The robots are coming... ... but we shouldn’t be too perturbed by the boom in medical consultation apps P14
How you can prepare for a happy result in the new Care Quality Commission regime for private doctors
now P48
By Robin Stride
A new age of transparency for consultants’ private fees was ushered in this month amid concerns over its accuracy and practicality.
Some specialists also have fears about the workload and possible confusion the Competition and Markets Authority’s (CMA’s) demands will cause their administrative teams.
And there are suspicions that some consultants, especially solo practitioners in specialties with fewer regular links to private hospitals, will be unaware of the new requirements until they read this story.
What consultants must do, under Article 22.2 of the CMA Order, arising from its long-running inquiry into private healthcare, is to send patients written fee information before outpatient consultation (operative by 31 December 2017) and prior to further tests or treatment – by the end of last month.
Letters need CMA approval, but to make it easier for doctors and providers, a team – led by BMI general counsel and company secretary Catherine Vickery – drew up a series of template letters covering the costs of a patient’s care following on from a consultation.
These have been endorsed by the competition watchdog and late
last month they were put onto the Private Healthcare Inform ation Network (PHIN) website.
Providers are required to ensure their consultants’ fee information is always given by a letter from the specialist.
This must also signpost a patient to PHIN’s website to find what the CMA hopes will ultimately be useful information on the quality of hospitals’ and consultants’ performance.
Hospitals may use these template letters or their own version, so long as they have been signed off by the authority.
Some have disregarded the template letters and produced their own, meaning a consultant with practising privileges in several hospitals in London, for example, must use a variety of letters depending on where the patient is seen.
The template letters comprise initial consultation; post-consultation – all patients, further tests; post-consultation for non-private medically insured patients’ treatment; post-consultation for insured patients’ treatment; plus, a signposting text for those creating their own fee letters.
A PHIN spokesperson said: ‘We welcome this as a positive step in improving transparency in private healthcare.
‘The letters sent out from the
end of February help bring greater transparency in pricing and also direct patients to PHIN’s website, enabling them to find information about the hospital providing their care and compare with other hospitals in the local area.’
A CMA spokesperson told Independent Practitioner Today: ‘It is great that the Private Healthcare Inform ation Network has made these letter templates available for hospitals.
‘These new templates will ensure that patients are able to make decisions confidently, with full knowledge of their treatment and its cost. This should mean fewer disputes over charges, as patients should be clearer about the total cost of treatment.’
It advised any consultant whose hospital group has not provided them with an approved template to ask it to do so ‘straight away’.
Independent healthcare management consultant Rosemary Hittinger, an associate adviser to
the Federation of Independent Practitioner Organisations (FIPO), commented: ‘Do I have sympathy for PAs. I can see everybody going mad, making sure they’ve sent the right letter for the right hospital.’ She said this was one of the issues FIPO had raised, as it was ‘very concerned’ the fees clarity drive would make things increasingly complex for consultants and patients.
➱ continued on page 3
Independent practitioners are to lose an influential voice in their marketing armoury – the Association of Independent Healthcare Organisations (AIHO) has dropped the bombshell that it is shutting up shop with the loss of five jobs.
It revealed a surprise plan for its role to be taken on from June by a trade association representing independent sector providers of NHS clinical services. n Read the full story on page 3
How to look after your data
Some timely tips about data-sharing and reporting serious data breaches P20
consultant entrepreneurs in action
What are the aims of the new research & outcomes centre for orthopaedics? P32
How the profession evolved author Suzie Grogan traces the development of surgeon-apothecaries P36
Something to build on our series on building your own clinic looks at registration and funding P40
By edie Bourne
cash flow: li£e-blood of your practice advice on improving cash flow by dint of better billing and collection P42
your second steps in private practice
Independent practitioners are being warned to beware of a potential new blow to their pension savings.
This ‘taper’ reduces the permitted pension contributions down on a sliding scale from £40,000 to as little as £10,000 a year.
Your ‘year two’ in private practice is a time for review, says a medical accountant P52
PlUS oUr regUlar colUmnS Business Dilemmas: a tricky power of
editorial comment
Our more senior readers may recall the bad old days when junior doctors had no craft body of their own nor negotiating rights with the Government. Instead, they were ‘represented’ (Of course they were!) by the Central Committee for Hospital Medical Services. That was the grand old title for the BMA’s negotiating committee. For consultants, dear boy.
Medico-political history and the fight for junior independence came to mind when we learned that the Association of Independent Health care Organisations was to be wound down and its role taken up by a
body many private consultants and GPs will have never heard of (see page 1 and page 3).
The NHS Partners Network. Really? Starting with the first word, it is an unlikely name for a private healthcare voice. How it will take over AIHO’s work and truly speak for this sector’s interests, we can’t wait to see.
Of course, it has stated that although part of the NHS Confederation group, it will represent ‘the interests of the entirety of the independent healthcare sector’. So that should mean private consultants and GPs, including fulltimers in private practice.
tell US yoUr newS Editorial director Robin Stride at robin@ip-today.co.uk Phone: 07909 997340 @robinstride to advertiSe Contact advertising manager Margaret Floate at margifloate@btinternet.com Phone: 01483 824094 to SUBScriBe lisa@marketingcentre.co.uk Phone 01752 312140
Publisher: Gillian Nineham at gill@ip-today.co.uk Phone: 07767 353897
Head of design: Jonathan Anstee chief sub-editor: Vincent Dawe Circulation figures verified by the Audit Bureau of Circulations
Specialist financial advisers have told Independent Practitioner Today that those who owe tax on their pension contributions due to breaching harsh new annual savings limits could face the ‘headache’ of now being unable to ask the NHS Pension Scheme to pay their tax charge – something that was available to doctors in the past.
If doctors breach the annual allowance, which restricts the amount that can be saved into a pension while still receiving tax relief to just £40,000 a year, they will be charged tax on the excess savings at their marginal rate of income tax.
Unfortunately, the ‘Scheme Pays’ option may only be applicable to the proportion of tax charges caused by exceeding the standard annual allowance of £40,000, not breaches of the new tapered allowance.
Patrick Convey, technical director of specialist financial planners Cavendish Medical, explained: ‘The tapered annual allowance is complex already, but the rules surrounding the taper and ‘Scheme Pays’ will cause a headache for many.
Normally, they will have the option of applying for ‘Scheme Pays’ – requesting that the NHS Pension Scheme pays some or all of the tax bill in exchange for reduced future benefits.
Interest accrues on the amount the scheme paid at the rate of 2.8% each year plus the relevant rate of inflation measured by the consumer price index.
The amount owed will be converted into a reduction of pension and lump sum benefits upon retirement, but there can be tax advantages in doing this.
But, since April 2016, there is also a new ‘tapered annual allowance’ for those doctors with adjusted earnings of over £150,000 – that is to say, all their NHS and private earnings plus interest from savings plus the actual growth in the pension itself.
‘If your pensions’ savings exceed both caps – the tapered allowance at whatever rate is relevant to you, plus the standard annual allowance, you could still qualify for ‘Scheme Pays’, but only on the portion of the excess above £40,000.
‘To make matters worse, you may not have received your annual pension savings letter from the NHS in time – or at all –so do not have a clear picture of your position. The NHS is only required to issue statements to those breaching the full annual allowance, not the tapered limit, so you may be entirely unaware of where you stand.
‘If you believe you may be affected, and most middle to senior doctors will be – do not delay in clarifying your own status. The deadline for Scheme Pays is normally 31 July each year, but it can take several months to gain the necessary information from the pension schemes.’
see ‘Can you afford your bucket list?’, page 48
By robin Stride
Private consultants and GPs have voiced concern over the shock announcement of the imminent demise of a useful ally – the Association of Independent Healthcare Organisations (AIHO).
The NHS Partners Network (NHSPN), launched in 2005 and later incorporated into the broader NHS Confederation, plans to take over the job.
On the latter’s website it describes itself as ‘the authentic voice of NHS leadership. We are the only membership body that brings together, and speaks on behalf of, the whole health and care system’.
AIHO has many more private hospital members than the NHSPN, but the big groups are members of both, fuelling concerns in some quarters over their subscription costs.
In a joint statement, they claimed NHSPN, while remaining part of the NHS Confederation group, would represent ‘the interests of the entirety of the independent healthcare sector’.
But the move drew an unenthusiastic response from the Independent Doctors Federation (IDF).
Its president, consultant physician Dr Brian O’Connor, said: ‘I am saddened to hear that AIHO will no longer represent hospitals delivering privately funded healthcare having acted for private hospitals focusing on independent sector care only.
‘NHSPN represented those independent providers of NHS-funded services. This was a perfect arrangement, as independent and purely private hospitals have different needs and diverse challenges to those providers of NHS-funded services.
‘The IDF is surprised to read that all private hospitals will now apparently be represented by NHSPN –without discussion or consultation with the medical profession, many of whom are in full-time non-NHS independent practice.’
AIHO chairman Des Shiels, chief executive at Aspen Healthcare, said: ‘As a membership organisation, it is vital everything we do reflects our members’ needs and changes with them.
‘As most of our members now deliver both NHS-funded and privately-funded services, it makes absolute sense for there to be a single organisation working to represent their interests.’
AIHO and NHSPN’s joint statement added: ‘The move reflects the fact operators in the market wish to see industry representation cover all parts of independent sector service delivery including both NHS-funded and privately-funded services.’
Traditionally, they recalled, both organisations represented two clearly defined areas of independent healthcare provision, namely NHS and privatelyfunded healthcare.
AIHO was the trade association representing hospital members delivering privately-funded healthcare services.
NHSPN was the trade body for independent providers of NHSfunded services covering a range of sectors from acute to primary and community care as well as
Plans to force consultants to publicise fees may by stymied by the practicalities of executing them.
Healthcare managment consultant Rosemary Hittinger said: ‘FIPO fully supports the concept of giving clear fee estimates, but it wants to continue to uphold professional integrity and standards so that each individual patient that comes to see a consultant receives the most appropriate care for their particular situation.
‘Overall, the transparency move is a good one, but the practicalities of implementing it in blanket fashion is going to raise all sorts of issues. But we are doing the best we can and trying to make sure
everyone knows what their responsibilities are.’
She said issues included:
Monitoring consultants’ compliance when patient pathways were far from straightforward;
Differing ways of working in different practices could alter how and when a patient might be able to get a fee estimate that was unambiguous and could inform their choice;
Consultants’ fees formed only a comparatively small part of the bill for inpatient care, so it would be difficult to give patients the full information. That could lead to mistrust and disillusion;
Private insurance policies vary in terms of excess and what they
do and do not cover. FIPO believes insurers ‘need to be as transparent as consultants’.
Part of FIPO’s work has been informing its member organisations about the fee letter requirement, but there was ‘probably some lack of knowledge about this requirement’ on the ground. But she added: ‘This is a beginning, it’s not a slam dunk completion.’
PHIN starts publishing consultants’ fees on its website next year. It is talking with hospitals and stakeholders on the implementation. A spokesperson said: ‘We are working with all these groups to make sure the system works.’
Templates are available on the website portal.phin.org.uk.
diagnostics and clinical home healthcare.
But they went on: ‘As the healthcare economy has developed over recent years, however, there has been a significant increase in the number of independent healthcare organisations simultaneously delivering services for NHS patients and for private patients.
‘In the view of the industry, this makes the time right for creating a single entity for the independent healthcare sector covering all parts of the market offering a stronger, united voice on behalf of the industry, which will help ensure patients receive the highest possible standard of care no matter how it has been accessed.’
AIHO’s remit has always been to represent hospitals, but independent practitioners benefited from much of the publicity it generated for the sector, its campaigns and resource materials.
Only a few weeks ago, it launched two major campaigns aimed at driving more self-pay patients towards private healthcare.
AIHO chief executive Fiona Booth declined to comment on the latest events.
our april edition sees the 100th issue of independent Practitioner today, which we launched in 2008. to celebrate, we will be publishing 100 tips for private doctors, drawn from every edition so far.
By Edie Bourne
The surgeon leading an independent review into how manslaughter by gross negligence is applied to medical practice is confident doctors will find the work valuable.
The former Royal College of Surgeons of England president Dame Clare Marx said each step of the process would be explored, from local investigations after incidents, to diversity matters surrounding the doctors subject to investigation and whether regula-
tory processes at the GMC could be improved in such cases.
She said: ‘Doctors are often working in an immensely pressurised system where mistakes can happen. This work will be valuable for the medical profession and I am pleased the GMC has decided to take this work forward.’
Dame Clare, chairman of the Faculty of Medical Leadership and Management, will study how gross negligence manslaughter cases are initiated and investigated.
Bupa Cromwell Hospital has moved closer to achieving its strategy to become paper-light by partnering with clinical technology specialist IMS MAXIMS to extend the roll-out of an electronic patient record.
The hospital will deploy the company’s electronic order communications and results reporting to introduce new processes to improve access to medical tests.
Hospital medical director and spinal surgeon Mr Matthew Shaw said the ‘fantastic example of leading-edge software’ allowed patients to receive more responsive care and consultants to work more flexibly from multiple locations.
The development will digitise the way clinicians manage diagnostic tests, starting with radiology and pathology services.
Staff should be able to order and view results instantly and eliminate delays, bottlenecks and errors associated with paper-based systems relying on manual interventions.
MAXIMS will integrate with the existing patient administration
system (PAS) and diagnostic systems, giving clinical staff access to results when they are on and offsite, at any time.
It said clinicians could be confident an order had been sent to the right person without the risk of transcription errors and could track progress in patients’ health records.
Key activities such as configuring the product for the hospital’s needs, defining new business processes, developing data and management reports, and training staff will be led by IMS MAXIMS.
Cromwell won’t have to find, fund or train additional internal resources, but the technology team will work closely with consultants to meet clinicians’ and patients’ needs.
Bupa Health Services IT director Paul Cowley said the hospital had ambitious plans for using digital to reconfigure and improve services.
The technology firm’s commercial director Leesa Ewing said the Cromwell was ‘laying the foundations for a world-class, digitally enabled hospital’.
The work will bring together defence organisations, patient, legal and criminal justice experts to analyse how existing processes can be improved. It will look at:
The pathway from reporting to investigation and prosecution;
Distinguishing between errors and exceptionally bad failings;
The expert witness role;
The need for reliable data to support a genuine understanding of incidence and trends.
It aims to support doctors in raising concerns and encourage
reflective practice, while improving patient safety.
GMC chief executive Charlie Massey said the review aimed to encourage a renewed focus on enabling a learning, no-blame culture, reflective practice and provision of support for doctors in raising concerns.
This work and the Department of Health’s rapid review into whether gross negligence manslaughter laws are fit for purpose in healthcare in England will inform each other.
Prof Hashim Ahmed, consultant urological surgeon at the Bupa Cromwell Hospital, has been named the UK’s Prostate Cancer Specialist of the Year in the Private Healthcare Awards 2018. He won the accolade at an event hosted by Global Health & Pharma, which celebrates innovative people, departments and firms in medicine.
their initial prostate check through to their diagnosis and treatment options.
Prof Ahmed was instrumental in rolling out Bupa’s prostate care pathway, a new diagnosis journey which quickly takes patients from
The pathway ensures that, if an irregularity is found, a patient can go through diagnostic testing at one of the insurer’s central London clinics, before being referred on to a consultant at the Bupa Cromwell Hospital or at a Bupa clinic within hours, if needed.
Bupa said the new pathway was designed to reduce customer admin and create a more efficient route to diagnosis and treatment.
Dr Brian Donley will run the Cleveland Clinic’s 205-bed hospital being built in London’s Grosvenor Place
Cleveland Clinic chief of staff and clinical operations, Dr Brian Donley, has been appointed chief executive of the company’s London hospital, currently under construction.
He plans to continue his current roles in the US and commute until the autumn.
Dr Donley said: ‘I’m confident in our collective ability to introduce our unique model of care into the London healthcare landscape. Our mission, vision and values translate well to all areas of the globe.’
Since joining Cleveland Clinic as an orthopedic surgeon in 1986, he has held numerous leadership positions. He is also a professor of surgery in the Cleveland Clinic Lerner College of Medicine.
The new boss of The London Clinic has promised the hospital is committed to helping its consultants grow their businesses.
Al Russell, appointed chief executive of the hospital permanently after being in charge on an interim basis since last September, said the clinic would work to establish a leading position in the capital’s private healthcare.
Clinic chairman Hamish Leslie Melville said Mr Russell’s appointment reflected ‘positive work in formulating a new business strat-
As chief executive in London, he will direct strategy and operations, guide recruitment and lead the opening of the 205-bed salaried consultant facility near Buckingham Palace.
The new hospital at 33 Grosvenor Place – a six-story, 198,000-squarefoot building – will be the clinic’s first facility in the capital and should open in the second half of 2020.
It will have eight operating rooms, a full imaging suite, endoscopy and catheterisation labs, day case rooms for surgery, and a full neurological suite with rehabilitation.
The facility will offer specialty services focusing on general surgery, cardiology and neurology.
Al Russell has been interim chief executive since September
egy that I believe will significantly strengthen the clinic’s performance’.
“Before joining the clinic as a trustee, he held various leadership roles at Vodafone.”
Around 800 consultants have practising privileges at the hospital.
By Olive Carterton
New guidance from the Royal College of General Practitioners (RCGP) is on its way to GPs thinking about offering alternatives to face-to-face consultations.
According to college vice-chairman Prof Kamila Hawthorne, innovative use of technology must continue to be explored in general practice, so long as it is safe, effective and leads to better outcomes for patients and the practice.
Responding to a study published on electronic alternatives to face-to-face consultations with GPs in the British Journal of General Practice, she said: ‘Many GP practices are already offering online consultations in some form, and we know that they are convenient for some patients.
