April 2018

Financial sunrise

With the new financial year upon us, many doctors may be considering how best to plan and maximise the £££ in their pocket. accountant Susan Hutter gives her guidance P10

is your practice millennial-ready? london millennials are more ready than ever for insured private healthcare. So has your marketing strategy caught up? Jane Braithwaite reports P12

When opening day arrives in the final article in our series about building your own premises, entrepreneurial psychiatrist dr ian drever reflects on the ups and downs of the process as opening day beckons P38

editorial comment

In this issue We’ve scored a century!

Welcome to our landmark 100th issue of Independent Practitioner Today

At 60-pages for the second month running, it’s another big issue for us and it is packed with more news and features than we ever envisaged possible when we first published back in 2008.

We hope you find the 100 big issues we’ve chosen to highlight (see pages 16-37) make up an informative and useful package of tips both personally and for your business’s progress.

All but the 100th have been published sequentially across our previous 99 issues. If you have been with us from the start – as lots of you have – then we figured many of you would find them a handy memoryjogger.

It might now be a good time to share them with newer partners, managers, administration staff and your private hospital.

If you have joined us later on

our journey, then we think it is likely that a good number of the experts’ tips we are re-visiting here could have you remarking: ‘If only I’d known that before!’

For the future, as in the past, we will always endeavour to keep you ahead in the ever faster-changing world of private practice. To ensure you don’t miss out, we suggest you follow our favourite tip. See point number 7 from issue 23.

A big thank-you to all the doctors and professional experts whose advice and tips have helped shape our unique editorial offering in the past.

We will, of course, be seeking plenty more news and features from a wide range of professional sources as we head for our second century.

So if you think you would like to make a contribution, we would be pleased to hear from you.

let experts do the bill chasing

So you have still not been paid? Well, sending the invoice is the easy bit. Findlay Fyfe shows what other complexities you need to master to collect your money efficiently P40

the grim days of body-snatchers Medical historian Suzie Grogan delves into the profession’s pressure to obtain corpses for dissection, in the second part of her book serialisation P44

the monster of charges is real to ensure a prosperous retirement, make sure you understand how your funds are performing and how much you are paying for the privilege, an investing expert explains P50

Business dilemmas: on genetic tests + keeping notes Medico­legal experts answer readers’ questions about genetic tests and on retaining notes after retirement P52

doctor on the road: off-roader that’s a luxurious cruiser our resident petrol­head doctor discovers he can get a massage while driving the latest range rover P56

Profits Focus: it’s costing them dear our unique benchmarking series finds urologists suffering from double­digit growth in their expenses P58

INDEPENDENT PRACTITIONER

TODAY

the business journal for doctors in private practice

IDF on a Spring advance

By robin Stride

The Independent Doctors Federation (IDF) is surging ahead with a total revamp in its bid to extend its influence and boost services for a fast-growing young membership.

Consultants and GPs at its annual general meeting (AGM) on the first day of Spring were told of a 15% increase in members last year – bringing the total to 1,313 and up 184 on the previous year. Leaders, aiming for 500 more new members this year, reported a big increase in applications from outside London.

And they set out a list of impressive plans – some already operational – designed to make the IDF a cutting-edge body ‘delivering great results for members in lots of different ways’.

These include:

 Help for consultants, as well as GPs, to cut indemnity costs;

 A new female group: women now make up 23% of the membership;

 Business services support from a team of professional firms;

 A second annual London Healthcare Conference on 18 June to highlight the independent sector’s innovative work;

 Meetings in Manchester and Newcastle-upon-Tyne for members in the north;

 More engagement with stakeholders in private healthcare and beyond;

 A new leadership team for The Indees – a social/networking arm for the ‘young at heart’;

 Seminars to educate and inform the public.

More younger members are

being targeted, there is fresh new branding for the organisation, a promotional video and an improved, responsive website is due in the Autumn.

A study weekend in October, in Milan, is expected to be oversubscribed, but many more breakfast meetings are planned.

The IDF last year held 55 man-

datory training and educational, events.

In a written report, chief executive Sue Smith said a key finding of a root and branch review of the organisation was that the IDF needed to be seen as more contemporary and forward-thinking to attract more younger members. She said: ‘Younger, tech-savvy doctors increasingly expect relevant, tailored and highly targeted communication, delivered instantly through contemporary portals.’

IDF president Dr Brian O’Connor reported: ‘As the IDF continues to expand, not only will we embrace change but we wish to lead.’

He said the body had always been open and transparent and would continue to place great emphasis on operating ‘in a culture of equality, diversity and transparency with respect to all’.

President-elect Dr Neil Haughton said interesting times were ahead as the IDF evolved into a modern representative organisation.

The AGM was told there had been a steady rise in the number of appraisals done by the federation.

It had to increase its number of appraisers by nine, to 45. It carried out nearly 700 appraisals, 556 for members who were connected to the IDF and 130 for members with a higher prescribed connection.

Rooms for appraisals can now be booked at the federation’s new headquarters at Lettsom House, Chandos Street, London W1.

 See reports from the IDF meeting on pages 6 and 7

attracting young independent practitioners: the new leaders of the idF’s social and networking arm, ‘the indees’ (from left) dr ian cole, dr Shaima villait and dr Jonathan Hoare

Inflation to aid pension

By Edie Bourne

High inflation is not normally good news, but this year it could be for some doctors because it will shield them from hefty pension tax charges.

The positive outlook was given to hundreds of independent practitioners by financial advisers.

Doctors in the 1995 NHS pension scheme have an ‘inflation’ allowance which softens the blow of their pension inputs for a year when tested against the annual allowance – the amount which can be saved into a pension annually year while still receiving tax relief.

The rate of inflation that is used to calculate pension inputs is set at 3% for 2018-19 – as opposed to just 1% in the previous year.

According to Patrick Convey, technical director at specialist financial planners Cavendish Medical, this means that pension inputs for the year will not be so high and therefore they will be less likely to breach the harsh new annual allowance limits.

He told Independent Practitioner Today: ‘For example, a doctor in the 1995 NHS scheme with pensionable pay of £100,000 at the start of the year, rising to £106,000 at the end of the year, would have a pension contribution of £63,175

Action to take after the Spring Budget

Private consultants and GPs have been advised to consider taking action in three main areas of their business following the Chancellor of the Exchequer’s Spring financial statement.

Independent Practitioner Today columnist Susan Hutter, a partner at accountancy company Blick Rothenberg and part of the team that advises medical practitioners, said doctors should look at the following financial topics:

Tax-free personal allowance

From 6 April 2018, the tax-free personal annual allowance increases from £11,500 to £11,850. So higher-band taxpayers should consider employing family members to make use of this allowance.

Mrs Hutter said: ‘For those who employ a lower-earning spouse in the practice, or indeed any of their children over the age of 18, this is important to bear in mind.

‘As long as the work carried out by these people is commensurate with the salary paid, it is a way of ensuring that the tax-free band is not wasted.’

Business rates

Business rates revaluation will be brought forward to 2020-21 and then moved to a revaluation every three years thereafter.

Mrs Hutter continued: ‘This is good news, as it should help those who are finding the practice rates’ bills quite high.’

Taking on an apprentice

Some doctors’ practices may find it helpful to avail themselves of the support the Government is giving to small businesses when taking on an apprentice.

Mrs Hutter explained: ‘For example, taking on an apprentice can help with short-term spikes in administration that the practice staff may not have time for.

‘The Chancellor is making £80m available to support small businesses when taking on apprentices. However, we will need to wait for the detail and clear guidance on how practices can access the funds.’

