.

t he lack of decent side-wall cushioning means that the ride is firm at all times and crashes over urban irregularities. Unfortunately, performance is also a little compromised if you choose the smaller, less powerful engines. While driving the 1.5litre turbodiesel with 108bhp, i had to stir the manual gearbox

quite a lot to keep up with normal traffic.

the more powerful 1.6litre dci 160 makes more sense, especially as it is linked to a twin-clutch automatic gearbox and progress is much less frenetic and well suited to the stop/start progress of urban and city driving.

Direct competitors include the c itroen c 4 Picasso, the Ford c-MaX and BMW’s more classy 2 Series active tourer. the Scenic is the best looking of the bunch and will also be helped by r enault’s award-winning sales and service standards.

So, can i recommend this latest version of the renault Scenic? Well, it is a real improvement over the previous model and for the independent practitioner who needs a good-looking family car that is cheap to run, feels modern and scores highly for practicality, the new Scenic is worth a good look. Go for a higher-specified version and you will not be sacrificing too much by holding off the purchase of a pricier premium-brand product. 

Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey

The flat-floored boot is a really well proportioned space even when the rear seats slide to their rearmost position

The portrait-style infotainment screen is clear and easy to use

mEdicAl TAlEs

Giving a cash injection

again and yet again my sharp and shining needle sank into fashionable buttocks, bared upon the finest linen sheets

TV doctor and full-time writer Dr Michael O’Donnell (right) continues with more from his new book, Medicine’s Strangest Cases. This month, he relates the case of a Harley Street doctor who invented a profitable disease of the rich

loNdoN, 1922

F OR T he first two-thirds of the 20th century, the most rewarding postgraduate qualification in British medicine demanded no special learning, attributes nor skills.

i t was not a degree but an address, and any doctor could acquire it by renting a room in what Louis Appleby has described as ‘a street that has grown rich on snobbery and second opinions’.

The address, of course, was h arley s treet and, in the 1920s, A.J. Cronin worked there before he established his career as a novelist.

Later, in his autobiographical Adventures in Two Worlds , he described how, as a young harley street doctor, he invented a disease to meet the needs of fashionable London society.

m ost of his patients were women; many of them, he says, rich, idle, spoiled and neurotic. he responded, in the best traditions of the romantic novel, by being darkly brooding, stern and bullying.

This role went down well with his clientele and ensured that his practice prospered. h is greatest triumph, however, was to give a name to his patients’ prevailing state of bored, self-centred idleness.

By giving their condition a name, he enhanced its status to that of a disease, so he told his patients that they were suffering from ‘asthenia’.

‘This word became a sort of talisman,’ he wrote, ‘and procured my entry to more important portals.

At afternoon tea in Cadogan Place or Belgrave s quare, Lady Blank would announce to the h onourable m iss Dash – eldest daughter of the earl of Dot: ‘Do you know, my dear, this young s cottish doctor – rather uncivilised, but amazingly clever – has discovered that i’m suffering from asthenia. Yes, asthenia. And, for months, old Dr Brown Blodgett kept telling me it was nothing but nerves.’

h aving created the disease, Cronin proceeded to invent a remedy. At the time, a growing

medical fashion was to give medicines like iron, manganese or strychnine and other ‘tonics’ not by the mouth but by injection through a hypodermic syringe.

Penetrating society

The technique served Cronin well. ‘Again and yet again, my sharp and shining needle sank into fashionable buttocks, bared upon the finest linen sheets. i became expert, indeed, superlative, in the art of penetrating the worst end of the best society with a dexterity which rendered the operation almost painless.’

That would have impressed the sort of patient who suffered from asthenia.

Well into the 1940s, patients would recommend a doctor because ‘he gives a painless injection’. The ritual would have been of more interest to Cronin’s patients than the actual substance injected. indeed, he doesn’t mention what he used, though some of his contemporaries injected minute quantities of sterile water guaranteed to inflict no pain. Pain

might distract the patient from the impressive liturgy of treatment.

Cronin admits he was a rogue, though no more so than many of his colleagues. Yet his treatment, this ‘complex process of hocuspocus’ as he called it, proved remarkably successful, probably because it was administered with such command and vigour.

‘Asthenia gave these bored and idle women an interest in life. my tonics braced their languid nerves. i dieted them, insisted on a regime of moderate exercise and early hours.

‘ i even persuaded two errant wives to return to their long-suffering husbands, with the result that, within nine months, they had matters other than asthenia to occupy them.’

 Medicine’s Strangest Cases, recommended price £7.99, ISBN 9781910232941.

Published by Portico, an imprint of Pavilion Books

Patients would recommend a doctor because ‘he gives a painless injection’

FocUs: RAdiologisTs

Seeing through figures

Radiologists’ profits are showing a healthy increase in our latest benchmark survey – but Ray Stanbridge warns those who are doing mainly NHS work to contact their accountant

This Time last year in this series, we predicted ‘the big potential for income growth seems to be in international radiology and for those who specialise in this area the future looks rosy’.

Well, this prophesy seems to have been fulfilled. Consultants in this specialty in private practice seem to have had a good year.

Our headline figures found that, on average, radiologists’ gross incomes from private practice have risen by 8.9% from £112,000 to £122,000 between 2014 and 2015.

Costs have also gone up – by much more – showing a rise of 17.2% from £29,000 to £34,000.

As a result, taxable profits have increased by 6% from 2014 to 2015.

We commented last year on the significant market changes that are taking place and making any inter-year comparisons increasingly difficult. There has been, for example, a growth in the number of radiology groups.

There are significant increases in the Nhs spend in private practice and many radiologists are increasingly doing work commissioned under the Choose and Book model.