‘However, we also know – and this research backs this up – that
they don’t necessarily help to alleviate workload pressures on GPs or improve access to general practice services for patients.
‘Online and telephone consultations can be great for some patients, but they won’t be suitable for others – and if practices do choose to offer them, then it should be as one way to access GP services, not the only way.’
She said the RCGP agreed with the researchers that any practices thinking about alternatives to face-to-face consultations should do so after careful consideration of the implications for itself and patients.
‘If this route to consulting with patients is being considered by a practice, practice policies must be developed carefully, agreed by all in the practice and followed to ensure patient safety.’
See ‘The robots are coming’, page 14
The GMC is to routinely accept an additional test as proof of English language skills from overseas doctors wanting to work in the UK. It aims to increase flexibility for doctors while maintaining a requirement for a high standard of English.
The medical regulator will start accepting the Occupational English Test (OET), as an alternative to the International English Language Test System (IELTS) it already accepts, as proof of a doctor’s language competency. OET is designed for healthcare
professionals and includes real scenarios similar to those they would be likely to encounter in typical workplace situations.
GMC chief executive Charlie Massey said: ‘We are giving overseas doctors an alternative way of demonstrating their English skills, but without reducing the high standards we require and that patients would expect.’
The test, recognised by the UK’s Nursing and Midwifery Council and others, can be taken in more than 100 locations in 40 countries.
nonsurgical methods still carry risk
By Leslie Berry
Plastic surgeons have issued an alert for patients to beware of dodgy deals in the aesthetics market following a national fall in cosmetic surgery procedures last year.
As expected, surgical procedures are still slightly declining overall – by just under 7% – now that there are so many less invasive enhancement options to explore.
But the British Association of Aesthetic Plastic Surgeons (BAAPS) has appealed to patients to be on their guard when considering treatment.
BAAPS president and consultant plastic surgeon Mr Simon Withey said: ‘Although there may be some new non-surgical options for cosmetic treatments, it is important to remember that “non-surgical” does not mean “non-medical”, and patients should be wary of anything touted which seems too good, or too cheap, to be true.
‘The climate of lax regulation has yet to be addressed in a satisfactory manner to protect the public.’
He believes the slight downturn in cosmetic surgery procedures demonstrates a ‘normalisation’ as the public are now more aware about the serious impact of surgical procedures.
Mr Withey added: ‘The slight downwards shift in surgical procedures overall hopefully continues to demonstrate that, at the very least, patients are realising that cosmetic surgery is not a “quick fix” but a serious commitment.’
The top surgical procedures for men and women in 2017. Total 28,315, a fall of 7.9% from 2016. Figures in order of popularity:
The top surgical procedures for women in 2017. Total 25,898, a fall of 8.6% from 2016. Women had 91% of all cosmetic procedures in 2017. Figures for women in order of popularity:
up 7% from 2016
The top surgical procedures for men in 2017. Total 2,417, a rise of 0.3% from 2016. Men had 9% of all cosmetic procedures in 2017. Figures for men in order of popularity:
Annual statistics from the British Association of Aesthetic Plastic Surgeons (BAAPS) have revealed a ‘surprising’ divide in aesthetic procedures between the sexes.
Men in 2017 eschewed almost all forms of body treatment – with procedures such as liposuction (down 20%), tummy tucks (down 12%) and ‘man boobs’ (gynaecomastia, down 7%).
They showed a marked predilection for facial procedures instead, such as eyelid and brow lifts surgery (up by 25% and 27%) and facelifts (up 16%).
Conversely, women’s choices were mainly focused on the body alone. The overall trend last year was to shun facial treatments –female facelifts declining by as much as 44% and brow lifts drooped by 31%. Breast augmentation perked up by 7% and remains the most popular procedure.
BAAPS, which represents the clear majority of NHS-trained consultant plastic surgeons in private practice, ascribe this change as indicative of changing societal trends.
Mr Withey said BAAPS’s 2017 audit of procedures done by its members also offered valuable new insights into the extent that Britons’ online personas may be driving offline behaviours.
Consultant plastic surgeon and former BAAPS president Mr Rajiv Grover, who compiles the annual audit, explained: ‘For men, the media’s adoption and celebration of the more natural looking “dad bod” is possibly a driver in this interesting trend, shifting the focus to the face rather than the body, in contrast to recent years. This shift has lessened the pressure to sport a sculpted figure and instead, accept a bit of roundness or softness. Society unfortunately has a history of being more forgiving towards men’s physiques than women’s.’
So why the body trend in
women? BAAPS suggested one reason might be developments in social media. Millennials are expected to take as many as 25,000 selfies in their lifetime and more than half of women admit to enhancing every photo they ever post.
Mr Grover continued: ‘The advent of myriad filters in social media platforms allows for the ubiquitous enhancing and facial feminising of “selfies”. However, there are fewer options to reach online “fitspiration” when it comes to body goals.’
He suggested it is also possible that fashion may also play a part; for example, the growing trend of activewear such as yoga pants and Lycra leggings being worn in everyday life, perhaps demanding a more toned shape.
‘Both of these factors may potentially be the reasons why women’s focus for cosmetic surgery in 2017 has shifted from their face to their body in order to address the stubborn areas that neither diet, exercise, nor filters can reach.’
It is also known that women prefer and post more portrait photos with direct eye contact, while men prefer more full body shots – but viewers are likely to be kinder to men.
Data from the 2017 BAAPS annual audit shows that the number of Britons undergoing cosmetic surgery is slightly decreasing – down 7.9% in 2017 from the previous year.
Consultant plastic surgeon Mr Rajiv Grover said: ‘Traditional liposuction is radically down across both genders (28% decrease), which we usually credit to the “cooling effect” of new non-surgical procedures such as fat freezing.
‘However, abdominoplasties (tummy tucks) are up – indeed increasing from sixth to fourth most popular procedure – as there are no less invasive options capable of achieving significant results to eliminate excess skin.’
DoCToR
SPeCiALTy
Mr Kavin Andi oral, maxillofacial, head and neck surgery
Dr Matthew Banks Gastroenterology
Dr Devinder Bansi Gastroenterology
Ms emma Beddow Cardiothoracic surgery
Dr Huw Beynon Rheumatology
Dr Phang Boon Lim Cardiology
Mr Luke Cascarini Maxillofacial surgery
Mr Peter Clarke Head, neck and skull surgery
Mr Simon eccles Plastic surgery
Mr Paul Harris Plastic surgery
Mr David Hrouda Urology
Dr Peter irving neurology
Dr Gavin Johnson Gastroenterology
Dr Alexander Lyon Cardiology
Dr omar Malik neurology
Dr Hadi Manji neurology
Mr Angus Mcindoe obstetrics and gynaecology
Mr Sean Molloy orthopaedic spinal surgery
Mr David nott General and vascular surgery
Mr Kevin o’neill neurosurgery
Mr Jonathan Ramsay Urology
Mr Guri Sandhu otolaryngology
Dr Jeannie Todd endocrinology
Prof Jayant Vaidya Surgery and oncology
Dr Mark Vanderpump endocrinology
Twenty-five doctors in the UK have been selected from nearly 2,000 nominations for the first UK Top Doctors Awards.
Doctor nominators were asked to put forward those specialists whom they themselves would go to in times of need and whom they would trust with their own health or that of their family
The awards were made by global digital company Top Doctors, which helps patients identify leading private specialists and clinics.
It said the awards acknowledged outstanding medical talent and the highest level of care in private and public healthcare as recognised by fellow doctors and specialists.
Similar awards have been running for a decade in the US and since 2014 within Europe and Latin America.
A spokesman said: ‘This award is positively valued by patients when searching for and choosing a specialist. It serves as recognition of the trust placed in the doctors by their own peers, and as acknowledgement of the high level of care and attention they provide to patients.’
It said specialists were not only identified for their experience, skill and abilities, but also for the time they took with each patient and their level of attention and care.
Globally, Top Doctors has more than 60,000 members and 500,000 appointments booked a year. First launched in the US, it is now present in Spain, Italy, Mexico, Colombia, Chile and now the UK.
It added: ‘Via a rigorous fourstep selection process, only one in ten specialists who apply to be a Top Doctor are successful. Selection is through peer-to-peer recommendation, external evaluation by Adecco Medical & Science, approval by a panel of expert clinical leaders and personal interviews.’
Nominations for this year’s awards are now open. All registered doctors can recommend those they feel deserve recognition through the ‘nominate doctors’ section on the Top Doctors web page www.topdoctors.co.uk/ nominations, which also contains further information on the nomination process.
By Charles King
A former independent doctors’ leader has retired with a high-profile blast at the red tape plaguing the private practice business.
Dr Martin Scurr said: ‘I’d always intended to work past three-score years and ten, but at age 65 I abandoned my practice because I just couldn’t face any more ridiculous inspections about the type of soap we use or the rigour of yet another annual appraisal.
simply down to the lure of gold.
Dr Scurr wrote: ‘I speak as someone who recently retired from the independent sector with no attached pension and what pushed me finally to give up was over-regulation.’
‘This testing process lacks any evidence base to support the hoops through which we’re expected to jump.’
The former chairman of the Independent Doctors Federation (IDF) let rip in his weekly Daily Mail column after reports of NHS GPs retiring earlier to avoid paying punitive taxes applying to £1m+ plus pension pots.
He said while many GPs benefited from healthy pensions, he doubted their early retirement was
About red tape, he said: ‘I had to prove my probity, that my conscience was clear – i.e. I’d not behaved in an inappropriate manner – as well as producing proof of endless sessions of retraining in political correctness, including child protection, CPR (resuscitation techniques) in classes aimed at the non-medical lay person, and various equally simplistic, but patronising, enforced charades.
‘I am not against regulation per se, but this was not the way to ensure quality medical care.’
He said generous pensions and tax penalties had made early departure possible. ‘Who could blame them?’
What’s the worst red tape that’s tying you up? Write to robin@ip-today.co.uk
Organisers of this year’s BMA private practice committee conference say they plan something for all types of independent practitioners.
The meeting, on 11 April at BMA House, London, will examine the ‘ins and outs’ of private practice from the logistics of first setting up to ensuring established practitioners are reaching their maximum potential.
With doctors in independent healthcare continually having to adapt their practices to an everchanging landscape, the conference will look at the threats and opportunies of going private and give new and established independent consultants and GPs lots of tips.
Attendees have a choice of sessions to go to in the afternoon, with parallel meetings for specialists and GPs on setting up and developing their private practice. A third session will cater for established practitioners.
The private practice committee said the meeting would end with a chance to network over drinks with colleagues who are at all stages of practice. New entrants have found this is particularly valuable.
Conference highlights include: Mr Geoffrey Glazer, chairman
of the Federation of Independent Practitioner Organisations (FIPO), highlighting the current issues facing secondary care clinicians; An update on the changing face of mandatory indemnity for doctors in private practice. The panel of speakers includes Dr Mike Devlin, MDU; Mr Andy Foley, Bespoke Medical Indemnity; Dr John Holden, MDDUS; Prof Carol Seymour, MPS;
Ms Clare Barton, the GMC’s assistant director of registration and revalidation, on revalidation of primary and secondary care private clinicians;
Dr Sarah Jordan, a GP at The Portobello Clinic, on how to set up as an independent GP.
BMA private practice committee chairman Mr Derek Machin told Independent Practitioner Today : ‘I would encourage doctors, particularly if they have never attended, to consider coming to our private practice conference. The theme of the conference is “Setting up and Developing Your Private Practice”.’ CPD accreditation applied for. Cost for BMA members is £150, non-members £200, including VAT.
To register, visit www.bma.org. uk/events/2018/april/privatepractice-conference.
Royal Marsden enters Harley street
Royal Marsden’s Council of Governors has approved a new private outpatients and day care facility on Cavendish Square to ease a shortage in private patient capacity which is limiting the trust’s growth.
It will open in April 2020 to meet growing demand for UK and international patients and to respond to the increasingly competitive private healthcare market in London.
The Private Care Diagnostics Centre will support the continued
expansion of private patients earnings in the trust, which, as the largest NHS PPU provider, reached £91.8m in 2016-17, representing 31.4% of trust incomes.
The importance of the £250m-ayear market in central London is such that to maintain a competitive position in the private healthcare business, the trust is considering an interim private patient diagnostics facility in conjunction with another NHS provider to fill the two-year gap before the Cavendish Square unit opens.
Harley street at Queen’s, Romford, closes
Harley Street at Queen’s has closed. The service opened at Queen’s Hospital, Romford, Essex,
in 2010 as a partnership between HCA Healthcare UK and Barking, Havering and Redbridge University Hospitals NHS Trust.
The trust received income from rent and a variety of service-level agreements for the provision of core services, imaging, theatres and critical care. Services included 14 inpatient beds, six chemotherapy treatment chairs and two consulting rooms in the outpatient department. HCA nursing and administrative staff moved out of the hospital when the service closed at short notice at the end of January.
A HCA Healthcare UK spokesman said: ‘After a successful sevenyear partnership, HCA Healthcare UK and Barking, Havering and
Redbridge University Hospitals NHS Trust mutually agreed to end our contract.’
It is understood that the service treated approximately 1,500 inpatient and day cases from a range of specialties, with oncology making up a majority.
Trust financial returns from the arrangement have been falling in recent years, with annual accounts showing £331k revenues in 201415 but down to £159k in 201617. It is unclear what the trust now intends to do regarding the local private patient opportunity, but it is understood the facilities have been redirected to NHS capacity.
Philip Housden is a director of Housden Group. See page 44
By Robin Stride
Consultants are doing better than hospitals in the race to publish private performance data ordered by the Competition and Markets Authority (CMA).
They have been congratulated for making good progress while many of the places they work at have lagged behind.
Over 10,000 consultants have been invited to begin checking their data and providing feedback on data quality, with over 3,000 doing so in the first few weeks.
The Private Healthcare Information Network (PHIN) online portal has been described by Independent Doctors Federation president Dr Brian O’Connor as ‘a superb opportunity’ for consultant to showcase their clinical expertise and excellence’.
It appears hundreds of specialists have taken this on board and the data publisher described this as encouraging and ‘well ahead of expectations’. It said it had so far received generally positive and actionable feedback to date.
PHIN is due to publish the first performance measures for individual consultants in private practice this summer, with fees information following from next year.
Chief executive Matt James said, however, that it had taken hospitals ‘a while to get started’ and it was not yet ready to publish statistical results.
PHIN chairman Dr Andrew
PHin has also released new information on Patient experience to work alongside the current recommendation score which mirrors the nHS Friends & Family test.
Private hospitals scored well on treating patients with respect and dignity and giving patients privacy (both around 98%), but less well on making sure that somebody is available for patients to talk to,
Vallance-Owen said just over 80 hospitals had shown some form of participation, ‘but more needs to be done.’
The organisation last month tried to encourage greater participation by revealing the private healthcare providers making the most progress toward being able to publish measures of the imp rovement patients experienced from common types of surgery.
especially about medicines (around 90%).
PHin boss Matt James said: ‘We require data from private hospitals that enable direct comparison with the nHS wherever possible.
‘the six patient experience questions were selected from the nHS inpatient Survey as that most relevant to elective care. overall, 94% of patients report that their needs were met.’
ment of the benefit delivered.
Circle Health had begun reporting health outcomes at its three sites, collecting and providing outcomes data for 20% of all eligible procedures. PHIN’s website rated these hospitals as ‘Good’ for participation in outcomes measurement, an interim assessment in lieu of full results.
Spire Hospitals lead the way with five hospitals making ‘good progress’ in collecting and providing health outcomes data, and a further 31 having started the process.
PHIN said The Spire Leicester Hospital had helped the highest number of private patients (137) to complete health questionnaires before undergoing common procedures, with a postoperative questionnaire enabling assess -
The Robert Jones and Agnes Hunt Orthopaedic Hospital, a specialist orthopaedic NHS hospital which treats private patients, was also praised for collecting and providing data from the highest proportion of eligible patients (28%), although PHIN added: ‘But, due to the lack of postoperative questionnaires, they currently appear on PHIN’s website as having made “Some” progress.’
Mr James said: ‘Health outcome measures help patients to under-
orthopaedic surgeon Mr Richard Carrington notched a european ‘first’ when he used the robotic-assisted navio system at Spire Bushey Hospital for a knee replacement operation using the navio Robot assisted system. He said: ‘this really is the cutting-edge of joint-replacement technology and i am sure it will prove a great success for surgeons and patients alike.’
the Smith and nephew system (pictured right, inset) allows surgeons to minimise the amount of bone removed from a damaged knee before positioning the implant in the
right place to achieve optimum joint stability. Spire said that unlike other robotic-assisted tools, navio took away the need for a preoperative Ct scan to provide an image of the operation area. instead a probe feeds a 3D ‘roadmap’ of the knee into a computer, providing the surgeon with all the data needed to create a specific surgical plan for each individual patient. the computer then feeds back information about the knee allowing the surgeon to accurately remove damaged bone to make way for the implant.
stand the extent to which they might benefit from surgery, for example, through reduced pain or increased mobility.
‘We have an ambitious programme of outcomes measures potentially covering 13 common procedures. It has taken the hospitals a while to get started, and we’re not yet ready to publish statistical results, but we want to recognise those hospitals that are making good progress and, hopefully, encourage others to do the same.’
The NHS has two mandatory outcome measures, for planned hip and knee replacements, and typically more than 50% of patients complete both questionnaires, PHIN said.
All hospitals treating private patients are required to collect data and report health outcomes for 13 common procedures to PHIN if they treat enough patients to have the potential to produce valid statistical results.
Former surgeon Dr VallanceOwen said: ‘Everything that PHIN does builds toward better information for patients and greater transparency in private healthcare.