She said all these issues required a close watch for measures to be introduced over the coming months and in the Autumn Budget.

if inflation is at one per cent, but £47,975 with inflation at 3%.

‘The standard annual allowance is £40,000 per year, so when inflation is high, there are less excess savings above the limit.’

Most senior doctors now face a ‘tapered’ annual allowance which can reduce their yearly limit to just £10,000.

Pension savings above the individual’s annual allowance figure are taxed at their marginal rate of income tax.

Mr Convey added: ‘As ever, the area of pensions’ tax, particularly when related to the NHS scheme, is complex. If you’re unsure where you stand, seek experienced help.’

Doctors already in receipt of their NHS pension will also see their pension income increase by 3%.

 see ‘when a pension can ensnare you’, page 54

Extensive cover for mental health

Bupa this month launched what is being hailed as the most extensive mental health cover available for businesses and employees.

Business Mental Health Advantage gives support and treatment to manage all long-term mental health issues except dementia and learning/behavioural development problems.

In response to increasing demand from businesses for mental health support, the policy covers for conditions such as depression, bipolar and anxiety plus those typically excluded, such as alcohol and drug abuse.

A removal of the three year ‘chronic rule’ means recurring conditions are covered, so employees have access to medical treatment and support if their condition comes back.

The insurer said it was also providing ongoing support for the monitoring and maintenance of diagnosed mental health conditions, to help employees manage their condition and prevent worsening symptoms.

Cover will be given for a mental health condition even if it is con-

nected with a condition Bupa does not cover, such as anxiety as a result of sleep disorder.

Over the last decade, Bupa has seen the number of employees claiming for mental health treatment double. Poor mental health costs employers between £33bn and £42bn a year – £1,000+ per employee per year.1

Stuart Scullion, chairman of the Association of Medical Insurers and Intermediaries (AMII), said for the first time UK businesses could be confident they were providing their employees with access to first-class mental health benefits and service whenever they needed it.

The Government is calling on businesses to provide more support for employees struggling with mental health issues. Industry figures show that mental health is now the most common reason for someone to be signed off, with 70m working days lost each year as a result.

1. Thriving at work; www.gov.uk/ government/uploads/ system/uploads/ attachment_data/file/658145/thrivingat-work-stevenson-farmer-review.pdf

Patrick Convey of Cavendish Medical

IDF In taLks to IMProvE onLInE CarE

the Independent Doctors Federation (IDF), which reports a rise in members providing online medical services in past last year, said it had worked with the CQC ‘to understand more clearly’ where the regulator had concerns.

President-elect Dr neil Haughton said the IDF has had talks with CQC digital advisers on how to develop remote doctoring guidelines.

He said: ‘Digital and remote medicine will become the norm for many and it’s important that delivery of primary care using these platforms is safe.

‘there has to be a collaborative approach between the regulator and the doctors in developing tools to ensure safe consultations and prescribing take place across the service.’

Dr Haughton said the IDF had started discussions with members providing or considering providing online primary care services.

Watchdog knocks online GP service

By Leslie Berry

Independent online primary care services providers have been hit with criticism about their quality from the regulator.

The Care Quality Commission (CQC) said businesses such as those providing GP consultations and prescriptions from independent websites and apps had improved in the last year, but more was needed to ensure they are as safe as general practice in physical premises.

At the end of February, 43% of the 55 providers inspected were found not to be providing ‘safe’ care in line with regulations – an improvement from 86% not fully meeting them on their first inspections.

Inspectors found:

 Inappropriate antibiotic prescribing, including lowered thresholds for prescribing, as a physical examination was not possible, and prescribing high volumes of opioid-based medicines without talking to the patient’s registered GP;

 Unsatisfactory approaches to safeguarding children and those possibly without the mental

capacity to understand or consent to a consultation;

 Not collecting patient information or sharing it with a patient’s NHS GP, who should have an accurate and up-to-date record of their previous and current treatments and health problems;

 Inappropriate prescribing for long-term conditions, including failures to monitor the volume of asthma inhalers being prescribed to individuals when their condition should be regularly checked.

CQC assesses online primary care service providers against five key areas – whether they are safe, caring, effective, responsive to people’s needs and well-led. 97% of the providers were meeting the regulations around being ‘caring’.

It said 90% of providers met the regulations around being ‘responsive’ to people’s needs.

CQC has found that online consultations have the potential to improve access and convenience for some patients, such as those with physical impairments for whom attending face-to-face appointments could be difficult, those with a sensory impairments, and those who live in rural areas and have poor transport links.

Prof Steve Field, CQC chief inspector of general practice, said: ‘New methods of service delivery that increase access to care and give patients more control over how and when they see a GP have huge potential not only for patients but for the wider health system.

‘However, while innovation should be encouraged, it must never come at the expense of quality. As with all health care services, patient safety must be at the heart of all decisions around what kind of care is offered and how it is delivered.’

Teamwork ‘can ease red tape’

A vital ingredient for independent practitioners’ success is an open and supportive culture where issues and errors can be discussed within the practice team, according to a management expert.

Jane Braithwaite, managing director of Designated Medical, told doctors it was important to constantly review the working of their practices, look for areas to improve and implement necessary change.

Speaking on ‘practice management made perfect’ at an Intuition

Communication seminar in London, she stressed the importance of communication within the team.

Ms Braithwaite, a columnist for Independent Practitioner Today, said her approach to achieving near perfection was to focus on creating exceptional processes and fully utilising the best systems to work in the most professional manner.

She told the audience: ‘There is much change in regulation that affects practice management and

we must ensure we educate ourselves.

‘The regulatory requirements often appear to be daunting, but, in reality, if our practice is being run well, then much of what is required is managed in our normal day-to-day processes. As new requirements are introduced, we can take pragmatic steps to ensure full compliance.’

She said there were numerous options for consultants to choose from when deciding how to resource their practice. They

might choose to employ permanent team members to manage the practice or a service provider to do so or a mixture.

The right solution depended on the characteristics of the practice and where clinics were located.

Ms Braithwaite added: ‘A good medical practice is driven by a desire to deliver high patient satisfaction. I suggest the way to manage our patients and our practices professionally is to create processes to ensure we deliver the best service.’

the IDF’s Dr neil Haughton wrote about online services in an article in last month’s issue

independent doctors federation: aGm 2018

Relationship with insurers improves

By Robin Stride

The IDF’s Specialists’ Committee chairman has vowed to make every effort to keep consultants well informed about upcoming changes so they can make the most of new opportunities.

Dr Sean Preston said private medicine’s landscape was showing a lot of uncertainty. It could be unrecognisable in two years’ time – but that also offered the chance for specialists to benefit.

He reported relationships with the private medical insurers were ‘in a better place’, away from the nadir of ‘open referrals’.

Now there was evidence of ‘green shoots of dialogue’ between them and clinicians – and examples of improved rewards for higher-performing clinicians.

Some committee members had been identified by insurers for their specialist and subspecialist expertise. They had been tasked with creating guidelines and standard operation procedures to increase efficiencies and target outlying clinicians, with the aims of improving clinical care and driving down costs.

Dr Preston and chief executive Sue Smith met with several insurers last year and aim to have discussions with the others soon. Although dialogue had sometimes lacked hard end-points, he said it was in its early stages and he was hopeful talks would lead to improvements for IDF members.

He had sat down with Bupa and seen the data collected about his practice was now ‘frightening’ in its detail. Not only more extensive, it was also more detailed and accurate, influencing subsequent referral pathways.