There are ongoing pressures on fees from insurers – but radiologists have benefited from growth

aveRage INCOMe aND eXPeNDITURe OF a CONSULTaNT RaDIOLOgIST WITH aN eSTaBLISHeD PRIvaTe PRaCTICe

in the self-pay market, particularly in the south-east.

growth in part-time work

Clearly, there has been some growth in the number of ‘parttime’ private practice radiologists. Radiologists, perhaps more than many consultants in private practice, can pick and choose the sessions they work.

All of these factors make any form of comparison increasingly difficult. As in previous years, we have imposed restrictions on membership of our surveys. Note that this income survey is restricted to those consultant radiologists who are not in full-time private practice.

To qualify for our survey, they must:

 h ave had at least five years’ experience in the private sector;

 earn at least £5,000 gross a year from private practice;

 Be seriously interested in private practice as a business. This condition effectively excludes most small earners who look to their practices merely to meet some school fees or holiday costs.

But given the growth in parttime radiologists as described above, there are an increasing number of distortions in our results;

 h old either an old style N hs

maximum part-time contract or a new contract;

 Work either as a sole trader through a formal or informal partnership, limited liability partnership or group or a limited liability company.

All in all, the market changes and our self-imposed restrictions mean our survey results – which are most definitely not statistically significant – can only give some guidance as to what is happening in the market place.

i ncomes for those in private practice are continuing to increase on a gross basis. in some places, where there is a significant amount of self-pay business, cancer or urology growth is significant.

Where there is a large amount of Choose and Book work, incomes have also shown an increasing upward trend. This is despite pressure on fees for both the insurers and, in some cases, private hospitals, who are seeking to reduce their costs and improve their own margins.

s ome costs have shown increases. medical supplies/assistants fees have shown a small increase, for reasons we cannot readily explain.

staff costs have, of course, risen. Almost certainly this is the result of the increase in personal allow-

RaNge OF gROSS INCOMeS FOR RaDIOLOgISTS

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd.

ances, which encourages those who employ family members to increase remuneration packages. There has also been a rise in professional secretarial costs, where these are used.

There have been some increases in the average costs of professional indemnity. however, here matters are becoming increasingly blurred. There are other companies on the market offering more competitive

products. Whether these will turn out to be cheaper in the long term is not yet known. We would expect the rate of increase in indemnity premium costs to stabilise. There has been a modest increase in motor/travel expenses. This figure is perhaps distorted by some members of the sample who enjoy more expensive courses and conferences abroad.

All in all, the picture looks good

and a preliminary look at our 2016 data suggests that radiologist’s private practice incomes continue to grow.

Potential problem

But there is perhaps one more potential problem that could affect the situation. The law seems to be changing for those who are working privately primarily in the public sector. This is through a change of interpretation of the socalled iR35 rules.

i t is possible – though by no means certain – that, from April 2017, the tax situation of those radiologists who are doing predominately N hs work may become less attractive. For those working in the traditional private sector there is no change.

The current position is still unknown, but those radiologists primarily working on Choose and Book activity should probably be seeking professional advice now.

For those for whom this work is a small proportion of their activity, the future still looks very satisfactory at this moment.

Next month:

Urologists

Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists Stanbridge Accountants

what’S coMing in oUr april iSSUe

Make sure you don’t miss our next issue, published on 20 april. you may not receive every issue if you have not yet subscribed to the journal. Don’t risk missing out on vital topics we tackle next time, including:

 Is your trading structure maximising opportunities for pension growth? Cavendish Medical’s Simon Bruce on why you should ensure your practice and your pension are working together

 Confidentiality. a useful new series from the MDU, helping you unravel latest guidance from the gMC, kicks off with: Sharing information with police and other third parties

 How the Budget will affect private doctors and tips of what you can do

 The state of private practice: reports from the Independent Doctors Federation annual meeting

 Tax is going digital – an update on what is happening and what independent practitioners need to do

 gary Nials, of Medical Billing and Collection, presents ten checks and balances to improve your billing

 every business should have controls to ensure good records and accurate financial reporting. ebert Hyman explains how an internal audit can help small private practice businesses assess the suitability and accuracy of their internal controls

 Did you know marketing need not cost you a fortune?

 Top tips for busy doctors: communicating with patients in the digital age

 keep it legal – terms and conditions when setting up new business

 How private doctors can take cues from the business world to improve their patient satisfaction

 Doctor expert witnesses: check out advice from the latest BMa conference

 Our accountant’s Clinic shows how to manage cash flow effectively

 Business Dilemmas answers more of your questions

 See our monthly Code Buster! feature to see what procedure/ diagnostic code changes affect you

 Our Profits Focus benchmarking survey examines urologists’ earnings

 Philip Housden looks at the challenges of right-sizing the contribution of outpatient and diagnostic services within a PPU

 Our motoring medic Dr Tony Rimmer checks out the volvo v90

 Medicine’s Strangest Cases

 Plus all the latest news and views

aDveRTISeRS: The deadline for booking advertising for our april issue falls on 24 March

Published by The Independent Practitioner Ltd. Independent Practitioner Today is editorially independent and thanks Bupa for its assistance with distribution. Printed by Pepper Communications Ltd Material is governed by copyright. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form without permission, unless for the purposes of reference and comment. Editorial layout is the copyright of the publishers. If you wish to use it for promotional purposes on websites or for reprints, we would be happy to discuss licensing the copyright to you.

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eDITORIaL INqUIRIeS

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Email: robin@ip-today.co.uk

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aDveRTISINg INqUIRIeS

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Email: margifloate@btinternet.com Tel: 01483 824094

Publisher Gillian Nineham Tel: 07767 353897.

Email: gill@ip-today.co.uk

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