‘I have always strongly advocated measuring health outcomes as a tool for listening to patient feedback and improving clinical care. With over 80 hospitals showing some form of participation, it is clear that progress is being made, but more needs to be done.’
By Robin Stride
Rocketing indemnity and insur ance fees are definitely not the fault of doctors, a defence expert assured a meeting of consultants.
Dr Matthew Lee, MDU profes sional services director, told them the whole issue of fast-rising costs was an issue that society needed to address.
Cases were now being brought against his members valued at over £20m each, he told special ists at an event organised by Federation of Independent Practitioner Organisations (FIPO)/ London Consultants’ Association.
The meeting also heard from defence lawyers at Hempsons who revealed some cases were trying for £40m.
claims were emerging as a particular problem, he said.
attributable to the cost of future care, but the MDU argued much of this cost could be mitigated if the law was changed to allow defendants such as his union to buy NHS and social care packages to meet patient needs.
Currently, Section S2(4)of the Law Reform (Personal Injuries) Act 1948 and subsequent case-law meant that the availability of NHS and local authority care was disregarded when calculating the compensation amount.
Dr Lee called for the law to be changed, diverting badly needed funds back into the NHS and public facilities for the benefit of all patients, including those whose need for long-term care was not due to negligence.
poll shows 40% suffer in silence
Baby boomers in the UK are needlessly suffering pain, preventing many from living their lives to the fullest, according to orthopaedics group Fortius Clinic, London.
In a study, they found 42% of those over 50 years of age are currently living with pain – such as knee, hip, back or neck pain – and 85% have suffered over the last two years.
The pain is so severe that twothirds of sufferers have been prevented from leading normal lives, being unable to drive, see friends or play sports, with one in ten admitting it has affected their mental health.
Dr Lee said rapid inflation in the size of high-value claims was not only costing the NHS billions of pounds each year, but was also driving up indemnity costs for independent practitioners in higher-risk specialties – with profound consequences.
He warned that the current clinical negligence environment was unsustainable. But this was not the fault of doctors. Their clinical standards remained demonstrably high and, if anything, healthcare governance and regulation had tightened.
Claim numbers and costs were outside doctors’ control at a time when some lawyers were stimulating more claims to rise by
Many higher-value cases had more than doubled in size due to the Government’s controversial change last year in the discount rate, the legal formula used for calculating compensation pay-outs.
An MDU case where a patient had tetraplegia following spinal surgery and 45 years’ life expectancy could receive a compensation payment of £9.2m under the previous discount rate. But this had shot up to £17.4m, under the new one.
Dr Lee took his audience through a detailed example, breaking down the cost of an illustrative claim of £11.5m for a 29-year-old male who sustained a brain injury after suffering a cardiac arrest.
Over £7m of the damages were
Optegra Eye Health Care has appointed Richard Armitage as director of its Birmingham hospital on the Aston University campus. Mr Armitage, who has had a diverse healthcare career with
Nuffield Health, said: ‘The structure at Optegra was of great appeal, as there is opportunity to really make a personal contribution and continue to build the Birmingham business in a growing market.’
While welcoming a Government review in the way the discount rate is set and whether further controls are needed of claimants’ legal costs, he said more radical measures were needed to curb clinical negligence costs.
The MDU continues to campaign for a package of legal measures that will make the claims system more proportionate and sustainable. Details available at themdu.com/faircomp.
That’s the way the money goes: In a later issue, Independent Practitioner Today will run a detailed article, breaking down all the costs and aspects assessed in a big pay-out. More news from the FIPO/LCA meeting next month.
But despite living in crippling pain, 64% are suffering in silence by either putting off or never seeking treatment. On average, those who delay treatment do so for 16 months.
Consultant orthopaedic surgeon Mr Andy Williams said: ‘The number of people putting off seeking help for joint pain is staggering.
‘Over-50s today are more active than ever and should be looking forward to so many more healthy years ahead – but by ignoring their pain and disability, and the success of joint replacement, they are condemned to prolonged suffering.’
Knee pain causes the longest suffering, with 57% delaying or never getting treatment and those who delay doing so for an average of 17 months.
Hip pain is the most commonly ignored with 63% of people delaying treatment or not seeking it at all. Those who delay do so for an average of 14.5 months.
Research was conducted online by Opinium among 1,013 over50s in the UK, 2-7 February 2018.
As anyone in private practice will vouch, having a good book-keeper or practice manager who can focus on the numbers and necessary administration can prove invaluable.
Yet how many in the profession are making sure their back office is working in the most efficient way for their business?
Susan Hutter (below) gives her guidance on how the profession can get the most out of their office team
One Of the biggest mistakes any independent practitioner can make is to only reconcile bookkeeping and other business records annually.
Letting everything pile up over a year means errors are often made and sorting these out can take ages to unravel.
And this can mean higher bills if your accountant has to get involved. Make sure as a matter of priority that administration and paperwork for your business is carried out monthly or, at the very least, quarterly.
That way, everything is much fresher, paperwork easier to find or access and fewer mistakes over the financials will be made.
Regular book-keeping means your accountant and business adviser can help cash flow and look at ways to reorganise debt, if necessary, or speak to the bank if extra funds are needed.
Get your practice manager or book-keeper to put a regular date in the diary where the focus is
purely on accounts and reconciling the books. This will go a long way to ensure the vital organisation is not cast aside for another important task.
for practices trading as a limited company, there is a much stricter format for accounts production and very strict filing deadline dates – within nine months of the year-end. e ven more reason to keep regularly on top of finances.
Robust software
Many consultants and practices use specialist billing software packages. However, many would benefit from more robust software packages, such as Xero or Quickbooks, which mean they can download directly from bank statements.
Consultants and sole traders should also consider using a specialist medical billing company to raise bills and collect fees. The money invested in paying a company is worth its weight in gold compared to the often vast sums of cash lost in bad debt.
The money invested in paying a company is worth its weight in gold compared to the often vast sums of cash lost in bad debt
Training and more training
Be prepared to invest in relevant training if your practice manager oversees the financials and does not have a book-keeping or accounts background.
f or example, if they are up to speed on how to do a bank reconciliation, you could save yourself money spent on outsourcing to an accountant.
When it comes to doing the year-end accounts and ascertaining what is owed to the practice, make sure your book-keeper is on top of this and prints out a list of all the fees, cash received and money owed.
finally, if any sole trader moves to a limited company status or simply moves banks, then ensure all parties are advised of the changes. Some forget to advise the likes of insurance companies and this is where money can go astray.
Susan Hutter is a partner at Blick Rothenberg and part of the team that advises medical practitioners
Check if your patients need vaccination against rabies before they go:1
PRESCRIBING INFORMATION
Rabies Vaccine BP ≥2.5 IU/ml, Powder and solvent for suspension for injection
Refer to Summary of Product Characteristics for full product information.
• Visiting an area where rabies is common and taking part in higher risk activities e.g. cycling or running?
• Working abroad in close contact with animals?
• Staying in an at-risk area for more than 1 month?
Rabies Vaccine BP from Sanofi Pasteur offers pre- and post-exposure protection against rabies.2
Order at www.vaxishop.co.uk or telephone our Customer Service team on 0800 854 430
Presentation: A single dose vial of powdered vaccine and pre-fi lled syringe of solvent for suspension for injection. After reconstitution, each 1 millilitre dose contains rabies virus (inactivated, strain PM/ WI 38 1503-3M) not less than 2.5 International Units of rabies antigen. Indications: Prophylactic immunisation against rabies and treatment of patients following suspected rabies contact. Dosage and administration: The dose of reconstituted vaccine in all cases is 1 millilitre given by intramuscular injection into the deltoid region. Reconstitute with the solvent supplied and shake carefully to ensure complete reconstitution. Following reconstitution the vaccine will be a pinkish colour and free from particles. Once reconstituted, the vaccine must be used immediately. DOSAGE FOR PROPHYLAXIS: 1 millilitre given on days 0, 7 and 28. For those at regular and continuing risk, a single reinforcing dose of vaccine should be given at 1 year after the primary course has been completed. Further doses should be given at three- to fi ve-year intervals thereafter. For travellers at intermittent risk of exposure, booster doses may be given in line with offi cial recommendations. DOSAGE FOR TREATMENT: For those known to have adequate prophylaxis - 1 millilitre should be given on day 0 and on day 3 following contact with a suspected rabid animal. For those with no, or possibly inadequate prophylaxis - the fi rst injection should be given as soon as possible after suspected contact (day 0) and followed by four further 1 millilitre doses on days 3, 7, 14 and 30 (the earliest that the 5th dose can be given is day 28 as per WHO recommendations). The use of Rabies Immunoglobulin should be considered in unimmunised or incompletely immunised subjects or those with uncertain immune status in accordance with official recommendations and/or expert advice. The treatment schedule may be stopped if the animal concerned is found conclusively to be free of rabies. Subjects with incomplete prophylaxis or unknown history of immunisation should be treated as non- immune. Contra-indications: Pre-exposure: Known systemic hypersensitivity to Rabies Vaccine BP or any of its components; febrile and/or acute disease. Post-exposure: no contra-indications. Warnings and precautions: Appropriate facilities and medicines should be readily available in case of anaphylaxis or hypersensitivity following injection. The vaccine may contain traces of neomycin and betapropiolactone which are used during the manufacturing process. If Rabies Immunoglobulin is indicated in addition to Rabies Vaccine BP, then it must be administered at a different anatomical site to the vaccination site. Rabies Vaccine BP should not be administered to patients with bleeding disorders or to persons on anticoagulant therapy unless the potential benefi t outweighs the risk of administration. The potential risk of apnoea and the need for respiratory monitoring for 48- 72 h should be considered when administering the primary immunisation series to very premature infants (born ≤ 28 weeks of gestation) and particularly for those with a previous history of respiratory immaturity. As the benefi t of vaccination is high in this group of infants, vaccination should not be withheld or delayed. Anxiety-related reactions, including vasovagal reactions (syncope), hyperventilation or stress-related reactions can occur following, or even before, any vaccination as a psychogenic response to the needle injection. This can be accompanied by several neurological signs such as transient visual disturbance and paraesthesia. It is important that procedures are in place to avoid injury from faints. Corticosteroids and immunosuppressive treatments may interfere with antibody production, check antibodies 2 to 4 weeks after course. Pregnancy: The potential risk of administration of Rabies Vaccine BP during pregnancy is unknown. Due to the severity of the disease, pregnancy is not considered to be a contra-indication to post-exposure prophylaxis. If risk of exposure is substantial, pre- exposure prophylaxis may also be indicated. Lactation: It is not known whether the vaccine is excreted in human breast milk. Due to the severity of the disease, breast-feeding is not considered a contraindication. Undesirable effects: Very common side effects include: lymphadenopathy, nausea, diarrhoea, injection site reactions (pain, erythema, pruritus, induration), chills, malaise, headache, arthralgia and myalgia. Common side effects: injection site bruising, dizziness, respiratory manifestations (dyspnoea, wheezing), angioedema, pyrexia, abdominal pain, vomiting and allergic reactions with skin disorders (urticaria, rash, pruritus). Other undesirable effects have been reported, although their frequency is not known. These include serum sickness type reactions, anaphylactic reactions, oedema, encephalitis, convulsion, Guillain-Barré Syndrome, paresis, neuropathy, paraesthesia and asthenia. For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Marketing authorisation holder: Sanofi Pasteur Europe, 2 Avenue Pont Pasteur, 69007 Lyon, France. Further information is available from the Distributor: UK: Sanofi, One Onslow Street, Guildford, Surrey GU1 4YS Tel: 0845 372 7101; Ireland: sanofi -aventis Ireland T/A SANOFI, Citywest Business Campus, Dublin 24, Ireland Tel: 01 403 5600 Package quantities and basic NHS cost: One single dose vial (powder) and one pre-fi lled disposable syringe containing 1 millilitre of solvent with 2 separate needles, basic NHS cost £40.84. Legal category: POM Marketing authorisation number: UK : PL 46602/0004 Ireland: PA 2131/004/001 Date of last review: February 2017
Suspected adverse events should be reported Reporting forms and information can be found at www.mhra.gov.uk/yellowcard and www.hpra.ie
Suspected adverse events should also be reported to Sanofi Tel: 08000 902 314 (for UK) and Tel: 01 403 5600 (for Ireland).
References: 1. Department of Health. Immunisation against infectious disease. Chapter 27: Rabies. Accessed November 2017 2. Rabies Vaccine BP Summary of Product Characteristics SAGB.RABIE.17.10.1326 11/17
We shouldn’t be too perturbed by the boom in medical consultation apps, says the admitted ol’ timer Dr Neil Haughton (below)
I freely admIt I am most happy being an old-school face-to-face GP. I like seeing patients in my consulting room following the old medical school routine of taking a history, examining and maybe doing a blood test or referring to one of my specialist colleagues.
Of course, I speak over the phone and answer emails, so I do some ‘virtual’ consulting as well.
In the past few years, however, numerous online services have been available privately and now a similar service is available to NHS patients. In fact, NHS england is investing £45m into developing virtual GP consultations.
It is inevitable, of course, as demand increases and the difficulty of seeing an actual GP gets ever more challenging.
I have been quietly wary of virtual consultations whether via email or video link; my main concern being misdiagnoses such as the cough that becomes pneumo-
nia and the jaundice that is hard to spot on the doctor’s screen. But patients overwhelmingly rate the services highly and complaints seem to be rare.
I needed more information to challenge my pre-conceptions, so I asked my younger colleagues about their experiences providing the service and trawled the internet pretending to be a prospective patient.
surprisingly easy
firstly, I was surprised by just how many options were available.then I was surprised by what I could actually obtain without even speaking to a doctor, and also just how convenient and easy to use the services were and for a reasonable price – although some medication charges did seem steep.
I didn’t even realise I needed some of the medications available until I clicked on the various body parts on one website. for £20 I could have a video link
consultation, a diagnosis and a prescription electronically sent to the nearest open pharmacy which they found for me. What’s not to like?
Well, the Care Quality Commission (CQC) has some issues, such as proving identity, compliance with prescribing guidelines and safeguarding issues, which is fair enough, as I suspect some providers are willing to prescribe painkillers, for example, a little too readily on demand.
the rCGP is also critical of the NHS version, as it self-selects the easier consultations leaving the ever more complex issues for the GP’s surgery. It does accept that online services have a role, but to complement face-to-face consultations rather than replace them.
I fear we may be undermining our professionalism by becoming as easy to contact as an Uber or a local pizza delivery company. Is that what we envisaged when we qualified? from speaking to my colleagues,
most do a few hours of online doctoring at the weekend in the comfort of their own home for a few extra pounds. the consultations are rarely complex and are mainly repeat prescriptions, simple ailments or sick notes.
anything more complex or potentially serious is referred to their NHS GP or a visiting service. So, it does not seem like a main career choice for most. Some of the apps – usually the US versions – give you a glossy photo of the doctor you can choose to speak to; almost like a dating app, apparently.
I was also a little alarmed to see the doctor’s presence removed altogether on some websites, with artificial intelligence programs diagnosing with equivalent – or better – accuracy than human doctors.
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gram or C t reading is already mainstream and removes human error and the effects of tiredness or distraction.
How often do patients now come into my surgery with a diagnosis from the internet and tell me what investigations and treatment they want.
Of course, nothing can replace the continuity of care provided by general practice and that innate knowledge that something has changed either physically or mentally in the patient we have known for years.
But that style of care is becoming increasingly uncommon: 65% of GPs in london are locums who will move from job to job every few months.
I was visited last year by an entrepreneurial md from Silicon Valley who provided a concierge medical practice via an app on his smartphone to which his patients could buy membership.
I have been pleasantly surprised by the standards of the online services on offer and the variety of ways patients can access convenient care
t hey just had to tap the icon showing their request, either a prescription, video consultation or referral, or even to make an appointment. He sat in his office, or wherever, responding to the demands of his signed-up clients.
maserati compensation
He was doing very well financially, as membership cost many thousands of dollars, but, by his own admission, he hardly saw any patients in person.
a dmittedly, most were young well dotcom millionaires who were too busy to visit their doctor, but did he really get any job satisfaction? t he m aserati probably made up for that…
So, what are my conclusions? Online consultations are clearly here to stay and with the CQC looking over their shoulders, the more maverick risky providers will be brought in line. they provide a genuine service
to people who would struggle to get a convenient alternative service on the NHS.
m y worry around accuracy of diagnosis without the ability to examine still remains, but then it is a different service being offered and the patient seems to realise these limitations as well.
t he technology will also improve as uploaded images, heart rhythm traces, blood pressure and even basic blood analysis being possible in the future.
If they could access NHS records as well, then the service would be dramatically improved.
I will still prefer to sit in my surgery seeing my familiar patients and suspect I’ll retire doing that.
Dr Neil Haughton is the Indep endent Doctors Federation’s GP chairman and presidentelect of the IDF
But I have been pleasantly surprised by the standards of the online services on offer and the variety of ways patients can access convenient care.
t he robots have actually arrived...
MRSL’s
Medical Groups Indemnity product is specifically designed for companies and groups, with premiums
SO me d OC t O r S would be in danger of being denied medical indemnity insurance cover if workplace risks are not being analysed sufficiently, according to industry experts.
the warning has been issued by m edical r isk Services l imited ( mr S l ), whose senior figures share decades of experience within the medical, insurance and financial services sectors.
t he concerns come as many spinal surgeons are now being denied insurance cover – and fears grow that other specialists may soon struggle to source medical indemnity insurance.
f ounded in 2004, mr S l provides comprehensive support and cover to protect doctors against potential claims.
Its medical Groups Indemnity product is specifically designed for companies and groups, with premiums based on detailed analysis of risks.
mr S l’s co-founder and C e O r oger Houston has a 30-year career in insurance claims.