Insurers had been explicit in their preference for their patients to be seen within group practices,

Dr Sean Preston, chairman of the IDF’s Specialists’ Committee

particularly those engaging, where appropriate, with multidisciplinary teams (MDTs).

In his written report, Dr Preston said: ‘The holy grail is to demonstrate high-quality care within this setting – easier in some specialities than others – but where this has been done, there have been several cases of improved renegotiation of “fee assurance” and we will continue to support our members in these discussions and explore mechanisms of demonstrating high-quality medical performance.’

Another opportunity for clinicians arose from the Competition and Markets Authority (CMA) ruling that clinicians could invest in firms providing healthcare if less than 5% was owned.

Hospitals had created several such examples of ‘joint ventures’ to align the incentives of providers and clinicians and aid consultant recruitment.

He said other providers had acknowledged the challenges of setting up in private health care and had created ‘salaried’ and ‘clinic’ models of employment to ease the burden.

With the ‘clinic’ model of groups of specialists having been championed by the insurers, the

IDF aimed to guide newly-qualified consultants in deciding what was most appropriate for them.

Turning to the Private Healthcare Information Network (PHIN), the agency mandated to deliver metrics of private healthcare to the public, he said this was an evolving process for all consultants.

On first inspection, the data appeared to be very ‘quantity’ driven, describing numbers of patients seen and numbers of procedures performed, but light in ‘quality’ information.

He continued: ‘Time will tell how the public will use this data and the impact it will have with respect to their choice of clinician. It is in all our interests to ensure these numbers reflect our practice and this responsibly needs to be shared with the hospitals, both private and NHS, from where it originates.’

On inspecting his own figures, he found significant differences in the quality of data between hospitals. This was a problem which would need to be rectified in the very near future.

High-quality health metrics were central in demonstrating clinical excellence and without this information, patients would undoubtedly choose to be seen by those who could show it.

Dr Preston cautioned that private practice rewards for newly qualified consultants were not as immediate as they once were.

With the costs of setting up practice increasing, higher medical indemnity fees and more litigation and complaints, it was no surprise that fewer younger consultants were practising private medicine and were instead heading towards ‘the lower-lying fruit’ of other work such as waiting list initiatives.

Private GPs get worse support than NHS doctors

Private GPs are having continuing problems in getting equal treatment to their NHS colleagues.

IDF GP committee chair Dr Neil Haughton said vaccine supply remained a recurrent trouble, with supplies of the new Hexavalent vaccine, among others, being denied to private clinics.

‘I have continued to write to suppliers and NHS England with little success. Most recently, we gained support of the RCGP and BMA, who asked their legal team to advise.

‘Unfortunately, there’s no realistic way we can force suppliers to sell us vaccines, despite it being discriminatory and compromising patient safety.’

He said the IDF would send out a copy of the BMA legal team report on request.

‘There are ways round the system, of course, and my practice sources vaccines from various suppliers, often European, but I’m not sure how long that will last.’

Hunt for referrals

IDF GPs are using a popular informal ‘speed dating’ format to meet up with and quiz a range of specialists.

New GP heaD: Dr Di Loudon, of Chelsea Medics Ltd, has taken over as IDF GP Committee chairman

independent doctors federation: annual General meetinG 2018

Help for GPs to set up in private care

The IDF is setting up a new advisory service to help the growing numbers of GPs trying to set up in private practice.

It is constantly receiving requests for information about how to start out and provide private primary care services.

The meeting was told the specialty was thriving in London in its many forms and increasingly

outside the capital. GP Committee chairman Dr Neil Haughton said: ‘I despair of the constant undermining of our NHS colleagues and the dumbing down of primary care.

‘But if we can support alternatives to help the public to access healthcare safely, whether via digital or traditional means, then that can only have a positive outcome.’

Private GPs to access NHS data

The Royal College of General Practitioners is backing the IDF’s campaign for private GPs to have access to the NHS information spine and for their details to be available to all NHS hospitals.

The federation sees this as increasingly important as patients

access healthcare in ever more varied ways.

IDF GP Committee chairman Dr Neil Haughton said: ‘I have also managed to get NHS England to agree to this and I am in discussion with their head of IT to facilitate the necessary changes.’

IDF arranges big savings on medical indemnity

Mounting defence costs mean independent GPs have been looking elsewhere for cover – and the IDF has come to the rescue.

The federation has negotiated its own bespoke product ‘at considerable saving over the main providers for the same cover’, according to the IDF’s out-going GP Committee chairman Dr Neil Haughton.

He said: ‘I have myself switched and the service received has been excellent.’

Specialists’ Committee chairman Dr Sean Preston said the entry of less traditional insurance companies into the market meant indemnity choices had increased both north and south of the bor-

der and prices had become more competitive.

What was previously a straightforward decision between two or three providers had now become a more complex process which could be challenging to negotiate without the help of ‘a medically literate meerkat’.

He hoped his committee would be able to steer members through this path.

IDF conference to highlight innovative care

The second annual IDF London Healthcare Conference, ‘CuttingEdge Medical Care’, will be held on 18 June 2018 at the Royal Society of Medicine in Wimpole Street.

Conference director Ted Townsend said the theme was chosen to highlight ‘the truly innovative work that often goes on in the independent sector’ and aimed to be more thoughtful and stimulating than traditional clinical updates.

The conference is open to all

GPs, consultants and other medical professionals.

He said: ‘Apart from the clinical content, it is also a great opportunity for delegates to engage with the IDF, who will be launching a new range of business services.’

In an innovative approach, the conference opens at 2pm and runs through to the early evening, so clinicians do not have to give up a whole day to attend. CPD points will be awarded.

The opening keynote address

will be by Dame Prof Parveen Kumar of Barts and The London, followed by a look at personalised medicine by Dr Nick Lench of Congenica. Barry Sweetbaum from SweetTree will then look at whether the Smart Medical Home is here yet.

A topical programme brings together expert speakers from the following disciplines:

 Cardiology: session chairman, Dr Rakesh Sharma, Royal Brompton;  Gynaecology (to be announced);

 Interventional Therapeutics: session chairman Prof Pallav Shah;  Oncology: session chairman Dr Sanjay Popat, Royal Marsden;  Urology: session chairman Prof Mark Emberton, UCL.

A session on hot topics for GPs will look at sepsis, antibiotic resistance and sexual health.

Early-bird registration rates are available until 16 April at www. londonhealthcareconference.org or call Marie-Claire on 07903 406187.

Dr Neil haughton, GP chairman, has switched to the IDF cover himself

Head for new salary unit

By Charles King

Consultant anaesthetist Dr Tim Wigmore has been appointed medical director of the soon-tobe-opened Schoen Clinic private hospital in Wigmore Street, London.

He will join from the Royal Marsden Foundation Trust where he has worked as a consultant since 2007, holding posts as clinical lead for critical care, divisional medical director, associate medical director and chief clinical information officer.

Dr Wigmore said the hospital, which will directly employ consultants on a salaried model, was ‘hugely exciting’.

A hospital spokesman commented: ‘There is no doubt that there is a need for such provision

in London; where private medicine has traditionally been delivered by clinicians who undertake multi-site operating, which is a model that inevitably results in a diluted focus.

‘The model at Schoen Clinic of predominantly employed consultants eliminates this issue and there is no doubt that patients and organisations benefit when the attention of clinicians is concentrated on a single locale.’

With dual specialist qualification in anaesthesia and intensive care medicine, both in the UK and Australia, Dr Wigmore has been anaesthetising in spinal surgery for over ten years.

He also chairs the North West London Critical Care Network and sits on the London Steering group for Critical Care.