Significantly, expertise is also provided by a team of highly experienced doctors and insurance professionals able to scrutinise and question evidence being presented as part of a potential claim against clients.
defensibility is the key f or mr S l , defensibility is allimportant.
It acknowledges that, due to the blame culture of patients and society, complaints will always be lodged against surgeons, and lawyers will always request notes.
based on detailed analysis of risks, reports Peter Anderson
A comprehensive package of support and insurance to protect against malpractice claims and their consequences
Above: MRSL co-founder and CEO Roger Houston
n Specifically designed for companies and groups
n Fully satisfies GMC requirements
a s a consultant anaesthetist, mr S l director d r r obert Baylis appreciates the huge importance of doctors having support from the moment a potential claim arises.
n Experience in defending doctors
n Premiums based on detailed analysis of risks
n Backed by financially strong insurers
Medical Groups Indemnity means a potential claim doesn’t fall on a single individual, with all the personal and emotional pressures that can involve ROGER HOUSTON
n 24/7 advice and support
n Includes legal cover for disciplinary hearings
He said: ‘the support of experts who have managed claims against doctors for decades is a huge strength of mr S l’s m edical Groups Indemnity.
Developed by proven experts financial services sectors, MRSL’s is designed to offer unparalleled moment a potential malpractice Our services are competitively analysis of your business and needs and activities. For us, defensibility zero-conversion rate from legal
‘Knowing that support is on hand from a 24/7 helpline from day one, including access to advice from highly experienced doctors and legal experts, is incredibly valuable.
For details on our full range of for doctors and their businesses,
T: 0203 058
‘doctors shouldn’t feel vulnerable or isolated.’
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Based on detailed analysis, not labels or assumptions, meaning we can high-risk specialisms such as spinal surgery that some other providers routinely
However, the business aims to achieve a zero-conversion rate of lawyers’ requests progressing to formal claims.
mr S l has been particularly alarmed by recent challenges faced by medical professionals confronted by sharply escalating indemnity premiums.
medical professional,’ he explained.
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‘ m edical Groups Indemnity means a potential claim doesn’t fall on a single individual, with all the personal and emotional pressures that can involve.’
insurance based on risks
m r Houston said: ‘It’s essential that insurance decisions are based on actual risks being taken.
‘ d octors are being penalised unfairly if cover is denied based on labels rather that what they’re actually doing.’
a ccording to m r Houston, mrSl’s focus on covering groups rather than individual doctors offers huge benefits.
‘It’s vitally important to cover an entity rather than a specific
He added: ‘mrSl’s product provides cover irrespective of who in an organisation actually carried out the procedure.’
Other important strengths of m edical Groups Indemnity include premiums being based on the number and types of procedures being undertaken, ensuring pricing is consistent and transparent.
In addition, the product fully satisfies G m C requirements for doctors to have ‘adequate and appropriate’ cover in place.
m eanwhile, with a successful background in insurance and financial services, mrSl director Christopher Cloke Browne sees the support of leading insurers for mrSl’s detailed approach to the risk as a major issue.
He added: ‘Our proprietary approach to analysing the risk of medical Groups Indemnity policy means mr S l brings a unique dimension to the discussion with underwriters.
‘the insurance is underwritten by some of the world’s leading insurers, including the l loyd’s market.’
f or further information on mr S l or for full details on the company’s comprehensive range of insurance products, please get in touch by phone 0203 058 3733, email enquiries@mrslenterprise.com or visit www.mrslenterprise.com.
I read wIth interest the article from Fiona Booth, chief executive of the association of Independent healthcare Organisations (aIhO) ‘GPs “block access to private care”’ in last November’s issue of Independent Practitioner Today
She reported the dissatisfaction at barriers to real patient choice, arguing that this was not related only to misguided disloyalty from GPs to the N h S, but also due to the lack of right facts, figures and scripts from consultants.
as a private GP, I agree with the facts and reasons put forward by Fiona. h owever, there is a more complex picture around GP referrals.
who are these GPs barring private care access? are they the ones who do not refer in time for cancer treatment, or do not read consultant reports?
are consultants who are not getting private referrals the ones with inadequate administrative support? what is a GP referral actually? what is its very meaning and usefulness?
Is a GP referral just a ‘permit’ given or not by a gate-keeper or a start of a conversation between clinicians about a patient, or both?
w hen I succeeded d r Philip e dmondson in 2002 in h arley Street, he gave me a ‘book’ with details of consultants for each specialty.
he also told me he used to bar consultants from that book –those who disappointed the patients or himself – arguing that patients judge their doctor on the quality of their referrals.
I quickly found out that the quality of my care was depending closely on the quality of my referrals. a nd quality of referrals depended not only on my diagnostic skills but also on consultant skills and access, with the need for good communication between primary and secondary care.
I carried on the tradition until recently, and it worked. I used to call a secretary of a consultant or even sometimes the consultant him/herself and get an appointment on the spot for the patient I was seeing.
I was then sending a clinical referral letter. this was followed in a timely manner by a courteous and professional report with acknowledgements of the facts
GPs are not blocking patients’ access to private care. It is more a case of consultants proving difficult to reach, argues Harley Street GP Dr Alix Daniel (left)
We reported in November on AIHO chief executive Fiona Booth’s speech to a healthcare conference
mentioned in my referral letter. It was about professional, efficient communication. It worked. however, this is now fading away.
Some of the consultants I used to work with are retiring and some of the new consultants I have met though conferences and other gatherings have been proved difficult to access.
Sometimes, they have no named secretary. Most of the time, no one answers the phone. this has prompted changes in my referral system. I am seldom calling to arrange appointments with consultants.
Call several times
I occasionally text some consultants I know well. Often, I send a referral letter and give details of the consultant to the patient. h owever, it is not unusual that the patient will need to call several times to get an appointment, prompting dissatisfaction and concerns. and it is not unusual that the consultant will have not read the referral letter at the time of the consultation.
So even if I have the knowledge of the ‘right facts and figures and a script’, as Fiona put it, it is proving difficult to refer patients as part of independent care.
I,
as a private GP, feel the very same dissatisfaction that patients feel and a certain frustration, even though I am independent
I, as a private GP, feel the very same dissatisfaction that patients feel and a certain frustration, even though I am independent. healthcare corporates or organisations have come up with solutions. I will call King edward VII hospital, h C a or the London Clinic’s dedicated numbers in case of relative emergencies and for the specialties for whom I just cannot find a contactable consultant.
even if these solutions are helpful, they limit my choice for best care. a nd I get the bad taste of being part of a mercantile healthcare, which I have always despised for my profession.
When you have to be right
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Doctors are under increasing scrutiny when it comes to reporting serious incidents and data-sharing in private practice. Jane Braithwaite presents a timely analysis and gives some useful tips
A recent BBc Panorama tV documentary entitled ‘ How safe is your operation?’ uncovered serious concerns about the sharing of data and incident reporting in the private sector.
With cases such as that of Ian Paterson – the surgeon who wounded patients and carried out unnecessary surgical procedures – making headline news, patients may be rightly concerned that the safety policies and procedures used in private healthcare are not up to scratch.
So, what can private practices do to ensure their services are safe and patient safety is taken seriously,
and what tools are available to support doctors in datasharing?
Why is data important?
First, let’s consider why this information is so important.
As with any industry, analysis of business data will allow companies to see where they are doing well and can help to identify areas that need improvement.
It’s a great way to monitor how the business is running and to pinpoint areas where process changes are required. In healthcare, without recording and analysing clinical data, it is incredibly difficult for organisations to have
any kind of handle on trends relating to symptoms, public health, procedure safety… the list goes on.
But why should this be particularly important? t he reason is patient safety. Without measuring clinical outcomes, organisations – either in the nHS or the private sector – cannot ensure they are providing the best possible patient care.
Why are the nhs and private sectors different?
According to the Private Healthcare Information network (PHIn), which was established by the
competition and Markets Authority ( c MA) following the 2014 investigation into the private healthcare market, the private healthcare industry has been largely excluded from national healthcare policy for some time. As a result, the industry is not included in nHS information systems, meaning data is not shared between providers, and treatment information is not reported consistently to national databases.
What data is required?
the private healthcare information that needs to be shared to
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It is in the best interests of the NHS, the private sector and, of course, the patients to share this information to increase knowledge and identify any areas that need improvement
supplement the n HS datasets relates to clinical audits, cancer surgery outcomes and figures relating to cosmetic surgery, for example.
Sharing this information will allow for complete oversight of patient outcomes. Policies and strategies in both sectors can then be shaped based on accurate and robust datasets, but basing policies on incomplete data will have a negative impact on patient safety.
It is therefore in the best interests of the nHS, the private sector and, of course, the patients to share this information to increase knowledge and identify any areas that need improvement. this, of course, means that serious incidents need to be properly documented and reported, as well as information on successful treatments.
However, having a thorough risk assessment policy that includes information on how incidents are reported can only be a good thing for private practices; it will increase patients’ confidence in the fact that, if an incident does occur, it will be dealt with efficiently by the practice.
What can private practices do?
the key issue here is for the different sectors to work together for the good of the patients; data standards need to be brought into alignment. But who is spearheading this and how can private practices get involved?
As mentioned above, PHIn was established in the wake of the c MA’s 2014 investigation and now provides information on private healthcare to the public.
All hospitals providing private treatment are required to publish information on service quality –for example, infection rates, mortality rates and admission figures.
Several n HS trusts have been contacted by the cMA after making insufficient progress in achieving this goal. this is more than a year on from the c MA announcing that private healthcare providers must submit information on their services, allowing patients to have access to information they need to make an information choice about their care.
➲ Review incident reporting procedures – who is informed when an incident occurs? Is a risk assessment carried out, and by whom? How are changes measured and assessed?
➲ Comply with any requests for information – Patients have a right to access their records.
➲ Make sure your practice is acting in line with data protection laws – the General data Protection Regulations are enforced in May (see p24), so now is the perfect time to review all policies relating to data to ensure that your practice is working in line with these regulations.
➲ Share your policies – Give patients access to your safety policies and procedures, if requested, so they can be confident you work to high standards.
➲ work together – Recognise the requests made by the healthcare authorities and share practice information in a timely manner; for example, to PHIN’s new portal for collecting information on individual consultants.
➲ Act with transparency – Be up-front with patients and healthcare authorities about safety information; do not manipulate clinical outcomes, and share this information with all relevant bodies as appropriate.
➲ utilise online portals such as those available on PHIN – using services such as this will help to identify gaps in data.
➲ Review your data-collection procedures – Conducting a thorough review will help you to be confident that you are capturing all the information you need.
➲ take data breaches seriously – Ensure you have a robust system in place to deal with any security breaches.
➲ Make sure you have the consent of the patient to share information – Most patients would understand that relevant information needs to be shared to provide their care, but some might not expect you to share this outside of your organisation to another healthcare provider.
you should make sure, therefore, that you make clear in any consent forms that their data may be shared with other organisations to contribute to outcomes databases, anonymised where necessary.
A single standard for data procedures and reporting, regardless of how the care is funded, is obviously needed
As well as publishing information on private hospitals, PHI n will also soon be making information available on individual consultants. A recently implemented new online portal allows clinicians to review their performance data ahead of the publishing of the data in 2018.
t his gives consultants the chance to review their information to identify any trends or missing data and the portal also features a members’ manual that answers frequently asked questions and contains more information on the process.
consultants therefore need to recognise that the landscape in this area is changing and, in future, it appears that datasharing between the private sector and the n HS will become more regulated.
Practices will need to review their internal policies relating to data – such as data protection, data sharing – and to risk assessment and reporting, and make sure that the relevant stakeholders are involved in their policies.
moving forward – clarity and consistency
Lawyers and national medical organisations alike are calling for greater consistency here; private hospitals should be subject to the same regulations as the nHS, as so many patients use both services.
A single standard for data procedures and reporting, regardless of how the care is funded, is obviously needed – especially when taking into account the fact that 95% of patients who have planned surgery privately are also nHS patients for other aspects of their healthcare.
t here is a clear need to unify standards across sectors. Setting consistent information standards will improve many areas of healthcare, including patient choice, access to information, interoperability between systems, quality of service and integrated care.
there is really no reason to say ‘no’ to joining forces and making patient care the best it can be.
see ‘Are you ready for the new data law?’, page 24
Jane Braithwaite (left) is managing director of Designated Medical
The current law governing the use of personal data in the UK is the Data Protection Act 1998. But, as Independent Practitioner Today highlighted last month, this law will change on 25 May 2018 when the European General Data Protection Regulation (Regulation [EU] 2016/679) will come into effect.
Chris Alderson of Hempsons solicitors reports on the details and sets out the steps your private practice should take
IrrespectIve of Brexit, the UK Government has made it clear that UK law will align with european law on the issue of data protection and a new Data protection Bill is currently before parliament. some matters that are currently recommendations of good practice – for example, ‘privacy by design’ – will become legal requirements.
privacy and data security
Any medical practice will be aware that ensuring confidentiality and the security of data is an essential requirement to operate in health care.
Our splash last month revealed that many practices are unprepared
t he 7th Data p rotection principle in the Data protection Act (DpA) states that ‘appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental loss or destruction of, or damage to persona data’.
t here is supplementary guidance within schedule 1 of the Act which stipulates that the level of security must be appropriate to the harm that could result from the breach of security and the nature of the data to be protected.
Given the nature of private practices and the potential harm that could result from misuse of health records, data controllers will need to demonstrate a high level of security and private practices will need to keep themselves up to date as to the industry standard guidance for security levels appropriate to healthcare data.
t he e uropean General Data protection regulation (GDpr) is much more specific as to the factors data controllers should consider where appropriate. these are:
pseudonymisation and encryption;
the ability to ensure the ongoing confidentiality, integrity and resilience of systems and services;
the ability to restore availability and access to data in the event of an incident;
r egular review and testing of security arrangements.
t he need for such systems is demonstrated by the recent experience of the Wanna c ry attack affecting many NHs organisations.
t he maximum penalty for breaches of the DpA is currently £500,000. once the GDpr comes into force, the maximum penalty for a data protection breach will be €20m or 4% of global turnover, whichever is the higher.
It should also be noted that while reporting data protection breaches to the regulator is currently voluntary, under the GDpr, reporting is mandatory within 72 hours unless the breach is of a nature where risk to the rights of individuals is unlikely. so it is essential that private practices have systems in place to ensure the rapid identification and assessments of potential data breaches. the DpA requires certain conditions to be met before personal data can be used and, in the case
it
reflect the more extensive requirements of transparency required
of sensitive personal data – which includes health data, there are further conditions that need to be satisfied.
In the case of personal data, the conditions include:
the consent of the data subject;
processing necessary for the performance of a contract with the data subject – or taking steps at the request of the data subject with a view to entering into a contract;
p rocessing necessary for the legitimate interests of the data controller or those to whom the data are disclosed, except where this is unwarranted in light of the data subject’s interests.
for sensitive personal data, the justifications include:
the explicit consent of the data subject;
processing necessary for medical purposes undertaken by persons under an obligation of confidence equivalent to that owed by health professionals.
there will be a significant change to subject access rights under the GdpR. the presumption is that the first copy set of records should be provided free of charge to the requesting patient, thus removing the previous £50 subject access fee for health records.
While the GdpR provides scope for national governments to depart from this rule in appropriate cases, at the time of writing, the data protection Bill makes no provision for the retention of subject access fees.
this may have a significant impact on private practitioners – any disclosure of records needs to be checked to ensure that no third-party personal data or other exempt material is disclosed.
it might be thought that the risk of this happening in relation to private healthcare records would be low, but the risk cannot be excluded.
in 2016, a Gp practice was fined £40,000 after disclosing sensitive thirdparty information, including address details when a subject access request made by a father in relation to his infant child was not screened to remove information about the mother of the child, his ex-partner.
therefore, there always needs to be screening of the records by someone with appropriate knowledge and expertise.
there is now only limited time before the GdpR takes full effect on 25 May 2018. We recommend all private practices undertake the following steps:
At the outset, map your data flows. identify what information you need to collect and process and where it is intended that data will flow to and for what purposes and under what safeguards.
A privacy impact assessment should be undertaken, assessing whether it is necessary for the data to be used in that way, what the risks to the data are and how those risks will be controlled. the outcome of this exercise should give you a clear idea of what further steps will need to be put into place to ensure project success.
Consider whether your systems are adequate to identify potential data breaches before they occur and flag up adverse incidents in time to comply with the deadlines for reporting.
identify whether you need to have a data protection Officer and, if so, who will be fulfilling that role.
the GdpR is much more prescriptive as to what terms must be included in contracts with data processors. if you use data processors, review whether your existing contracts will meet the GdpR requirements. if they are no longer suitable, you will need to agree new GdpRcompliant terms with your processors and be satisfied that they will be implemented.
the information Commissioner has made it clear that she expects data controllers and processors to be compliant with the new law from the day it comes into force. But she does have discretion in how she uses her enforcement powers. data controllers who identify and report data breaches promptly and can demonstrate appropriate work has been done to prepare for the new law are much less likely to receive a fine than controllers that have done little or no preparation for the GdpR.
the new eU regulation on data protection comes into force in May
these justifications are largely replicated in the GDpr. However, what was previously called ‘sensitive personal data’ – for example, health data – will now be known as ‘special category personal data’, and it is explicitly recognised that the ‘medical purposes’ justification extends to health or social care.
patient consent for a private practice, the consent of the patient may initially seem an attractive option to rely on as your justification for processing their data, especially as consent is required for treatment.
However, it must be borne in mind that consent once given can be revoked and if consent is used as the justification for processing, the business model must be able to cope with the immediate cessation of data processing in the event consent is withdrawn.
t he requirements for demonstrating consent as the basis for processing under the GD pr are also much more stringent and arguably can never be met in the healthcare setting, as certain data processing must be accepted in order to receive treatment.
In practice, while consent will be an important part of ensuring that the usage of data is fair and transparent, it is unlikely to be useful as a justification for the processing undertaken.
Aside from the need to satisfy the conditions for processing, data controllers are under an obligation to ensure that processing is fair
and lawful and appropriate information is given to data subjects as to how their data is to be used. this is commonly in the form of a subject information notice, sometimes called a privacy notice. such notices should demonstrate transparency as to how the data is used to ensure that there are no surprises to the data subject as to how their data is to be used and shared.
Data controllers will be expected to explain, in straightforward language,what data relating to the data subject will be collected, how it will be used, the purposes for which it will be used and how their data may be shared, and for how long records will be retained.
It is necessary to prepare subject information notices appropriate for children, if their data is collected and used.
If a practice is proposing to use the data it collects for purposes other than the direct delivery of the agreed service to the patient, any secondary uses of the data should be clearly explained and the data subject should be given the opportunity to opt out of secondary uses.
for example, if the data controller intends to undertake additional analysis of data that is unconnected with their patient’s care, then it will be necessary to either obtain the patient’s consent to this use of their data or to ensure that any such analysis is undertaken on effectively anonymised data.
Again, under the GD pr , the requirements as to the information to be given to data subjects will be more extensive, and there is an emphasis on providing information to data subjects proactively, rather than simply having the data available on request.
It will therefore be important to ensure that the practice’s privacy notices are reviewed and updated to reflect the more extensive requirements of transparency required under the new law.
data protection officers the GDpr obliges data controllers to appoint a Data p rotection officer if they are a public authority or a ‘large scale’ processor
of special category personal data.
t he role of a Data p rotection officer is defined in the GDpr as being the source of expert knowledge, training, advice and guidance on data protection, and to monitor the controller’s compliance with the GD pr and be the point of contact with the UK’s Information c ommissioner’s office.
t he Data p rotection o fficer should have ready access to the board or other top level of management, but should not be part of that top level.
r emember, the role has statutory protection – a Data protection o fficer cannot be dismissed for doing their job – and so it is important to ensure that the person appointed to the role is up to the task.
practices
the current guidance as to what large scale processing entails is not very helpful. It indicates that an individual doctor would not be a largescale processor, but a hospital will be.
so a controller with, say, 2,000 patients on their list will not be required to have a Data protection officer, but a controller with, say, 100,000 patients on their list would be.
Unfortunately, there is no further guidance as to where the dividing line will be. A single independent practitioner will not need to appoint a Data protection officer, but larger multiplelocation or corporate private medical providers may very well need a Data protection officer.
If practices are not required to appoint a Data protection officer, but nevertheless wish to have a data protection lead, it is very important that such a lead is not given the title Data p rotection officer, as this has a specific statutory meaning and will result in all the relevant laws applicable to such a post applying.
Chris Alderson (right) is a partner and information law specialist at Hempsons Solici tors. You can email him at c.alderson@ hempsons.co.uk
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The Care Quality Commission has now started its compliance inspection programme for private doctors. Martha Walker (right) shows how you can prepare for a happy result
All independent doctors will have undergone a compliance inspection by the Care Quality Commission (CQC) by March 2019. Currently, private doctors do not receive ratings; they are just classed as being safe, effective, caring, responsive and wellled – or not.
Generally, doctors are being given four weeks’ notification. Here are ten things to do in preparation for your compliance inspection now.
it’s not an exhaustive list but it should help you and your staff in preparation for the CQC visit. inspection is all about evidence. if you say you do it, ask yourself and your staff how can you prove you do it.
PREPARATion FoR THE insPEcTion
1
Ask staff for their input
Ask all your staff. Remember, the CQC considers staff to be anyone who works in your clinic: employed/ pAY e , self-employed, those with practising privileges, contracted to provide medical services, volunteers, students.
What do they think the clinic does to demonstrate it is safe, effective, caring, responsive and well-led (S e CRW) – particularly
within the area they work; for example, reception or nursing?
2 devise a presentation p repare a 20- to 30-minute presentation for the inspection team to introduce it to the clinic and to showcase what you excel at. Use examples of the SeCRW that the staff have given as part of this. Highlight clinical/non-clinical examples of where you have improved because of an incident, suggestion or review.
3
see how others do it l ook at the reports on the CQC website of other clinics’ inspections. You can learn a lot from both independent and nHS practice inspection reports. d ownload the p rof n igel Sparrow’s Mythbusters from the CQC website – they are an excellent resource and can support your best practice or show how to achieve it.
THings THE cQc HigHligHTs As missing, incomPlETE oR oUT oF dATE
4 staff-related areas
HR, appraisals and training: Remember to include everyone who works in you practice, volunteers, students.
HR files: this is the easiest thing for you to get right and the easiest thing for the inspectors to find errors with, such as no certificates from the d isclosure and Barring Service, induction record, references or job contract.
Annual staff appraisals: this is something that should be planned in advance so that everyone knows when their appraisal is due. if you have a year planner such as the one that comes free every n ovember with Independent Practitioner Today, then mark appraisals on it.
Keep a record of the appraisal and action plan in the HR file and make sure the staff member has a copy of both. don’t forget to follow up the points on the action plan. Collate evidence of annual reviews for doctors working under practising privileges or a contract to provide medical services. this is not to be confused with the doctor’s annual GMC-related appraisal or five-yearly revalidation. if that appraisal and revalidation takes place elsewhere, then you should be having a review of the contract/performance with the doctor in regard to how they are working in your clinic. i deally plan it before their appraisal so the feedback from
your clinic can be included in that appraisal. Keep a record of what was discussed in the doctors’ HR file and give a copy to the doctor.
Training: d ecide who needs what training and how often. Can it be delivered internally or should you use an external company?
Create an annual training record or matrix. t his is supported by staff training files that the staff keep. it’s a waste of time locking the training files away with the HR files.
the staff need to make their own notes on what they have learned together with any certificates they receive. You as the employer can evidence the training through the matrix, invoice, registration record. Some training topics to consider are: safeguarding, equality and diversity, complaints, life support and manual handling, confidentiality and chaperoning.
Clinical governance meetings: do you have a robust clinical governance committee or group with regular meetings to discuss, review and develop governance issues?
Policies and other documents: Are the policies that you hold in ➱ p30
date – they should be reviewed at least every three years – and relevant to what happens in your clinic?
i f you buy in policies, ensure the content reflects how you operate and don’t just have your logo at the top of them. How do you cascade policies to staff?
Quality assurance: How will you demonstrate the quality of the service you deliver? do you carry out audit? What do you measure and why? What do you do with the results?
How do you build on the good practice you already deliver? How is this recorded?
How often do you carry out patient satisfaction surveys? they should be at least once a year.
Management and staff meetings minutes: Minutes from meetings are an effective way of evidencing how you discuss clinic performance/events/incidents/ development.
Make sure the minutes are available to everyone and the points actioned do happen.
i f you tend to speak regularly with staff but hold few formal meetings, then keep a record of what is discussed each week in a diary or similar and if there are points that need to be highlighted to staff, either put them on a notice board or email everyone. Have the minutes available for the inspector.
6
infection control, house-keeping and health and safety
Infection control: Who is responsible for infection control? Where/who does your infection control lead get support from?
infection control covers everything from deep cleaning in the minor ops room to ensuring that the patients’ toilets are clean and stocked with toilet roll. How does your infection control lead oversee all the cleaning activities in the clinic?
Housekeeping: You aim to deliver five-star clinical care, so your clinic accommodation should also be five stars.
De-clutter: if you don’t use it, get rid of it. Make sure the clinic accommodation is in good decorative order and clean.
How can you demonstrate the clinic is cleaned?
do you have a cleaning log?
Who inspects the cleaning?
don’t forget the dust traps you only see when you are sat at the desk, such as the framework on equipment, skirting boards, light fittings.
Where do you store cleaning materials and is the cupboard or room kept locked?
Clinical rooms: Minor operation rooms need very prescriptive cleaning regimes and your nurse should be responsible for this.
i f you move instruments to a dirty room, how will you demonstrate the transport process? Where do you store clinical and non-clinical waste?
if you use non-disposable items such as couch covers, pillow cases or examination curtains, then show your documented cleaning regime.
inspection is all about evidence. if you say you do it, ask yourself and your staff how can you prove you do it
d o examination areas have sinks with paper towels and soap? Ayliffe handwashing guides should be visible around all sinks used by clinicians.
i s personal protective equipment (ppe) such as gloves, aprons, goggles or disposable nail brushes available as appropriate?
d o you have a needlestick injury protocol and does everyone know where it is?
Health and safety: Make sure your health and safety law poster is on display for staff. Undertake emergency evacuation procedures and record it in the fire safety book.
Make sure all fire extinguishers, alarms and emergency lighting have been professionally tested. do you require legionella testing? if you are not sure, ask your plumber or heating engineer.
i f you have a landlord, then ensure you have evidence in the form of your contract/service level agreement and can show copies of relevant certificates to the inspector.
7 medicines management
Here are some things to consider:
Are all your medicines and related consumables in date? do you have a way of checking and recording this? don’t forget this includes emergency medicines and oxygen.
does everyone know where the emergency meds/crash bag or trolley is and is it easily reached by everyone and is it checked regularly?
do you have a system for ordering stock and consumables, checking it in and storing it –including stock rotation?
Are your pharmacy fridges kept locked when not in use and are temperatures recorded?
Can you demonstrate effective cold chain procedures and can air travel freely around the pharmacy fridge – that is to say, it’s not packed solid with medication.
d o you have an up-to-date
The cQc inspector will want to see some patient records to be satisfied they are contemporaneous, clear and complete
British National Formulary (B n F), and if you see children, the BnF for children.
8
Records and prescribing Patient records: the Gp specialist adviser/pharmacist/CQC inspector will want to see some patient records to be satisfied they are contemporaneous, clear and complete.
d o they all contain consent forms and, if relevant, evidence that the patient has given or refused permission to share information with other doctors.
Can you demonstrate how you share that information with other doctors?
Repeat prescribing: t his is likely to attract scrutiny at inspection. What system do you have for handling repeats? How are repeats recorded in the patient’s medical record? Consider creating a flow chart to demonstrate how it works.
9 complaint and incidents
Patient complaints: do you have a complaints log? How many complaints were upheld; what did you do to resolve the complaint and/or change practice?
Sudden untoward incidents (SUIs) or near misses: How do you record SUis and near misses? Can you show what lessons were learnt, how practice has improved and, if an incident involved a patient, that you were open with them, apologised and kept them up to date with the investigation?
10 don’t work in isolation
if you are a sole practitioner, how do you share best practice and not work in isolation? d on’t forget, you can use your appraisal and revalidation evidence.
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The London Sports Orthopaedics practice and HCA have launched a new Research & Outcomes Centre and the Sports Orthopaedics Research Foundation. Mr Ian McDermott sets out the aims
PerhaPs most people associate research with universities and with labs. But research underpins most of the clinical care that we deliver on a daily basis – and this applies as much, if not more, to the independent sector as it does to the Nhs
I left the Nhs ten years ago and founded the London s ports orthopaedics practice. We are a growing practice of currently 15 consultant orthopaedic surgeons, sports physicians, rheumatologists and pain specialists based in the heart of the the City of London.
We’re lucky enough to have benefited from considerable investment in our clinic by hCa, so that our outpatient diagnostic centre at 31 old Broad street is one of the best equipped in the country. t here are plush consulting
Mr Ian McDermott at the opening of his clinic’s Research & Outcomes Centre
Nowadays, it’s not enough to say that you’re good at what you do; quite rightly, you’re now expected to provide evidence to back up what you say and to demonstrate quality of care
rooms backed up by state-of-theart imaging facilities, with on-site X-ray, three ultrasound machines and two mrI scanners. one of the latter is the best quality 3t scanner I’ve ever seen.
o ur consultants operate out of London Bridge hospital, the best private hospital in UK. But that’s not enough. all the consultants in our practice have academic links, with most coming from some of the top London teaching hospitals, with two of us holding honorary professor associate academic positions, and with a long list of publications to our names. What underpins our combined approach and ethos is a deep desire to provide every one of our patients with the very best care
possible, every time. this means having a full knowledge of the latest research into not just what’s new but what’s best in each of our individual subspecialist fields. t his isn’t something that just ‘happens’ – it requires constant hard work and effort to keep fully abreast of all the latest opinions, techniques and technologies, with an analytical mind to critically appraise what’s best in the real-world clinical setting.
I remember well working in the N hs where any time you approached an N hs manager about anything new, the only question was ‘is it cheaper?’. Now, however, I’m lucky enough to work in a supportive environment where there’s a genuine drive for excellence and ➱ p34
where, instead, the answer to the question is: ‘is it better?’.
Nowadays, it’s not enough to say that you’re good at what you do; quite rightly, you’re now expected to provide evidence to back up what you say and to demonstrate quality of care.
t he one good thing that has come out of the Competition and m arkets a uthority’s ineffective review of the independent sector is the creation of P h IN, the Private h ealthcare Information Network.
While P h IN’s reception from many consultants has been perhaps luke warm at best, what P h IN has done is to crystalise many people’s long-lasting ‘good intentions’ about publishing their outcomes, so that outcomes are now becoming mandatory.
Limited data
Our February issue reported on the opening of the research centre
ist and two research physiotherapists.
the National Ligament registry and the National o steotomy registry, among others.
s oon, we’ll be in a position where our data collection will far outstrip that of any other similar medical practice. however, for us, that will be nothing more than just the basics and our plans far exceed simple patient-recorded outcome measures (Proms).
We are already undertaking a number of retrospective clinical audits, including:
the effect of Vivostat PrF biological glue in total knee replacement outcomes: a retrospective review of 120 cases;
a retrospective audit of the outcomes of meniscal allograft transplantation in the knee: what is ‘success’?
professional development sessions for allied healthcare practitioners. these are all based at or near to our practice and all aimed at disseminating the latest subspecialty information and disseminating best practice.
the problem with this is the fact that data gathered by relatively disinterested third-parties with no particular vested interest in accuracy is rarely particularly reliable, and the extent of the useful dataset that can realistically be easily gathered is, inevitably, rather limited.
so the consultants from London s ports o rthopaedics have now assisted in the creation of a new independent body called t he s ports o rthopaedics r esearch Foundation (sorF).
sorF has been set up as a charity and is in the final stages of the process for formally registering with the Charities Commission as an independent charity (www. sorf.org.uk).
It has two trustees from London s ports o rthopaedics and three independent trustees, and its remit is the promotion of clinical audit, research, medical/surgical training and education in the field of orthopaedics and musculoskeletal medicine.
the aim is to generate funds to support projects, with a dedicated grants committee that reports to the trustees.
In tandem with this, hCa has funded a major refurbishment of the clinic at 31 old Broad street, with the jewel in our crown now being a dedicated r esearch & outcomes Centre at the front of the clinic, with a research office staffed by a clinical nurse special-
t he centre is kitted out with some high-end equipment, with a new top-of-the-range Biodex Isokinometer for measuring strength, speed and power, and the KneeKG video gait analysis kit from emovi – this being the first time that this high-tech kit has ever been used in the UK.
customised system
Whatever other kit might be required for any of the various subspecialties will simply be brought in as and when needed.
Data collection is facilitated with the m eridian software from optimum Contact, who already provide data collection for many Nhs trusts.
London sports orthopaedics is, however, working closely with o ptimum Contact to develop a customised system dedicated to the collection of a dataset that far outstrips the basic requirements of P h IN, and that matches and surpasses the datasets of all the relevant national specialty registers, such as Beyond Compliance,
Internal bracing for tendoachilles reconstruction: a review of 50 patients with two-year follow-up.
But the real nirvana for us is to establish prospective clinical trials and, so far, we’ve already got two running:
the effect of patellar taping on patellar tracking and perception of pain in patients with patellar maltracking of the knee using flexion mrI scanning;
Cartiva interposition for symptomatic hallux rigidus: a prospective study of 30 patients.
and we already have several further potential studies in the pipeline.
We are lucky to be surrounded by a number of superb private physiotherapy practices and our physiotherapy partners have already started submitting various project plans to us, which we will be working on moving forwards.
In parallel to this, we have also already established a full diary of subspecialty multidisciplinary team meetings and continuing
A patient at the research centre is put through their paces on the KneeKG video gait analysis machine by Alex Fuentes of manufacturers Emovi
research, clinical audit, training and education are more than just nice optional added extras. these core activities underpin any decent clinician who cares about the quality of the services they provide. In the future, all practices will eventually have to follow a similar path and prove that the care their patients receive truly is up to scratch, let alone excellent. our practice is already a hospital Innovations ‘Centre of excellence’ for meniscal transplantation surgery. We are also a Vivostat ‘Centre of excellence’ for the use of biological glues in knees.
o n top of this, we are a Conformis ‘ s urgical Visitation Centre’ for training other surgeons in the techniques required for custom-made knee replacement surgery. But, for us, our r esearch and o utcomes Centre and r esearch Foundation are now the jewel in our crown. this is because patient education and patient empowerment, with access to data about quality of clinical outcomes and proof of excellence will be key in the future as the expectations and demands of the consumer in the modern healthcare market evolve. We are deeply grateful to hCa for its belief in us and its enormous support.