Opening in June 2018, Schoen Clinic London will offer rapid assessment, diagnostic imaging,

treatments and rehabilitation all under one roof.

It said it would be working with some of London’s leading spinal surgeons, orthopaedic consultants, musculoskeletal physicians, radiologists, physiotherapists and sports physicians. The hospital will treat private patients from elite sports-persons with musculoskeletal injuries to people with arthritis or back pain and international patients with complex spinal conditions.

 A £900,000 MRI scanner has been installed at the clinic. At over 20 tonnes, its arrival represented both a logistical challenge necessitating the demolition of a large part of the exterior wall.

The clinic’s opening is delayed until late July earliest following ‘an unforeseen construction issue’.

Compiled by Philip Housden

Royal Brompton expands PPU at Harefield Harefield Hospital, Uxbridge, has opened a 16-bed private patient ward, a high-dependency unit and a transformed private outpatients and diagnostic suite.

David Shrimpton, managing director of Royal Brompton and Harefield Hospitals Specialist Care, said demands for its service had rapidly expanded.

‘The development has been a success in terms of an increase to business, but more importantly we have received outstanding feedback from our patients, referrers and our own consultants. Consultations and multiple tests can be scheduled on the same day, which we know patients and consultants are looking for.’

Derby Private Health invests and expands

Derby Teaching Hospitals NHS Foundation Trust is investing £2m for a dedicated operating theatre for private patients at the Royal Derby Hospital.

‘Derby Private Health’ profits, over £1m last year, are invested to the city’s teaching Hospitals NHS Foundation Trust.

Its suite has 11 ensuite inpatient rooms, five consultation rooms, a chemotherapy suite and minor procedures room. An ophthalmology outpatient clinic is due in 2018.

General manager Sue Searle said the theatre would cater for a bariatric, orthopaedics and general surgery among others and would shorten waiting lists.

nHs treatment of private patients: Impact on nHs finances and nHs patient care

PPU revenues were £596m in 2015-16, but now a Centre for Health and the Public Interest (CHPI) report proposes an independent review into whether PPUs make a net contribution to NHS finances, and whether they reduce capacity to treat NHS patients.

The report appears not to give full weight to the purpose of PPUs and how they work. They cater for

a range of work private hospitals cannot do for insured patients, essentially complex procedures, and those requiring specialist equipment and skills unavailable at a smaller private hospital.

Where there is no PPU, many privately insured patients default to the NHS, squeeze already scarce capacity and increase waiting lists.

Any review should aim at enabling best practice to be shared between NHS trusts. PPUs are an opportunity, not a threat to the NHS.

PPU national event

PPU managers met to network in Birmingham at an SBK Healthcare event, hearing case studies on private patient models, insurers’ answers to their questions and a presentation on the Private Healthcare Information Network (PHIN).

Philip Housden (right) is a director of Housden Group.

 see his financial analysis of PPUs on page 42

New chief at the helm at Optegra

Eye health care provider Optegra has appointed of Dr Peter Byloos as group chief executive. He has worked in healthcare industries across Europe, most recently as a partner in the healthcare arm of private equity firm Gimv, chief executive and president of Handicare Group in Norway, and at medical devices company CR Bard.

PPU watCH

Dr Peter Byloos

Dr Tim Wigmore: the Royal Marsden anaesthetist starts at the Schoen Clinic next month

HCA appoints chair of new advice group for quality

HCA Healthcare UK has appointed Ed Smith to chair its new advisory board, set up to support the hospital group’s agenda around quality care and sectorwide collaboration.

Mr Smith is the former chairman of NHS Improvement and deputy chairman of NHS England. Board members will come from regulatory, health, academia and consumer backgrounds.

HCA UK’s chief executive Mike Neeb said: ‘He brings considerable experience and knowledge, which will no doubt be of immense assistance to our strategic agenda.’

He said HCA had always focused on providing the best possible clinical expertise and care to its patients and, with the board’s input, it hoped to be able to find new ways of driving continuous improvement.

Taxpayers have been warned that time is running out for anyone with offshore assets before tougher penalties kick in.

New, tougher penalties take effect from 1 October and HM Revenue and Customs (HMRC) advises anyone with overseas assets to put their cards on the table quickly or risk much bigger fines.

It said it would prosecute the most serious cases of tax evasion.

Doctors’ accountants have warned clients in the past of the pitfalls of offshore schemes and about HMRC’s efforts to step up its campaign to improve the tax take.

The new penalties are part of the Government’s drive to ensure there are no safe havens for people trying to evade paying tax.

HMRC said it held a vast amount of data on offshore assets and this was growing all the time.

A spokesman added: ‘The majority of taxpayers with offshore assets already disclose them in line with UK law so have nothing to worry about, but for the minority of tax-dodgers time is running out.

‘The Government recognises that some people may not realise that they must declare their overseas income to HMRC if, for example, they have worked overseas or are receiving income from a rental property outside the UK.’

People with overseas income who are unsure if they have paid the correct tax are advised to check HMRC’s guidance and make

TEll uS youR SToRy

contact if necessary before the new, tougher penalties take effect.

HMRC has recently published a consultation on the implementation of a new 12-year minimum time limit for it to assess offshore tax.

For guidance on making a disclosure, visit www.gov.uk/ guidance/worldwide-disclosurefacility-make-a-disclosure.

Ten things about offshore assets and income can be found at www. gov.uk/government/publications/ ten-things-about-offshore-assetsand-income/ten-things-aboutoffshore-assets-and-income.

Share your experience of what has and has not worked in your private practice. Even if it’s bad news, let us know and we can spread the word to prevent other independent practitioners falling into the same pitfalls.

Contact editorial director Robin Stride at robin@ip-today.co.uk

Taxman tightens up on offshore assets How docs get in trouble

By Robin Stride

Consultants have been warned that failing to balance private practice with any NHS work remains a major cause of hassle from the authorities.

Hempsons solicitor and qualified doctor Tania Francis told them the overlap between the two spheres was the number-one area that led specialists in to trouble.

She said: ‘When things go wrong, the managers will suddenly forget they knew where you were on a Wednesday morning.’

But it was not just NHS eyes watching. She outlined a recent case where a doctor was reported by a private hospital’s managing director following concern that he had admitted a patient on seven occasions in 18 months, including 13 endoscopic procedures.

He was not found to be at fault.

Mrs Francis, speaking on how to avoid complaints and a GMC referral, assured her audience that most complaints to the council went nowhere.

However, she highlighted some key areas to members of the Federation of Independent Practi tioner Organisations (FIPO)/ London Consultants Assoc iation (LCA) meeting that could lead to misconduct allegations.

alleged fraud, including insurance claiming and billing.

Mrs Francis highlighted some recent cases:

 A doctor seeing private patients without insurance. She expressed surprise at how many doctors did not realise this was ‘a no-no.’

These included personal misconduct, unrelated to professional practice; relationships with patients/ sexual assault/inappropriate examinations; prescribing for self, family and friends; and

 Working without a licence to practice;

 Inadequate assessment of a patient on a ward round and then lying to the coroner about it.

Her colleague solicitor Nadya Wolferstan stressed the need for good record-keeping and early communication if things went wrong.

She told the London meeting that an early and honest commu-

nication increased the chances of preserving the patient trust relationship.

Doctors should use the information they had at the time and explain why they might not have all the answers.

A contemporaneous account of their clinical input was vital and they should ensure relatives were involved, where appropriate, and that there was someone to support them if the unexpected happened.

On ‘saying sorry’, she said an apology was not an admission of liability.

Ms Wolferstan quoted a University of Michigan Malpractice Study (2009) which found a 47% reduction in damages awarded and a reduction from 20 months to six months in settlement following effective communication and well-timed apologies.

Tania Francis is both a qualified doctor and a lawyer

ACCoUnTAnT’S ClInIC: ThE nEw TAx yEAR

Financial sunrise

With the new financial year upon us, many doctors may be considering how best to plan and maximise the £££ in their pocket. Susan Hutter gives her guidance

Pension contributions

Have you used up all your annual allowance for pension contributions? You can go back three years. But the rules around pension contributions have changed. Be careful if you earn £150,000 or above, as this means the maximum contribution is reduced.

If you earn below £150,000, the maximum you can pay as a taxdeductible pension contribution is £40,000. For those earning above £150,000, the last years for which you can pay up to £40,000 are 2014-15 and 2015-16, so now is the time to ‘mop up’ if this affects you. From 2016-17 onwards, the £40,000 is eroded, depending on your actual earnings, all the way down to £10,000.

As always, take advice from a financial adviser – especially if you have an NHS pension, since there are many complex issues.

Make the most of dividend allowances if you operate as a company

Up to the tax year 5 April 2018 you can take a tax-free dividend of £5,000 and pay no tax. However, that level is reduced to £2,000 from 6 April 2018.

Transfer income-producing assets

If you have a lower income-earning spouse, think about transfer-

ring income-producing assets such as property or bank deposit accounts to them.

If it is a property you are thinking of transferring, although there is no inheritance tax or capital gains tax consequences of transferring to a spouse, there will be stamp duty implications if there is a mortgage on the property above £40,000.

Rental properties

If you have rental income, you can claim relief on the cost of replacement furniture and fixtures and fittings. This allowance came in from 6 April 2016.

Gains on disposals of residential property

From April 2019, the Government intends to make taxpayers make a payment of ‘payment on account’ of capital gains tax within 30 days.

Factor in the time it takes to collate all the necessary information from the original purchase and make sure you have clear records for legal fees and other costs so you can offset them.

It is worth collating the information early so that your accountant can calculate the capital gains tax in time for the new deadline payment date. Current legislation means if you sell a property now, you do not have to

pay for capital gains tax until the 31 January following the end of the tax year.

Indexation Allowance

If you trade through a company that has investment assets (stocks and shares/property), when the company sells those assets, it can index up the original costs based on an Indexation Allowance.

However, the Indexation Allowance has been frozen since 31 Dec ember 2017. There is a possibility that the indexation allowance will be abolished altogether, maybe in the next Budget.

So, if you have assets in a company and you were considering disposing of them, consider selling before the 2018 Budget, towards the end of the year, as this could make a big difference to how much your company will have to pay in tax.

ISAs

Do remember to take advantage of ISA allowances – £20,000 a year for each adult in the family. For those with children, the Junior ISA and Child Trust Fund Subscription Allowances are increasing to £4,260 per child from the 6 April 2018.

Children tax planning

If you are buying a residential property for the first time, either

for yourself or someone in the family, then any property costing £500,000 or less can take advantage of the First Time Buyers Scheme. This means you pay no stamp duty on the first £300,000 and the next £200,000 is charged at 5%.

Premium Bonds

The maximum amount you can invest in Premium Bonds is £50,000 per person, so make sure you are making the most of allowances.

While the return tends to be about 1.25% – and may not seem that high – bear in mind that all winnings are tax-free. Considering interest rates are still fairly low, the return on Premium Bonds is not bad for a higher-rate taxpayer.

Enterprise Investment

Scheme

Tax relief on investments into qualifying trading companies for Enterprise Investment Scheme purposes means the investor gets 30% tax relief on their investment.

The annual subscription limit is going up to £2m where subscriptions above £1m are made into ‘knowledge-intensive’ companies. 

Susan Hutter is a partner at Blick Rothenberg and part of the team that advises medical practitioners

Physicians in the United Kingdom trust UpToDate for reliable clinical answers. When surveyed, UK subscribers reported the following:1

98% trust UpToDate as a point-of-care clinical information resource

97% report that UpToDate improves the quality of care they provide

94% say UpToDate keeps them current

UpToDate is the premier physician-authored clinical decision support resource. With over 1.3 million users worldwide, it is no surprise that many physicians in the UK rely on UpToDate.

1 UpToDate Individual Subscriber Survey, October 2016 (N=125)

Is your practice millennial-ready?

London millennials are more ready than ever for insured private healthcare. So has

your marketing strategy caught up?

Jane Braithwaite reports

Key to the success of any business owner, including private healthcare practitioners, is to understand their clients/patients so that the marketing and delivery of services can be tailored to meet their exact needs.

It is imperative to understand how patients’ views are changing over time, particularly with the progressing use of technology and ways this is applied.

Understanding the characteristics of different age groups is also vital, particularity when considering technology.

those marketing and communication methods that were success-

ful five years ago are probably not ideal today and who knows what our patients will expect in five years’ time.

o ne effective way to keep abreast of changes is to consider the results of patient surveys. t hey give us some valuable insights into the minds of our patients and we can learn a great deal on the changes we should be making now to ensure continued long-term success.

top Doctors, the global company connecting patients with healthcare specialists, recently commissioned a survey to better understand the beliefs and atti -

tudes of Londoners towards healthcare.

Residents from all 33 London boroughs were questioned in September 2017. Being one of the most diverse places to live in the UK, it is safe to say this survey is likely to have questioned people from many different backgrounds.

interesting reading t he results make for interesting reading – particularly, the differences in opinion between the different age groups questioned. the survey found 41% of 18- to 34-year-olds (or millennials) have private health insurance, compared to just 20% of Londoners over the age of 55. these figures represent a change in terms of the typical user of private health, as the post-war ‘baby boomers’ would historically have been the generation most likely to have private health coverage. the figures are also indicative of •

•

It is imperative to understand how patients’ views are changing over time, particularly with the progressing use of technology and ways this is applied

How to engage wItH mIllennIals

➲ Recognise why private healthcare is popular in this age group and do what you can to tailor your service to their needs. If it is longer consultations that are popular, look at amending appointment times. If it is same-day appointments that prove popular, think about how and if this could work for your business.

➲ liaise with your target audience and market your practice based on your findings. If you have existing patients in this age group, reach out to them to request feedback and ascertain what is important in terms of what they expect from the patient experience.

➲ Use appropriate platforms to market your business. Use social media, gaming and apps to reach this generation.

➲ Be authentic. Use testimonials and appealing stories of people’s healthcare journeys to help people to engage with your practice brand and better understand your values.

➲ Use content that is high-quality and shareable on social media – this will be more effective in terms of reaching out to this group than more traditional advertising methods.

➲ think about how you can use technology to communicate with these patients.

Communications that are tailored to the individual and accessible through smartphones might be attractive to this age group, but practices should be mindful of concerns about security and privacy.

➲ millennials are highly likely to research their symptoms online before visiting a doctor. Private practices should recognise this behaviour and may want to provide health information on their websites as a way of engaging with this group.

➲ millennials look for companies that reflect their personal values when choosing products. think about what kind of impact you want your practice to make on society, and make sure this message is incorporated into your marketing. ➱ p14

“MedSecretary have gone above and beyond my expectations. their services to anyone”

“MedSecretary have gone above and beyond my expectations. their services to anyone”

a difference in market use between our capital city and the rest of the country. Recent research released by health and social care market intelligence provider LaingBuisson found that, overall, just 10.6% of the UK population have private medical cover.