Mr Ian McDermott is a consultant orthopaedic surgeon specialising purely in knees. He was the youngest ever surgeon to be elected as a council member and trustee of the Royal College of Surgeons and he has also been appointed as an honorary professor associate in the School of Sport and Education at Brunel University. He is one of the UK’s leading experts in the fields of meniscal transplantation, complex knee reconstruction and custom-made knee replacements, and is the president of the UK Biological Knee Society. Email: mcdermott.admin@sportsortho.co.uk
Website: www.sportsortho.co.uk and www.kneesurgeon.london
So where did your business come from?
In her new book, Suzie Grogan (below) traces the development of surgeon-apothecaries in the remarkable century of change between 1750-1850. This month: the structure of the medical profession
In the 18th and early 19th centuries, the medical profession was beginning to develop a level of professional feeling that was to lead to a drive for greater status and reform of the structure of medical training.
the way a medical man saw his career at the beginning of the 19th century was markedly different to the attitudes that existed 100 years earlier.
Apothecaries had once been viewed as mere tradesmen; their manufacture and dispensing of medicines something that operated from a shop or warehouse rather than a surgery.
But by the early 19th century, they had become recognised as doctors in their own right, rather than simply a servant of the university-trained physician.
the occupation of ‘barber-surgeon’ disappeared mid-century when the barbers and surgeons parted company and set up individual guilds. no longer was the man who cut your hair also allowed to take your leg off.
Specialist surgeons in hospitals were treated with greater respect, if not quite yet as a ‘gentleman’.
t hose pure physicians, who were generally higher up the social scale and had diagnosed, but not physically treated, illness in their patients – other than by the prescribing of medicines – were now joined by a larger group of practical, well-educated young men. these were sons of the burgeoning middle-classes and had trained in Scotland or in europe.
t hose who had, in the early 18th century, practised medicine in rigidly defined groups were now more likely to be perceived by the public as one professional class.
But among the professionals there was rivalry and suspicion, and for the physicians, a determination that not too many of the ‘tradesmen’ or craftsmen would climb the professional ladder.
Mercifully, by the turn of the 19th century, jealousies and petty battles were settling, which could only be good news for the patients, who were always divided into those who could pay the physician’s inflated fees and those who could not. the latter had to consult their local apothecary for medical advice.
In general terms, medical men were still officially divided into three categories before 1815: physicians, surgeons and apothecaries.
Physic was the diagnosis and treatment of internal diseases by medical rather than surgical means. A physician would take a patient’s full medical history, as far as it was then understood, including their lifestyle and general constitution. the pulse was taken, the breathing observed and often a disproportionate amount of notice was taken of a patient’s urine.
Surgery necessitated the treatment of external disorders, including those of the eye and teeth. Sexually transmitted diseases came within the purview of the surgeon, as did fractures and dislocations, the dressing of ulcers and wounds, and any internal medical problem requiring an incision. Pharmacy was the domain of the apothecary or druggist who compounded their own medications and preparations and sold them wholesale or over the counter in his own shop.
Midwifery was, in many cases, the traditional domain of the
female midwife. In the 18th century, doctors – then all male –asserted that their skills as ‘man-midwives’ offered women a safer option.
PhysiciAns
this branch of the profession was ostensibly reserved for the man who had studied at university and had obtained a degree in medicine. If he were not an Anglican, he would have had to study abroad or in Scotland, as those with a non-conformist background were not admitted to university in england.
those practising in London had to be members of the London (later Royal) College of Physicians and were often graduates of Oxford, Cambridge or trinity College, Dublin, who may have had no contact with a patient during their training.
that training was largely based on studying the writings of hippocrates and Galen. their final examination was a thesis defended in Latin – and it was even possible to pay someone else to take this for you.
Physicians were regarded as the highest branch of medicine, and so they never undertook to use their hands in manual treatments, rarely touched patients and would certainly not consider dispensing their own medicines.
t heir education, supposedly taking in all aspects of surgery and pharmacy as well as physic, gave them the right to oversee the medical work undertaken by a surgeon or apothecary. But they may have had little experience of patients, other than by observing their masters in college.
Physicians were generally considered gentlemen. Commentators felt that to be a gentleman was a pre-requisite for the job.
Other physicians did not belong to the Royal College, however, especially men who trained and worked outside London. In Scotland, for example, many belonged to other colleges, such as those established in Glasgow in 1599 and edinburgh in 1681. they could not become ‘fellows’ of the Royal College as those who attended Oxbridge and Dublin universities could, so had no say in the way their professional body was governed.
they were considered of lower status, and some felt them to be subversive, or worse – ‘unpatriotic’. t his led to disputes within the Royal College itself, as these ‘licentiates’ felt that they should qualify as fellows after a period of time. Many had good reputations in London or positions in hospitals.
taking out teeth, administering enemas, and undertaking amputations. t hey would, of course, also cut your hair and offer a shave.
An 18th-century apothecary at work
bers after they completed an apprenticeship, but this was undermined when their examiners ceased to require proof of apprenticeship.
Coming under attack, the fellows emphasised that, in fact, most in their ranks had taken additional lectures in Scotland and abroad, and were regularly seen walking the wards of London hospitals in the position of pupil. t heir determination to retain the privilege of an education in Oxbridge and Dublin universities led to charges of ungentlemanly conduct within the college as fellows moved to restrict even the most qualified of men on the basis of low birth and their ‘democratical and levelling spirit’.
e nglish barbers and surgeons had created separate guilds until 1540 when h enry VIII merged them into the ‘United BarberSurgeons Company’. his actions took no account of the surgeons’ belief that they were a profession worthy of greater respect. t he year 1745 saw a permanent parting of the ways when King George II established the London College of Surgeons.
Barbers were no longer permitted to do any surgical procedures other than pulling teeth and blood-letting.
t he college remained a City Livery Company in order to offer the Freedom of the City to mem-
the Company of Surgeons had also failed to include anything in the new Act that covered the powers to compel surgeons to serve an apprenticeship or to take an examination, thus making it weaker than when it was allied with the barbers.
In the mid-18th century, the standard of teaching began a decline. Many surgeons saw their calling as practical rather than academic and thought students were best taught by example rather than by the rigours of a bookish, university education.
A surgeon in a hospital or infirmary might agree to take on a
19th-century surgical instruments used in kidney stone removal ➱ p38
sURgEons
the physician’s main competitor was the surgeon. the profession of ‘barber-surgeon’ developed across medieval e urope and included those willing to perform surgery, unlike other doctors who would not.
they were often responsible for treating those injured at war, on land and sea, and would usually learn as an apprentice to an older, more experienced man.
In the earliest days, they were often ill-trained and illiterate, but they performed vital services that others often would not, such as
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number of students to become their assistants and to train under them purely in surgery. t hese young men paid a premium for the privilege, and others could watch the work for a lower fee. t hose outside the capital did not always consider it necessary to become a member of the company, as it did not affect their status or impact on their work.
Further undermined
t he traditional system was further undermined in 1749 when ex-officers who had been in the services since the accession of George II could take up any trade without serving an apprenticeship.
Many of them had been saving lives using a form of surgery, albeit it very rough and ready, and they refused to be examined by the company.
Much of the early instruction in surgery was offered by private
schools, such as that established by William hunter, but it was the development of the large hospitals that once again established surgery as a regulated, respected profession. Most were launched by public subscription, to ensure treatment and medicine was available to the poorest.
Although e nglish universities still remained aloof from this practical method of educating surgeons, the Scottish medical schools and trinity College, Dublin, became the best and, in addition to expert tuition, could offer examinations and licensing qualifications unavailable to students at english hospitals.
A change occurred in 1769 when it was agreed that all practising surgeons should occasionally offer lectures on their subject. this prompted Guy’s hospital to start a course of surgical teaching. each surgeon could take on up to four students as apprentices or
‘dressers’ who were, in effect, a surgeon’s assistant, caring for and taking responsibility for less serious cases, and although the number of formal apprenticeships went into decline, ambitious pupils were still keen to attach themselves to the best surgeons, often at great expense.
For example, when, in 1789, a young man bound himself to Dr William Blizard, a surgeon at the London hospital and co-founder of the medical school there –mostly at his own expense – he paid £500 for the privilege.
By the early 19th century, the teaching of surgeons had become more organised, with less onus on the student himself to ask pertinent questions and more emphasis on the role of the surgeon as a tutor.
the change in the way surgery was taught was not universally popular. Some surgeons were con-
cerned that it offered the opportunity for apothecary’s apprentices in a country practice to become surgeons in less than a year, and there were doubts as to the efficacy of lectures as a replacement for teaching at a patient’s bedside.
Rapid developments in the teaching of surgery left the Company of Surgeons in a difficult position. Modernisation was required and, in 1796, it was decided to apply for a new constitution. new properties were purchased in the area of Lincoln’s Inn Fields, London.
In 1800, the Royal College of Surgeons in London was born on presentation of a new Royal Charter. It did not become the Royal College of Surgeons in e ngland until 1843. Where the Company of Surgeons had failed to impact on the lives of many provincial surgeons, the Royal College began to impose its new structure.
APoThEcARiEs
t hese traditionally dispensed medicines they had prepared themselves. the apothecary was often the person the public would turn to for advice, especially as they began to diagnose and prescribe as well as make their own medical preparations, but to many, the apothecary was a tradesman rather than a professional.
Apothecaries started off as members of the Company of Grocers, but they had their own society by 1615 and in that same century began to come into direct conflict with the physicians.
Until the 18th century, the role of the apothecary had been very much at the behest of the physician. t he apothecary was only allowed to make and dispense medicines as prescribed by a physician; they could not diagnose or treat a patient directly. And if they did so, they were liable to prosecutions for encroaching on the rights of the physician to be the sole dispenser of physic. But it became clear there were many more apothecaries than physicians and that the public, particularly the poor, would regularly turn to them for medical advice, even going as far as to ask them to make home visits, very much the domain of the physician.
By the beginning of the 18th century, apothecaries outnumbered physicians by ten to one in London. the persistent challenging of physicians culminated in a court case ruling the apothecary’s status as a ‘purveyor of goods’ rather than as a medical man, despite acknowledging that in practice, he was a regular attendee, offering advice at the sick beds of the poor. t his case has been quoted as having implications for the status of apothecaries and the GP well into the 20th century. Apothecaries undertook an apprenticeship, usually of five or seven years, after which they might supplement learning with a spell walking the wards of a hospital, taking in dissection, midwifery and further medicine. the profession was more closely regulated after 1815. Following a mandatory five-year apprenticeship, a student had to attend courses in chemistry, materia
medica and medical botany, two courses in anatomy and physiology, and two on the theory and practice of medicine.
Many also entered themselves for Royal College of Surgeons membership. But once in practice, there were few who acted as pure physicians or surgeons.
If a doctor was an ‘irregular practitioner’, then they could have been from one of the many groups who exercised influence outside the ‘regular’ categories. these men and women provided medical services for centuries – midwives, horsedoctors, chemists, nurses and pedlars, even the village wise-woman. Far from being seen as ‘quacks’, they were, despite having no fomal training, often respected members of a community. the true ‘quack’ sold medicine knowing that it wouldn’t work. Many medical men considered any alternative treatments to those generally accepted, having no proof of efficacy, were as good as quackery. t his labelled many herbalists and chemists alongside those travelling pedlars hawking expensive and useless cure-alls. the 19th century saw a significant increase in the requirement to pass professional exams and obtain a licence to practise from relevant bodies. these qualifications quickly became the professional ‘standard’ and, by 1840, over 90% of all newly qualified medical professionals had the letters MRCS LSA (Licentiate Society of Apothecaries) after their names.
next month: Feeding the horrors of the anatomy table
☛ Adapted from Death Disease & Dissection –the life of a surgeon apothecary 1750-1850, by Suzie Grogan. Pen & Sword Books Ltd, ISBN 1473823536, Price £12.99
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Using a consultant psychiatrist’s practice development as a case study, Maurice Citron sketches out some important issues you will need to consider if you decide to acquire, develop and trade from your own clinical property.
This month, he considers some points on the Care Quality Commission registration process and development funding options
T HE C ARE Quality Commission (CQC) regulation process needs to be tailored for each individual practice. It will depend on the practice’s particulars, whom it treats and what treatment is offered.
In general, the more complex the medical offering, the more complicated the CQC regulation process.
In principle, all applicants are required to meet CQC fundamental standards. These are high-level concepts including person-centred care, consent, safe care and treatment, premises and good governance, among others.
The inspection process follows key lines of inquiry and practices are judged to be safe, effective, caring, responsive and well led.
It’s a complicated process involving a fair amount of paperwork. Practices need to understand what applies to their circumstances and what they need to do to achieve regulation and keep compliant.
After having spoken to several practitioners on this subject, their experiences share one common
overriding theme. The best way to explain it is this. You’re setting up your business and you are in the thick of it; working out a multitude of different things: the premises, recruiting staff, marketing the business, refining the business plan, juggling accounts and a host of other matters.
The regulation process forces you to stop, step outside of yourself and document every aspect of your business and how your business will operate. All the information is in your head. Committing it to paper requires grit and determination.
The documentation process is multifold. Let’s look at one example, which would apply to all practices – complaints. The business will require a complaints policy document setting out a system for identifying, receiving, handling and responding to complaints. A complaints register will record complaints, the particulars of each case and the subsequent outcomes. The business compliance
plan will set out your general approach to complaints and how the business will review procedures and systems over time.
This last point is important, as legislation is always developing. A case in point is the recent move to replace the Data Protection Act 1998 guidelines with new standards set out in the EU General Data Protection Regula tion (see feature on page 24).
All documentation relating to record-keeping will need to be updated to reflect the new standards. Keep in mind the general idea: if it’s not written down, the CQC can’t assess it. If it can’t be assessed, it can’t be regulated.
Construction phase
Every property is unique and every site will have its own construction issues. Access is a familiar problem on sites, particularly in built-up urban areas, and it applied to our case study of consultant psychiatrist Dr Ian Drever at Esher Groves, Esher, Surrey.
The property is end of terrace. The rear is accessed via a narrow lane from the street, with the Grade II listed church grounds located on the adjacent side. Given that most of construction was to the rear of the property, getting material onto site and off site was a real problem.
In my December/January article in Independent Practitioner Today, I discussed the neighbours’ right of way, so the laneway had to been kept accessible for them as well.
The contractor had to meticulously organise material onto and off site for the build to work. This meant smaller deliveries and a series of drop and load skips to take material away.
This, of course, increased costs, as the frequency and number of skips required went up. It’s a very important issue for sites located within the M25. We have worked with clients who have had to mothball sites because access issues had a significant impact on the build costs.
How you decide to structure the relationship with the contractor will depend partly on the size of the build. If the build is considerable and involves ground-up
Every property is unique and every site will have its own construction issues. Access is a familiar problem on sites, particularly in built-up urban areas
works, many practices choose to employ a dedicated project manager.
There are several such companies who specialise in healthcare development and understand the nuances involved with medical properties.
If the build is less complicated, as in the case of Esher Groves, you may want to have a direct relationship with the contractor. A simple way to structure this is using an industry standard construction contract, known as a Joint Contracts Tribunal (JCT) agreement.
It is best to try and document as much detail in the schedule of works as possible at the beginning of negotiations. There’s usually a certain amount of contingency and add-on costs involved on any site, so it is beneficial to try and minimise these from the start.
If you would like to keep some space between yourself and the contractor, consider retaining your architect to certify works as they are completed. Payment is then controlled, subject to receipt of the architect’s certificates. The architect can also act on your behalf if there is a contentious problem on site.
There are two types of finance that clients usually secure when they build their premises: shortterm bridging finance or traditional development funding. Each type is structured differently and consequently is suited to some types of build and not others.
Bridging loans are secured on the existing ‘day one’ value of the
property and complement refurbishment and extension works, especially if the works can be completed in relatively short periods of time.
Development loans are structured on the gross development value or end value of the property when all the works have been completed. They are more relevant for projects where land is acquired and property is built out of the ground.
The general perception is bridging loans are more expensive than development funds. But the lending market is much more nuanced in practice, and pricing covers a range of values for both types of finance. Citron Singer can source bridging and development funds with interest rates from anywhere between 5% and 18% a year.
Understanding some of the factors that will have an impact on pricing will help doctors who are developing premises better understand the funding market.
The first factor to consider is the loan amount. For example, a simple straightforward well-located development that only requires £150,000 of funding will be priced mid range, say 10% to 11% a year. An equivalent site requiring £1.5m will be priced more competitively with lower interest rates applied to the debt.
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The second consideration is LTV (loan to value). Leverage, or the proportion of debt to value, correlates with pricing. As one goes up, so does the other. When the lender funds at higher loan to values, their risk increases, and that risk is compensated with a better return for them.
This principle is applied in general by lenders who will risk-assess each project on a case-by-case basis. Therefore, if the location and nature of the build or trackrecord of the developer raises risk concerns, the pricing will be adjusted accordingly.
In our final article next month, I will showcase the finished property. And I will look at different marketing strategies to attract clients as well as building up a clinical network with related primary and secondary care providers located nearby.
Dr Ian Drever, principle of Esher Groves, will also offer advice now that he can reflect on successfully acquiring and developing his own practice.
Maurice Citron (right) is director of Citron Singer Property Finance, a commercial property finance broker specialising in the healthcare sector
If cash is king, cash flow is his queen, so it is vital you get your billing and collection in good order to have a successful private practice. Findlay Fyfe shows how
So what exactly is cash flow and why is it so important? the short answer, of course, is that cash flow is the amount of money coming in to a business or practice and the amount of money going out.
t hink of it as a water tank: water comes in at the top and drains out the bottom. So to keep the tank nice and full; you want more coming in than going out. End of article, right? well, not really….
Cash flow is the life-blood of your practice and comes from your private work. this could include private medical insurance companies like Bupa and aXa PPP, self-payers including excesses, co-share payments and shortfalls, N h S Choose and Book work, medicolegal and finally from embassy work, mainly in London.