So, what do these results say about the attitude of millennials living in the capital to healthcare and, by extension, the private healthcare industry? And how can London’s private practices ensure that they are engaging with this age group?

Millennial attitudes to healthcare

t he top Doctor survey results show a clear change in the behaviours of millennials and baby boomers, but what is behind this difference in attitude?

Let’s first consider attitudes to the NHS. t he 2013 King’s Fund report Time To Think Differently

showed millennials do not consider collective welfare as important an issue as older generations, and also found ‘marked differences’ in NHS satisfaction rates between those over and under 65.

With this being the case, it could be said millennials might be supportive of individuals contributing financially to healthcare rather than it being solely the responsibility of the state.

the King’s Fund research put forward the idea that the generations following the baby boomers will not benefit from the same levels of financial security as those who came before them and, as a result, may be more focused on their own needs than those of others.

Could this be a reason why there appears to be an increase in private healthcare coverage in younger age groups?

t he idea that millennials are stepping away from the NHS is further supported by another

survey carried out in 2017 by Doctap.

t his survey found that sameday appointment services offered by private practitioners were popular with the millennial age group and that many would prefer to pay for such services than wait for an NHS consultation.

Additional benefits, according

to those surveyed, include consistency of care – that is to say, being able to see the same doctor at every appointment – longer appointment times and a sense of being able to take their time with their clinician.

t he Health Foundation also found that younger generations are much less committed to the

notion of the NHS being the sole healthcare provider in comparison to older generations.

Millennial use of private healthcare insurance

Despite the evidence seeming to point to the idea that millennials favour private healthcare over the NHS and the fact that they are more likely to have a private healthcare plan, only half of this age group use their insurance to make a claim. Why is this?

you could say that there is simply less need for younger generations to access healthcare as much as older generations. People of this age group will, of course, be healthier and less prone to chronic conditions that occur with age.

those who do have conditions that require regular specialist care may well find themselves in the position where their insurance policy will not cover any pre-

existing conditions and, as a result, it is more financially viable for them to receive their treatment on the NHS.

Some younger patients may simply be minded to avoid using their healthcare policy because it does not provide extensive coverage. For example, some workplace private healthcare policies do not cover all aspects of care. the policy may only cover outpatient tests or there may be a financial limit on the amount a patient can claim back.

Furthermore, an opinion from the US is that millennials are more cost-conscious.

this age group is more likely to consider the cost of treatments before receiving them and when taking into account that a workplace may have a limit or an excess to pay, there may well be added costs associated with private care that millennials are not prepared to commit to.

How can private practices engage with this group?

t he top Doctors survey found that in London just 50% of the 18 to 34 age group have used their private healthcare insurance. this is high when compared to the over-55s, where just 35% have not used it.

t here is, of course, no way to convince people to attend consultations and receive treatment if there is no need for it, but for those who do need to access expert healthcare in the private sector, it would be sensible to ensure your business is reaching this age group, who are – in London – more likely than any other group to have private medical insurance. 

Jane Braithwaite (right) is managing director of Designated Medical

practice and consequently more motivated to help you improve it. Remember that your secretary, practice manager or practice management team are the face of your practice. Empower them, equip them and motivate them to get on with the jobs that you have not spent years studying to do. tina Barrett, PHF Services Ltd

7 protect famous patients from the media

There are plenty of things a good hospital can help you with. If your patient is very well known, discuss privacy and security at the outset. Chose a ‘new’ name for the admission – not an obvious one either! – and arrange that the hospital has a specific list of visitors and callers with a code name each caller must use to be identified as genuine.

And another tip: tell them not to accept flowers at reception. When trying to find out where a famous singer was having her baby, as a reporter for the Sunday tabloids, I used to send flowers to several hospitals and the one that accepted them was ... well... more than likely to be the one. neil huband, Priority Counsel Ltd

8

use a diy pr tip toolbox

 Generate goodwill among your chosen audience;

 Define what makes your practice special or unique;

 Prepare biographies and photos;

 Use factsheets about any new equipment/technology;

 Do a patient poll to make news;

 Be available for local community talks;

 Research the right outlet and journalists. tingy simoes, managing director, Wavelength Communications

9 Make your hospital work for you

Build and maintain a strong working relationship with your private hospital.

Make it a point to get to know and understand its marketing department and actively engage it in discussions in order to explore new opportunities.

The success of your practice is in the hospital’s best interests, so

work with its managers to see how they can raise your profile, whether it be through giving talks and seminars or simply being added to their existing marketing literature and websites.

darren clare, managing director, Create Marketing Ltd

10

Keep on the right side of your nhs trust

Juggling two jobs? Things which put you in trust managers’ bad books include:

 Disputes with clinical staff, particularly trainees and nurses, where complaints of rudeness, aggression or bullying are made;

 A reputation for absence during direct clinical care sessions, or repeated lateness, especially if associated with times when you are known to have private commitments;

 Lack of co-operation with management and administrative staff over rotas and booking of leave;

 Poor attendance at NHS meetings, particularly multi-disciplinary team meetings, directorate meetings and clinical governance meetings. These can be a trigger for management action;

 Not adhering to trust policies, especially around leave of absence and mandatory training.

dr Mike roddis, director, Healthcare Performance Ltd

11 form a group

The way in which we practise private medicine is changing rapidly. Healthcare insurers are becoming more costconscious, overt medical marketing and competition is steadily evolving and governance in private practice is becoming more demanding.

It will become increasingly difficult to work as a single-handed practitioner in the forthcoming years in the way that GPs have experienced in the past. Slowly and steadily, more groups are being formed in all areas of private medicine and I believe that those willing to spend the time, effort and money to organise themselves now will see their efforts rewarded in the future.

Mr Brian cohen, medical director and consultant orthopaedic surgeon, London Orthopaedic Clinic

Slowly and steadily, more groups are being formed in all areas of private medicine

12 Get on with partners

Choose partners that share your values, hold regular, minuted meetings and divide up business responsibilities between each other.

Identify your target markets and define your value proposition: who are you and what do you do that is of value to your market?

Ask each prospective partner to make a financial commitment up front to cover initial costs: this will shake out those who are not committed.

Appoint a legal adviser with experience of setting up partnerships and a financial adviser to advise on incorporation and tax issues: don’t skimp on their fees. Take advice from a business development professional who will help identify the quickest route to revenue generation and reduce unnecessary expenditure. Avoid ongoing financial commitments until you have secured regular revenues. Don’t be distracted by operational detail before you start trading: focus on what is essential and urgent. alun davies, business development consultant

13 use a coach

Private doctors are looked up to by so many that they often find it hard to see an opportunity to talk about their own needs and share their concerns openly.

Friends are fine, but they often give just nice words to placate their friends without supporting them through the big changes they face.

So who will tell you the hard truths when you are working excessively and lose sight of what else is important in your life or when you have lost perspective?

Nowadays, doctors in private practice need not only to be technically brilliant, they are expected to have commercial expertise, creative thinking and excellent customer focus.

But, as with any leadership role, seniority can be accompanied by an increasing sense of isolation. When people are deferring to you, who is really going to challenge you without fear of reprisal?

This is where I think coaching

comes to the fore. Having a coach as an independent-thinking partner to challenge, support and hold you accountable can be a really powerful force for good.

vanessa anstee, life coach

14 develop a communications plan

☛ Keep it simple – your communications plan does not need to be pages long, just clearly presented and easy to understand.

☛ Make it focused – do not try to do everything; be realistic about what is achievable.

☛ Know who – consider all your audiences, not just patients. Include staff, investors, media and so on.