Cash is also important because it later becomes payment for things that make your practice run: including medical indemnity/insurance, website, rent, staff, mobile, medical equipment and other operational expenses –and it quickly adds up.
Positive cash flow means your business is running smoothly. Surplus cash flow is even better and will allow you to invest in your practice – such as hire employees, develop your website, open another location – and further grow your practice.
Conversely, if there is negative cash flow, more money paying out than coming in, this will put a burden on the practice and will
eventually lead to problems if not reversed.
Get organised and plan
Positive cash flow is driven by two things: organisation and planning.
Start by looking at the cash you have in hand, this could be money you have invested in the practice, cash in the practice bank account, loans that you have received or perhaps an investment from a partner.
If you are just starting your practice, make a list of all the one-time start-up expenses that you have paid or expect to pay.
t his will include incorporation fees for a company, legal and accounting fees, security deposit perhaps on a rental agreement or purchasing property, marketing materials, initial inventory or supplies, fixtures like office supplies, furniture, and equipment.
Next, you want to determine your monthly expected cash flow – and be realistic. If you are a new practice, you might want to project income conservatively. It’s better to outperform than underperform.
If you have already started your practice or are purchasing a practice from someone else, you have a distinct advantage: sales history.
h istory cannot predict the future, but it can paint a decent picture of what the future looks like and what practice changes you might need to make.
Finally, you will need to assess your monthly expenses. t his
can be a bit tricky because it is easy to overlook things and get a surprise you really don’t want.
Monthly expenses to factor in include both the items already mentioned such as rent or mortgage, medical indemnity/insurance, marketing, mobiles, tablet and finally, paying yourself. the most important thing about the process is being honest and objective. Do your homework and get accurate estimates of costs.
so having to wait over 12 months or for any length of time more than one month could easily lead to poor or negative cash flow. Make sure, therefore, that either yourself or a trusted member of staff is keeping a close eye on this. If the above is not in place – and reviewing your outstanding invoices would be a good place to start – it might be time to consider outsourcing this crucial part of the practice.
If you invoice patients/ customers and they have a flexible time-frame in which to pay you, that will make planning tricky and cash flow a likely problem. However, there are several ways in private practice to ensure better cash flow:
➤ Issue invoices promptly with a sensible time-scale for payment, normally 14 or 28 days and follow up on them regularly. This sounds simple, but many people avoid paying simply because they are not chased.
➤ Ensure you have a broad range of income from various sources – including PMI and selfpay work. For most successful private practices we come across, these form the bedrock of the practice’s work.
➤ Be careful not to confuse being busy with having a
Equally, balance this against what is a realistic target for patient activity as well as fees charged.
Findlay Fyfe (below) is managing director at Medical Billing and Collection
successful practice that has good cash flow.
Embassy and medico-legal work are notoriously slow for paying invoices. With embassies, especially the larger ones such as Kuwait, UAE and Qatar, this is largely due to the volume of work they manage. With medicolegal work, this is due to terms of payment normally agreed –and if it is on a case completion, basis, you will most likely have to wait years before getting paid.
➤ Check an invoice has been received and diarise when it is due to be paid. You can therefore chase it when it falls due, increasing the likelihood it will be paid.
Also keep a watchful eye on your practice bank account to see when payments are made and reconcile these against invoices.
If costs look high, simply projecting seeing more patients when you or your practice does not even have the capacity to see those patients will not fill that proverbial water tank. So perhaps you need to tighten the outflow. t hink, what can you reduce or cut?
It is also worth mentioning that tax is due on invoice, not payment,
We reported last month that analysis of NHS trusts’ 2016-17 annual accounts reveal that total private patient incomes rose by 4.6% to reach another new record of £594m. But this headline figure masks significant differences across the UK. Philip Housden’s series examines private patient services across England, by region, starting with London
T he 22 acu T e trusts in greater London when analysed by private patient revenue growth and by percentage of overall trust patient incomes can be divided into four distinct groups (Figure 1 opposite):
1 The big four of Royal Marsden, Great Ormond Street, Royal Brompton and Imperial, each with earnings of £40m a year or more, enjoying significant year-on-year growth and with private patients now accounting for between 12% and 31% of overall incomes and an average of £58m a year each.
2
The next six significant earners of Moorfields, c helsea and Westminster, uc L, Guy’s, Royal Free and King’s. For this group, earnings are between 1.5% and 5.2% of total trust incomes, incomes are growing and are between £26m and £14m a year.
3
The Royal National Orthopaedic hospital, St George’s, Bart’s and North West London are four trusts that comprise a potential group of next movers, each with significant infrastructure on which to grow their present earnings which range from £3.5m to £6.5m a year.
4
The final group is made up of the eight lowest earners, for whom private patients account for not more than £563k a year and 0.2% of trust revenues, significantly below the national average of 1.1% of acute trusts, and where revenues are in decline. When ranked by revenues as a percentage of total trust incomes,
the concentration of private patient activity within the largest ten trusts becomes apparent.
comparison by growth and percentage of incomes demonstrates how the largest trusts are pulling away from the rest (figure 6).
These ten trusts now account for over 59% of all N h S private patient revenues, up from 57% in 2015-16. These trusts have driven the market as much as responded to it.
In recent years, the overall trust brand and the private patient services of these trusts has become largely synonymous. Volumes have largely grown from overseas patients attracted to the superspecialised nature of many services and the highest quality infrastructure that these international tertiary centres provide.
The big four have expressed ambitions to invest to grow further and so this trend is expected to continue.
Royal Marsden is well on the way to its previously stated ambition of £100m a year from private patients, growing over 50% in the past three years and the closest trust in england to a fully mixed public-private model of care.
Great Ormond Street has also cultivated the international market, but has reported significantly high potential bad debt liabilities, mainly from overseas governments.
Royal Brompton has invested in a diagnostic and outpatient centre in Wimpole Street to support the private market and has entered the Middle east market.
Imperial is enjoying sustained modest annual increases in revenue and has significant resources operating across five sites (Figure 2).
The second group of significant earners are similarly following a strategy of investing to grow. Guy’s and St Thomas’ has recently opened a £100m integrated partnership cancer centre with hca on the Guy’s campus following a similar approach to uch
Royal Free has recently invested in opening a new facility at hadley Wood, Barnet, to extend capacity and referral catchment.
Moorfields is arguably already among the biggest hitters and is achieving rapid growth, also with a presence in the Middle e ast (Figure 4).
Our third group is made up of four trusts with ambitions to grow private patient activity. These trusts are all relatively under-performing when benchmarked alongside other central London trusts but are taking steps to be the next movers. (Figure 3)
Bart’s health grew nearly £2m in the last 12 months, achieved by a thorough review of present tariffs leading to renegotiated prices with major insurers and a drive to capture and charge for all activity.
Further medium-term growth is expected now that the trust has signed an agreement with Nuffield to open a private patient facility developed from former surgeons’ accommodation and pathology buildings.
The Royal National Orthopaedic h ospital at Stanmore faces a capacity dilemma and has oper-
ated at a flat £6m a year for several years. The trust has refreshed its private patient management team and opened a presence in harley Street.
and it is known to be close to a decision on whether to go ahead with a partnership approach with a leading independent hospital provider to invest in new bed and theatre capacity to unlock the potential of the £100m musculoskeletal services market from which it presently only enjoys a small share.
St George’s has not yet moved forward with a tender for a PPu, but this remains a likely viable option. King’s college hospital in south London is also expanding its private patient services and is another investing in the Middle east to meet international demand.
Finally, a word about the eight other trusts presently missing out on this growth (figure 5). e ach is physically located further away from central London and cannot therefore enjoy the same access to the international patient market. But it is striking that they are underperforming a high number of similarly sized trusts outside the capital. Their combined revenues are around £2.4bn a year and benchmarks suggest that 1% of turnover would be an achievable target. This would represent approximately £2-3m a year revenues for each trust and it is likely that the absence of active private patient services in these trusts is leading to a missed opportunity.
Philip Housden is a director of Housden Group
At last! NHS private patients units in England have started to adopt the private sector’s complaints code. Sally Taber (below) reports
Patients in private patient units (PPUs) have occupied an anomalous position when it comes to resolving their complaints.
they have been unable to resort to the Health service Ombudsman or the independent sector equivalent, the i ndependent s ector Complaints adjudication service (isCas).
Patients have been left helpless to resolve their complaints, adrift in an administrative gap. i t has been an unacceptable situation.
But now the Department of Health’s Patient experience and Maternity Branch has helped break the log-jam by confirming that PPUs may indeed belong to isCas if they wish.
Patients in PPUs may now finally bring their complaints to resolution – providing the PPU where their complaint arises decides to subscribe to isCas
Why ISCAS is the right choice to provide this service treatment in a PPU is separate from the n H s , being at base a commercial transaction.
PPUs are run for profit by nHs trusts, and therefore is C as is a better fit than the n H s
Ombudsman, who constitutionally cannot deal with private healthcare cases.
is C as is the only complaints framework of its kind operating in the independent healthcare sector. i t runs a voluntary code of practice for complaints management.
all the major acute healthcare providers across the UK are subscribers as well as a range of smaller independent providers, including the i ndependent Doctors Federation (iDF).
it has existed for 17 years and in 2016-17 it helped to bring to conclusion more than 240 complaints from 78 patients.
Healthcare providers pay a fee to isCas related to their turnover. t here is no charge to patients who make a complaint; the additional costs of an adjudication are met by the healthcare provider.
t he emphasis is upon finding
what went wrong and putting it right. Financial goodwill payments to patients, in the cases where they are appropriate, relate to the inconvenience suffered. across the 78 patients in 20162017, goodwill payments totalled £42,840. this was without cost to the taxpayer.
How ISCAS works and why
it fits ppUs’ needs so well t he is C as code of practice requires a three-stage process:
1. Local resolution (hospital level);
2. i nternal appeal (corporate/ group level);
3. independent adjudication. the emphasis is on local resolution, since this can focus on the immediate resolution of the problem.
Where the matter is complex, then much greater effort is required to assemble evidence and this is done at corporate level.
For adjudication, evidence is sifted, sorted and analysed by highly qualified, highly skilled, independent adjudicators. Patients and providers undertake beforehand to agree that the outcome of the adjudication will be final.
there is no cost to the complainant and subscribers meet the costs of is C as with each adjudication case. t his is important when considering any future arrangements for the PPUs in the independent sector – is C as operates without any government funding and no direct cost to the taxpayer.
It took a long time to get here
Over ten years, in fact, through four ministers and dozens of unresolvable complaints reported to us at isCas Baroness Fiona Hodgson is
the chairman of the isCas Governance Board because of her work and experience as a patient representative.
Her involvement began before 2000 and it was she who finally moved ministers to enable a satisfactory end to the impasse. it was a ghastly example of poor patient care that motivated this outcome. Over the preceding few months, is C as had been approached by complainants from no less than six PPUs, which were named to the minister, and accompanied by a redacted summary of a complaint from one of the busiest n H s PPUs dealing with many vulnerable patients.
Shocking case
t he case shocked – it was very badly handled and gave no relief to the patient.
is C as had to tell the patients from these six PPUs that there was
nothing it could do to review their complaint.
the previous Health Minister Philip Dunne was the most receptive of the need for change. t he Public s ervices Ombudsman Bill, which might have changed the rules that restrict the nH s Ombudsman from examining independent healthcare, was not in the 2017 Queen’s speech.
Lacking primary legislation change, and needing an independent third stage of complaints management in PPUs, the Patient e xperience and Maternity Branch, Department of Health, agreed we were able to include in the is C as 2017 Code the following statement:
‘nHS private patients Units Patients who receive care in an NHS PPU – a separate ward or set of rooms, allocated solely for private patients –may be covered by this Code if the NHS trust they have been treated in is a subscriber to ISCAS.’
nick Fox, the new executive director of Private Patients i mperial College Healthcare n H s trust, immediately saw that this solves the problem. i mperial Private Healthcare is one of the new subscribers to isCas and it applies the isCas Code to all complaints in the unit.
shaan Malhotra, its customer services manager, ensures the code is applied in all its three stages as well as incorporating a data processing agreement.
Learning will be shared with the Care Quality Commission and the Department of Health as an example of good practice for other PPUs to follow. and to ensure good practice applicable to PPUs is shared, shaan attends our governance advisory group as it continually evaluates change and greater patient benefit.
Sally Taber is director of ISCAS
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sAving FoR RETiREmEnT
dr Benjamin Holdsworth (right) explains why you should consider now how to make your retirement dreams a reality
When We polled Cavendish clients to ask their intentions for retirement, we were delighted with some of their unusual responses.
As well as the more familiar replies of exotic travel and driving classic cars, one client’s dream is to conduct an orchestra, others would like to own micro-pigs, win a BAFTA, learn bell-ringing, visit a prison and complete a dry-walling course in Derbyshire.
Unsurprisingly, the majority were looking forward to travelling, with Australia, n orth America, South America, Antarctica and the Galapagos Islands included among the desired destinations.
Some 35% of clients had a formalised bucket list, which included car racing, enjoying more time with family, volunteering abroad and learning a new language.
Our clients’ ideas for life postmedicine are always inspiring and we know from the many postcards and emails received that they certainly enjoy fully-charged retirements.
Luckily, their aspirations are achievable thanks to careful planning and a full consideration of their financial requirements at every stage of their life.
For other medical professionals, this is not always the case. While retirement years can be a golden era with the time and resources to enjoy the sweet life, for those who are not financially prepared, despite an apparently comfortable position at present, it could be
One couple who ensured they had a financial check-up before retirement is retired radiographer susan Pickman and her husband dr andrew Platts, a retired radiologist.
Both worked for the NHs and were confused with regards to the many options available to them upon retirement.
susan explains: ‘We decided to seek financial advice, as we knew the advisers understood the intricacies of the NHs pension system and the implications of those intricacies on retirement finances.’
andrew takes up the story: ‘Our adviser combed through my finances and quickly realised that I had been underpaid for many years, which was something I would never have noticed had I not taken advice.
‘Rather than being told which financial decisions to take, we were given options; for example, we expressed that we will frequently travel during our first years of retirement and so need the funds for this but will also require an income as we get older.
‘Being presented with the choices regarding our pension was invaluable, as the NHs pension is so complex, and the explanation and clarification allowed us to navigate to a satisfactory solution.’ the financial steps the couple chose to take paid off. they recently enjoyed a trip to British columbia, and have many more adventures planned, allowing them to indulge their passions of windsurfing, horse riding and paddle boarding. andrew also hosts an annual medical conference in tarifa, andalusia. andrew says his retirement lifestyle is thanks to his financial decisions. ‘do not assume everything is working to your advantage; you need people to help you, to check basic information and outline your choices.
‘It is likely that there is a benefit to retiring on a particular day, something that you would not know without advice.’
a time to ‘make do’ on a reduced income during their sunset years.
The nhS pension is a generous scheme by many standards, but it will not fully fund modern-day fruits of your labour retirement. Those earning over £200K while in practice might be tested to lead a similar lifestyle when transitioning to a £50K annual pension.
In addition, some of the benefits of the nh S pension have started to disappear over time and the amount of potential problems have increased. The main issues include recent changes to the taxfree lifetime and annual allowance contribution limits, which are forcing some to contemplate their membership of the scheme altogether.
People are also now living longer – we may have to finance our standard of living up to the age of 90 or even longer.
nearly 70% of our clients would like to retire by 65.
susan Pickman enjoying one of her adventurous pursuits – see case study, left
Just over a quarter aim to retire before 75 and only a handful are willing to wait until age 76 or beyond. To be ready to retire when they decide, doctors must ensure they are on the right path to achieving their own personal objectives.
The easiest way to do this is to ensure that every part of your
finances is working as hard as you. Your retirement plan needs to be fit for purpose, considering new regulations governing pension savings limits and tax relief.
One of the most challenging parts of our job is helping people who have left any form of financial planning until they are about to retire, or harder still, until after they have retired and finally have the time to think about their future.
For example, the taxation of pensions is a complex area, but with intelligent organisation ahead of time, liabilities can be reduced significantly.
If you do have a retirement plan, is it still an accurate reflection of your objectives? h as it kept pace with your current standard of living?
If you sought advice ten years ago but have not reviewed your financial status recently, now is the time to check everything is in order.
A good financial adviser will listen to your aspirations and put into place realistic preparations to help you and your family reach your goals and enjoy a long, happy retirement.
Dr Benjamin Holdsworth is a practising medic and business development director of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS.
The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.
Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.
Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.
Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.
Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.
Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.
Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.
We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:
We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:
We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:
• Setting up in Private Practice
• Setting up in Private Practice
• Setting up in Private Practice
• Developing your Private Practice
• Developing your Private Practice
• Developing your Private Practice
• Tapering of the Annual Allowance
• Tapering of the Annual Allowance
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SPECIALIST MEDICAL ACCOUNTANTS
• Reviewing your PAYE Coding Notices SPECIALIST
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• Reviewing your PAYE Coding Notices
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. T
T 01625 527 351
E info@sandisoneasson.co.uk W www.sandisoneasson.co.uk A Rex Buildings, Wilmslow, Cheshire, SK9 1HY Also at 1 Harley Street, London, W1G 9QD
QI am a consultant
oncologist and I have been asked to act as a certificate provider for a lasting power of attorney relating to money, finances and property for one of my patients.
The patient initially asked me to do this a couple of weeks ago. I agreed in principle, but said I would seek advice as to whether it would be appropriate for me to do this.
Unfortunately, during this time, the patient’s condition has deteriorated and she no longer has capacity. I had spoken to the patient, in the presence of her family, about her wishes at the time she asked me.
She had completed the form and signed it in the presence of a witness and it has also been
All they need is the doctor’s signature. But as one of our readers finds, it is not as simple as Dr Katherine (right) answers her query
signed by the attorneys. All that is needed is my signature.
Based on my previous discussions with the patient, can I still act as a certificate provider?
ALasting power of attorney (LPA) is a legal document that lets the donor choose attorneys to make decisions about their health and welfare or their money, finances and property on their behalf.
Decisions about health and welfare cannot be made on someone’s behalf unless they have lost capacity to make those decisions themselves. However, a donor can choose to allow an attorney to make financial decisions on their behalf even where they do still have capacity.
For a LPA to be valid, it needs to be signed by at least one impartial person called a certificate provider.
This needs to be an independent person who can confirm that the donor – the patient in this case –
understands the purpose and scope of the authority it gives to the attorney.
There are two types of certificate provider: a knowledge-based provider who has known the donor personally for over two years, and a skills-based provider who has the relevant professional skills to assess the donor’s capacity. The latter could include a registered healthcare professional.
The certificate provider must be satisfied that no undue pressure has been applied to the donor and there is no fraud. To fulfil this role, the certificate provider will need to have discussed the LPA with the donor alone to ensure that there has been no coercion, without the attorneys present.
The certificate provider would need to be satisfied that the donor had the capacity to create a LPA at the time of signing and must sign the form after the donor and preferably on the same day, or as soon as possible afterwards, but before the attorneys.
As the consultant oncologist involved in your patient’s treatment and care, you would be considered an acceptable certificate provider.
However, in this case, as two weeks have elapsed since you had spoken to the patient and you had not had the opportunity to discuss the details of the LPA with the patient in private to ensure her wishes were being followed, the attorneys had also already signed the forms. So it would not be appropriate for you to act as a certificate provider on this occasion.
Dr Katherine Leask is a medico-legal adviser with the MDU
If the LPA was ever challenged, the certificate provider could be called to the Court of Protection to justify their opinion. They would be expected to be aware of the provisions of the Mental Capacity Act 2005 and its Code of Practice.
took an unexpected turn after a paediatrician conducted a routine follow-up appointment. Dr Katherine Leask gives her advice
QI am a consultant paediatrician specialising in respiratory medicine and have been involved in the care of a child with a suspected non-accidental injury.
I examined the child during a routine follow-up appointment for their asthma.
Following this, I was contacted by the police to inform me that the father had been arrested two days later in relation to unexplained bruising that had been found on the child’s chest by a health visitor.
I provided a factual report stating that I had not noticed any bruising when I examined the child’s chest.
Now I have been contacted by the local authority in relation to a court hearing regarding the welfare of the child and I have been invited to intervene.
I was unsure what this meant and whether it had any implications for me.
AWhere child protection proceedings are taking place and a person, including a healthcare professional, receives documentation such as a letter from a
solicitor or a local authority inviting them to intervene, it suggests that allegations have been made against them with regards to how the child sustained the injury.
In this case, where the father of your patient has been accused of causing the injury, it is likely that he has alleged that it was caused by you or a colleague during the examination of the child’s chest.
As this could result in criminal liability for you, it is important that you contact your medical defence organisation as soon as possible.
You may need legal representation to protect your interests and represent you at the hearing. It will be necessary for your legal representative to request full disclosure of documents being relied upon in court so that the exact nature of the allegations can be established and who the allegations have been made by.
This type of case emphasises the need for good medical recordkeeping.
You had no reason to know that child protection concerns would be raised after your consultation with the child, but your notes will be vital with respect to your evidence, and the fact that you contend that no bruise, or other injury, was visible during the examination.
• Completely open scanner that is well tolerated by claustrophobic patients
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• Patients who are large or cannot lie down can be accommodated
Your ‘year two’ in private practice is a time for a review, says Ian Tongue A PRivATE PRAcTicE: yEAR 2
NO DOubT your first year of private practice has been a whirlwind, but it is important that you take time to pause and ensure you are best placed for your second year onwards.
Taking advice from a medical accountant can be invaluable to ensure that you are running your business efficiently and not overpaying tax.
The single most important decision nowadays is which trading structure to run your private practice. It is important to understand that, as your circumstances change, so can the optimum trading structure, so make sure you are discussing your circumstances with your accountant annually.
The three main trading structures for a private practice are:
Sole trader;
Limited company;
Partnership.
being a sole trader is often the easiest way to trade and allows you to run your practice with the minimum administrative burden. It may not, however, be tax-efficient and, in many cases, the trade-off for less hassle is paying more tax and National Insurance.
A limited company is often the preferred structure for your private practice and is usually the one with most flexibility. The tax efficiency of this structure will depend upon your specific circumstances, with the key factors being:
Whether your spouse or other family members can be involved in the business;
The anticipated profit level;
Your pension growth (see below);
Whether you need all of the money.
A partnership – a particularly useful structure for those with spouses actively involved in the private practice – allows a reasonable percentage of the profits to be allocated to your nearest and dearest. This can be particularly tax-efficient if they pay tax at a lower rate than you.
If you are unaware of the pension tax-free annual allowance, it is important that you take time to understand this, as it can be a
If you are unaware of the pension tax-free annual allowance, it is important that you take time to understand this, as it can be a nasty surprise and is often referred to as a penalty for working hard
several great software packages which will save you time and soon pay for themselves.
Soon there will be a requirement to report more frequently to HM Revenue and Customs. It is called Making Tax Digital. Most will find that this additional burden of administration will force them to use a practice management or accounting package.
After submitting your accounting records, ask your accountant if there is any feedback on the records you prepared. This should ensure accuracy of the figures and help keep costs down.
The amount you spend on your website, marketing and PR will largely depend on your specialty. Effective spend in this area can make a huge difference to the volume of work carried out, particularly in specialties such as plastics. It can also be a big waste of money if you don’t keep an eye on what works and represents good value.
However, everyone should invest in a professional website, as the first port of call for patients can often be the internet.
nasty surprise and is often referred to as a penalty for working hard.
The pension annual allowance is £40,000 for those earning up to £150,000, at which point it is removed or tapered down to as little as £10,000 for those with earnings of £210,000 or more. The definition of earnings is different to taxable earnings and, as it includes your annual NHS pension growth, it can be much higher.
The reason this is such an issue is that your actual NHS pension contributions are disregarded, and your annual pension growth is substituted and compared to your pension annual allowance.
The calculations are different between the 1995/2008 and 2015 pension schemes and pay increments and inflation factors can make a big difference.
To put things in context, ignoring inflation factors and pay rises, a consultant with a superannuable salary of £90,000 would have pension growth of £26,667 under the new 2015 scheme.
This equates to a tax charge of £7,500 for someone with a tapered annual allowance of £10,000, assuming there is no unused relief from the three previous years to extinguish the excess.
In many cases, the impact of the tapering of annual allowance can be mitigated and therefore reviewing your circumstances as your private practice grows is essential.
With a year under your belt, it may be time to consider investing in your practice management and accounting systems. Spreadsheets are fine for a period, but there are
All doctors will carry some form of professional indemnity/insurance, but the cost ramps up as you develop your private work.
It is important to revisit the figures supplied to your indemnity provider for your first year and compare with the actual amounts earned. Often a shortfall arises and it is important to let the accountant know to include this in your accounts.
It is also important to ensure that you clearly identify work that is already indemnified in order that this can be excluded from your income figure disclosed to your indemnity provider.
Likewise, medico-legal work carries different risk to clinical work and is disclosed separately within the calculations. To add further complication, your financial yearend may be different to your indemnity year for disclosing your income, so ask your accountant to help you work out the figures to disclose.
Often, the private hospital you work in will assist you in marketing yourself, as it has a vested interest in you working there.
With the ever-changing world of the NHS, it is important you keep an eye on where opportunities and threats exist. A private practice dependent on NHS work in the private sector may carry more risk due to the political factors around waiting lists and work carried out in the private sector.
It is important that you identify opportunities for your private work either as an individual or perhaps working in a group which can be very successful.
Reviewing your business regularly is an essential part of private practice success. Your accountant should be able to assist in many areas so ensure regular meetings.
Private ophthalmology business in the North-west Clinic equipped to a very high standard with a fully compliant theatre suite. The facilities are significantly underutilised with potential for additional or alternative surgical procedures from there or to sublet part of the building.
2017 Adj turnover: £812,000. Adj EBITDA: £263,000
The majority shareholder is the only surgeon within the company. He wishes to retire and realise a return on his investment. Offers are invited for 100% of the share capital of the company, or a sale of the goodwill with a leaseback of the property to the acquirer.
For more information, please contact Lorraine Dewhurst at Cowgill Holloway at Lorraine.Dewhurst@cowgills.co.uk or phone 01204 414266
Could Volkswagen’s new offering be set to regain buyers’ confidence following the ‘Dieselgate’ fiasco?
Dr Tony Rimmer (below) thinks so
ThE SUCCESS or failure of both our medical and business endeavours are ultimately determined by human frailties. We are reliant on the morals and ethics of our colleagues and fellow team members to ensure good practice. If one part of the group falters or makes some bad decisions, it is the whole organisation that suffers. Recovery from this position may be slow and will inevitably involve the close monitoring of on-going activity. This continuing activity needs to be above average to counter the negative connotations.
This is exactly the situation that the Volkswagen Group, the world’s largest car maker, finds itself in following the notorious ‘Dieselgate’ fiasco that was uncovered in 2015.
To regain buyers’ confidence, it has to release great-value classleading vehicles with a wide option of petrol-powered variants. To find out whether it is doing this or not, it was with great interest that I approached the very newest Volkswagen model to be launched, the T-Roc.
Based on the same floorpan as the latest Golf as well as many other Volkswagen Group products, the T-Roc is a small SUV and a latecomer to the popular and highly competitive SUV/crossover segment of the market. The current class leader is Nissan’s Qashqai with Seat’s Ateca a close second.
There are four main trim levels available: S, SE, Design and SEL,
and four engine options: three petrol and one diesel.
The 1.0 TSi has three cylinders and produces 115bhp, the 1.5 TSi has four cylinders and produces 150bhp, the 2.0 TSi produces 190bhp and the diesel 2.0 TDi produces 150bhp.
Six-speed manual gearboxes and front-wheel drive are the order of the day, but the 2.0 TSi has a seven-speed DSG auto box and four-wheel drive.
As a reflection of the current public car-buying preferences, Volkswagen had plenty of petrolpowered variants of the T-Roc available to drive at the recent UK launch in snowy Oxfordshire.
In the flesh, the T-Roc has an almost coupé look to it. Less boxy and upright than most SUVs, the styling certainly gives
Based on the same floorplan as the latest Golf, the T-Roc is a small SUV and latecomer to the popular and highly competitive SUV/cross-over segment of the market
it a smart and modern appearance. Various body contrast options are available to personalise your own car and this follows the current fashion to attract younger buyers.
Let down
Any Golf driver will be familiar with the interior. Clear dashboard and controls are only let down by a rather cheap and hard plastic used on the fascia and upper doors. I fail to understand why Volkswagen has allowed this anomaly as its use of materials have always been a higher quality than in the sister SEAT and Skoda brands.
Rear head- and leg-room is great for two passengers, but it is a bit of a squeeze for three. The hatchback boot is spacious, but, again, not quite as roomy as rivals such as SEAT’s excellent Ateca.
I slipped behind the wheel of a £19,610 1.0 TSi SE model and took to the road. Immediately, I knew that Volkswagen had designed something a bit special with this new small SUV.
The engine is sprightly, the
gearbox is easy to use and the steering is nicely weighted and direct. With this goes tidy handling and a sporty but not overfirm ride. The T-Roc is great fun to drive and this base three-cylinder engine variant has real character and does not feel underpowered at all.
This is just how Volkswagens are supposed to drive. The icing on the cake is the claimed overall fuel efficiency of 55.4 mpg. In the real world, that means an easy average above 40mpg; and it is not a diesel.
I then swapped over to a £22,685 1.5 TSi Design model to see what an extra few thousand pounds gets you. It drives just as well; the extra 35bhp make it feel sportier still. Claimed overall mpg is still very impressive at 53.3mpg.
The extra features of the Design model include a contrasting colour roof and some more driver safety and comfort systems. To get standard sat-nav and VW’s active dashboard display, you have to move up to the top SEL
model which costs an extra £1,600.
Top of the range is the £31,485 2.0 TSi SEL with four-wheel drive and a DSG gearbox as standard. It uses a slightly de-tuned version of the Golf GTI’s engine and it drives like a GTI.
If you like your driving and want a little more room than a Golf, then this might be the car for you. Pick of the range for an independent practitioner looking for best value but decent standard features would be the 1.5 TSi SEL at £24,520. Also, the DSG sevenspeed auto will be available on this model later in 2018.
Volkswagen has been clever with the new T-Roc. It has produced a stylish small SUV that has real character and is good value compared to premium rivals.
It is a shame about the quality of the interior plastic, but you soon forget this when you are zipping around town or along your favourite B-road. Look out for competition from Skoda’s new Karoq and Jaguar’s new E-Pace.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
To get standard sat-nav and VW’s active dashboard display, you have to move up to the top SEL model
VW has produced a stylish small SUV that has real character and is good value compared to premium rivals
Body: Five-seat hatchback front-wheel-drive SUV
Engine: 1.5 litre four-cylinder petrol
Power: 250bhp
Torque: 250Nm
acceleration: 0-62mph in 8.3 secs
Top speed: 127mph
claimed fuel economy: combined 53.3mpg co2 emissions: 120g/km on-the-road price: £24,520
All you need to know about accountancy for private practitioners
Radiologists are not only boosting their incomes, they are also managing to keep their costs down. Ray Stanbridge reports on the latest figures in our unique benchmarking series
Two years ago, I predicted in Independent Practitioner Today that there was a big potential for income growth for radiologists, especially for those who specialise in interventional work.
well, I am pleased to report the prophecy is still coming true. average private practice incomes of consultant radiologists have increased by 6.6% between 2015 and 2016, going up from £122,000 to £130,000. Their average costs have risen by only about £1,000 (at 2.9%)
from £34,000 to £35,000. a s a result, taxable incomes have increased by 8% from £88,000 to £95,000.
radiologists are, in effect, a service function to other medical professionals. They may choose to conduct their Choose and Book independently or through Paye The growth of Choose and Book work has, in our view, distorted the growth of private practice income figures.
Notwithstanding all the above, income generally has shown
aveRage INCOMe aND eXPeNDITURe OF a CONSULTaNT RaDIOLOgIST WITH aN eSTaBLISHeD PRIvaTe
Expenditure
Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)
Source: Stanbridge Associates Ltd.
strong growth trends between 2015 and 2016. This is a result of a general rise of activity.
In addition, radiology fees do not seem – so far at least – to have been hit by aggressive price increasing tactics from insurers.
Costs for most radiologists in private practice have remained constant.There have been modest increases in staff costs, which on average have gone up from £13,000 to £14,000.
But, as we observed elsewhere, there is a correlation between the growth of ‘average’ staff costs and the personal allowance.
s urprisingly, there has been a fall in indemnity/insurance costs. obviously, our figures are delayed, but there is some evidence that prudent radiologists are actually shopping around.
o ne or two have switched to cheaper providers and this has affected average figures. o nce again, we are not able to comment as to whether they are getting comparable cover from new insurers. what then of the future? we are seeing a significant growth in day case right around the UK. we are also seeing a rise in the use of diagnostic and other tests.
RaNge OF gROSS INCOMeS
Surprisingly, there has been a fall in indemnity/ insurance costs. There is some evidence that prudent radiologists are actually shopping around
For both of these reasons, our view is that the future prospect of radiologists remains rosy. The question is whether or not the NHs is revitalised by politicians. of course, it is very important to stress that our analysis is not statistically significant.
a s we reported in our March 2017 edition of Independent Practitioner Today, it is increasingly
difficult to make inter-year comparisons.
This is because of the growth in the number of radiology groups and the changing way in which radiologists do their business. Increasingly, they are remunerated through hospitals or ‘preferred’ suppliers and these can lead to significant income changes.
an increasing number of radiolo-
gists are also trading through their limited liability company, which, in several cases, has had the effect of reducing their tax liabilities.
The market for radiology service delivery is constantly changing and this means that meaningful comparison is increasingly proving difficult. Having said all that, we have tried to ensure that criteria for entry in to our surveys are consistent.
To qualify for our survey, radiologists must:
Have 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 primarily to meet school fees and holiday costs;
Hold an old-style NH s maximum part-time or new-time contract;
work as a sole trader through a formal or informal partnership, limited liability partnership group or limited liability company.
Next month: Urologists
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates
How ARE YoU doiNg?
oncologists
Anaesthetists
Urologists
years ending 5 april Source: Stanbridge Associates
Coming next month on 19 april is Independent Practitioner Today’s 100th issue
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Also in April:
It is imperative to understand how patients’ views are changing over time, particularly with the changing use of technology and ways in which it is applied. Understanding the characteristics of different age groups is also vital, particularly when considering technology. Jane Braithwaite reports
One of the most significant financial risks a consultant can face is now the pension annual allowance, as it can lead to huge unexpected tax liabilities. Check out a medical accountant’s advice
Dr Benjamin Holdsworth, of Cavendish Medical, reveals how eU directives have helped reveal the true costs of some investments
What’s financially hot and what’s not among southern counties PPUs
Digging for dissection – feeding the horrors of the anatomy table
Creating your own premises for private practice. The last in our series featuring consultant psychiatrist Dr Ian Drever’s realisation of a dream
Profits Focus, our unique benchmarking series, checks out the latest results for urologists
a round-up of the tax changes affecting you in the new financial year
Doctor On The Road columnist Dr Tony Rimmer tests the Range Rover velor
PLUS all the latest news and views
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