☛ Hold a brainstorming session

–talk with colleagues to trawl for fresh ideas and approaches.

☛ Think outside the box – external factors may have a bearing or influence on your plan.

☛ Be prepared to be flexible –update your plan as you go along, making the most of experience and opportunities as they arise.

☛ Keep your eyes open – look for opportunities for working with external organisations or partners who may be targeting the same groups as you.

☛ Feedback – ask colleagues for feedback on your plan, as they may have useful suggestions, carys thomas ampofo and Kelly Blaney, Ash Healthcare

15 Break through the £300k profit barrier

The secrets of success to be a top earner: find the right location, choose the right specialty, add value, avoid trouble with insurers, ‘market market market!’, go for self-pay, specialise in a particular procedure, avoid a divorce and hone the administration. Oh, and be prepared to work hard.

ray stanbridge, partner, accountancy, finance and tax advisory medical specialists Stanbridge Associates

16 hold an open evening

Check the level of presenting skills of the doctor/person presenting. A confident consultant does not always equate to a confident presenter.

In plenty of time, ask for col -

leagues to volunteer to help greet guests and to show them around the facilities. Time in lieu is offered back to our staff.

If you are running a series of open evenings, it will be more economical for you to block book media, rather than buying advertising space month by month.

Ask your guests to tell you how they found out about the open evening; it will help your media spend.

Depending on the time of your open evening, lots of food is not always a necessity, but good wine and soft drinks are.

lorna slater, Optegra

17 observe the golden rule

‘Do not mess with a colleague’s private patient.’

Miss Gubby ayida, consultant obstetrician and gynaecologist, founder of The Women’s Wellness Centre, Chelsea

18 Market yourself to Gps

The most effective investment any new consultant can make is that of time; time writing to and meeting and talking to GPs in your catchment area.

Holding breakfast seminars at your independent hospital is extremely valuable, as are trips to larger GP practices in the evening. They’ll always remember the consultant who made the effort to visit their surgery.

The cornerstone is the messages you will give GPs: how GPs can reach you quickly for an urgent referral, what sets your work apart from others and why your outcomes are among the best. And how patients will be looked after when you are on leave or ill.

James Barr, chief executive, The Lister Hospital, London

19 Be a smart entrepreneur

➤ Protect your idea or design and always use a non-disclosure agreement (NDA).

➤ Research your marketplace to prove an unequivocal need for your idea.

➤ Identify your competitors and make sure your offer is better.

➤ Identify your route to market and customer base – sales are king.

➤ Keep your overheads low and profile high.

➤ If you part with shares to raise funding, make sure it is to people who can add value.

dr vincent forte, GP, inventor, Forte Medical

20 survive an acquisition

➲ It is crucial that the individuals concerned need to accept that when they effectively sell their business they relinquish control. If you aren’t prepared to do this, think twice about even considering an approach.

➲ You need one or two key, committed people to drive the process otherwise things just won’t happen. These key people need to organise the meetings, overview and manage the various processes and ensure everyone is on board, throughout what is an extremely lengthy process. Commitment to the cause is crucial.

➲ It is vital to appoint a competent legal team and ensure other advisers like accountants are fully on board with the activity.

➲ Parties such as banks need to be fully appraised of the situation and have a full awareness and understanding of proceedings.

➲ Agree realistic time-scales –don’t be too optimistic, as an acquisition is a very labour-intensive process and simply cannot be rushed.

➲ Always leave a contingency in terms of time to complete the deal.

➲ Financial and legal due diligence is the most time-consuming aspect of all– it is important not to underestimate the time this takes and to accept that it is an unavoidably lengthy process.

Yorkshire Eye Hospital ophthalmologists Keith davey, oliver Backhouse and John Bradbury – acquired by Optegra

21

Write a press release

1. Develop a catchy headline.

2. Capture the essence of the story in the first two paragraphs –don’t expect a journalist to wade through reams of words to get to the core of the story, because they won’t.

3. Remember the crucial five ‘W’s – WHO, WHAT, WHERE, WHEN, WHY.

Make sure you address all of these elements in the first couple

of paragraphs and then pad out the release with other facts, figures and background information.

4. Include a quote from a spokesperson. This adds a personal touch to the story and can be an effective way of getting a namecheck for your organisation in the final editorial.

5. Round off with a summary about you and your organisation – including details about your website or a number for patients to call for more information.

6. Always conclude with your contact details – journalists will often want to speak to you to clarify some of the details or they may need additional information. Include your email address and phone numbers.

Jo Gulliver, Trinity

PR

22 attract investors

However knowledgeable you may be about a particular aspect of medicine, investors will want to know that the team they would be backing have the business skills, experience and openmindedness to adjust the strategy to fit the world as it is, not as it could or should be.

Too often, investors see entrepreneurs who are scornfully dismissive of their competitors. Often, they are told that there are no competitors for a particular new product or services.

Or, if competitors exist, they are assumed to be foolish or ignorant and unable to adapt to whatever innovation the entrepreneur is planning to bring to the market.

Investors know this is very rarely true and that businesses actually succeed by staying one step ahead of their competitors. This can only be done by understanding what competition exists or is on the way, so hearing that competition is not an issue is a real warning sign.

steve adkin, partner, Apposite Capital

23 subscribe to independent practitioner today ten tips from my first year in private practice

 Regard your private practice as a serious business investment, don’t cut corners;

 Invest in a practice management system with online access; ➱ continued on page 20

 Get a notebook PC and go paperless;

 Get a secretary who will be a true ambassador for you;

 Invest time networking with consultant colleagues and GPs

 Get to know the team at your local private hospital. Greet everyone by name and they will respond positively;

 Subscribe to Independent Practitioner Today – it’s a great resource for information and advice ( Editor’s note: just ring 01752 312140 or see page 59. A subscription by direct debit costs doctors just £75 a year before tax);

 Get a professionally-designed website;

 Send out all bills promptly;

 Remember, it’s all about Availability, Ability and Affability.

Mr Krishna vemulapalli, orthopaedic surgeon, Spire’s Hartswood and Roding hospitals

24 retain and attract international patients

As the international patient market becomes more competitive, UK hospitals and specialists must up their game in all aspects of the ‘international patient experience’.

Too many specialists pay little attention to the customer service aspects of international patient care, believing that their skill, expertise and reputation will ensure a steady flow of international patients.

But it is often these customer service aspects that build a reputation and create a competitive edge for a particular specialist. Keith pollard, managing director, Intuition Communication

25 Business plan!

Business plans should be regularly updated and provide

logical, clear rationale for funding requests.

Provide details of the business’s historical financial performance, highlighting key figures and trends and providing explanations of anything unusual.

Details should be provided of the current financial year and forecasts for the next few years. Banks will expect to see up to three-year forecasts and a clear business strategy.

Those seeking to set up a business for the first time should provide a forecast of income and expenditure. Assumptions, which should always be realistic, will need to be explained.

And for consultants seeking to group together, a bank will require a breakdown of each consultant’s past and current earnings – evidenced by individual audited accounts, if available, or tax return. This should be combined with a projection for the future, taking into account any synergies to be derived.

tony Burgess, HSBC senior commercial manager

26 use social media

Social media activity should form an integral part of your overall marketing strategy; if it is not, then you are missing out on a beautifully organic and free opportunity to spread the word about your services.

But be warned. Diving headfirst into social media without doing your homework can be as damaging as not dipping your toe in the water at all.

Social media marketing is a very different discipline to traditional marketing and to maximise its value, it is essential to recognise this and put a considered strategy for using social media in place.

sara robinson, Working Word communications agency

27 really communicate with your patients

In the case of the independent doctor, the patient’s heart and mind has to be won or they will simply go elsewhere. Communication skills are not just a nice but fluffy addition to your practice –they can make or break it.

The first rule of good communication is to take responsibility for the delivery of the message.

Do not ignore the signs that a patient has fully understood, and ask the right questions to ensure that they have.

The right question is not ‘Do you understand?’ because most often, nervous patients will say they have even though they have not.

The right questions are:

 ‘Is there anything about that you would like more detail on?’

 ‘Have I managed to explain this well or would you like me to explain this differently?’

 ‘Would a diagram help my explanation for you?’

 ‘I am happy to answer any more questions’;

 ‘Tell me if these are things you already know’.

dr ali shakir, founder, Harley Therapy Institute

28 avoid partnership profit grievances

It is almost inevitable that at some stage in a partnership’s history there will be some grievance about remuneration.

You therefore need to make sure that you have in place in your agreements a comprehensive and transparent remuneration structure which will go a long way towards stopping arguments and retaining the most talented partners – and the goodwill that goes with them.

The remuneration system needs

to be aligned to the objectives of the practice.

The temptation is obviously to link remuneration to profits generated by each partner, but this does not always encourage partners to focus beyond their own individual practices.

Consider the other activities required to operate a successful business, such as practice development, marketing and development of skills.

We have seen cases where all these non-chargeable activities fall on the shoulders of one or two of the partners but without any specific remuneration and this can cause resentment and ultimately the break-up of the partnership.

You should therefore consider how each partner’s contribution should be remunerated.

A ‘one size fits all’ approach rarely works.

chris inson, Capital Law LLP

29 expand – slowly

Work on the demand and then fulfil it, not the other way around.

Expanding your practice should be a slow, low-risk and phased process that is a response to demand.

Bringing in more doctors or nurses and then attempting to fill their time through marketing is a high-risk strategy.

The marketing should come first and only when you find yourself turning away patients, consider bringing in medical colleagues in a phased approach –perhaps initially for a day, and then two and so on.

Make sure you do the maths –you might be increasing your turnover by bringing in another doctor, but are you more profitable?

Remember that more doctors means more medical supplies, more rent, set-up costs and administrative support as well as the doctors’ fees.

If the maths work, then go for it. Bringing in colleagues means that you continue to earn when you are not working; it frees you up to see higher-paying patients and can increase your appeal to corporate clients.

dr enam abood, founder, Harley Street Health Centre

30 consider saturday teach­ins

We did not want to get a group of GPs in and lecture them. Not only is this a boring prospect on both sides, but also it does not allow for us to meet and interact with them and it is far less likely they will feel comfortable in asking questions.

We felt a format in the style of an objective structured clinical examination (OSCE) would be different, allowing us to communicate in short sound bites using visuals – on laptop computers –with ample opportunity for questions.

We brought patients along to give that human element to the message, and we felt that it would be better for them to only be speaking to a small number of GPs each time to make it less intimidating for them too.

We had six ‘stations’ for the workshop– a group member on each to cover a few topics under their specialty. There was capacity for 40 people, with 35 attending and nearly all of those who said they would come did so.

Mr Mark chapman, consultant bowel surgeon, North Birmingham Colon Care

31 let in the cameras

A documentary team followed consultant bariatric surgeon Mr Shaw Somers for 18 months to create just a one-hour television programme on his work with a patient claimed to be The World’s Fattest Man.

His verdict: ‘From a business perspective, taking part in the documentary gave us a real platform to make more people aware of Streamline Surgical and the services we offer.

‘I feel the debate it generated around obesity was worthwhile and it was fantastic to see the team I work with receive recognition for the incredible work they do.

‘Following the documentary, the phone did ring more than usual – and that, of course, is a real benefit.’

32 stick to agreements

A consultant group was at an advanced stage of negotiation with a hospital for a joint venture.

Solicitors had been involved and instructed. Heads of Agreement had been signed and legal issues were being finalised.

One member of the group suggested instigating a very fundamental rewrite of the whole deal. Result – the hospital became fed up at the lack of seriousness of the group and withdrew from the negotiation.

independent practitioner today guide to negotiation, by Ray Stanbridge

33 Beware image copyright on your website

‘I think the digital age has blurred the boundaries of image copyright in many people’s minds and some business owners mistakenly think that because an image is freely available on the internet, it can be reused without permission.

businesses entrust web design companies with the whole process of registering and creating their website, and presume that their web design company will only use images they are entitled to use.

‘However, this isn’t always the case, so I would urge business owners to check they are legally entitled to use each and every image on their websites.’

phil orford, The Forum of Private Business

34 have an overseas patient strategy

As more countries become interested in medical tourism and governments work with both hospital providers and tour operators to develop a ‘medical tourism cluster’, the levels of non-clinical services in many countries is getting hard for UK doctors to beat.

For example, many overseas hos-

Expand slowly. Work on the demand and then fulfil it, not the other way around ➱ continued on page 23

‘Additionally, many smaller

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pitals have opened international outpatient centres to provide multilingual services and travel arrangements including visa application, airport transfers and assistance for patients’ families.

In Korea, a dedicated reception area for inbound medical tourists has been established at the international airport.

It is against this background that consultants need to consider the implications for their practice and develop strategies with the UK hospitals to maintain their current patients and attract new patients. International work requires a long-term commitment and strategy.

elizabeth Boultbee,managing director of Boultbee & Co

35 Brand your procedure

For branding my own procedures, I always try to use attractive terminology that anyone in the street can relate to.

For example, I could easily have named my latest lip plumping and shaping treatment something wordy, but instead went with a simple and straightforward ‘Heart Lips’.

It resonates with people as a positive, voluptuous image. It is a concept that will grab the attention of the consumer and, from a purely marketing standpoint, members of the press.

Similarly, the ‘Dr BK Lift’ – a combination I have developed of Botox and fillers to soften an angular jaw – identifies me instantly as the founder and creator of the procedure and makes it a marketable and promotable proposition. dr Bob Khanna, cosmetic and dental surgeon

36 Know who owes you

Always know the patients who owe you money so you can bring it up in any follow up consultations. colin Miller, general manager, financial report, Nuffield

37 understand your defence body small print

A lot of people are spending thousands of pounds and not realising what they are buying. They would not do it in any other area of life… The survey we undertook

revealed up to 70% ignorance rate on crucial points.

Considerations such as what ‘claims made’ and ‘losses occurring’ mean, what is a ‘limit of indemnity’ or what is meant by, and the significance of, ‘run-off cover’ .

Failure to understand these points could result in significant financial loss.

Kevin Mccluskie, author, On The Market For Medical Malpractice Indemnity, for the Federation of Independent Practitioner Organisations (FIPO)

38 audit for finance fitness

Establish:

 How much you are owed, how old your debt is and how much is collectable or needs to be written off;

 Which patients owe you the most money and decide if they are a risk;

 How far behind you are with the billing – what date was the last clinic/that you billed;

 What procedures are in place to chase the outstanding invoices;

 If the procedures you have are being followed;

 What percentage of your practice is with self-pay;

 Establish what percentage of your practice is with Bupa and monitor that situation.

Then decide what action to take to gain control of your finances and to stop losing money.

Garry chapman, Medical Billing and Collection

39 Beware the dangers of 1

The problem with one of anything is dependency and vulnerability.

 One source of referrals;

 One source of income;

 One critical assistant;

 One merchant account;

 One consulting room;

 A relationship with one private insurer;

 One key business customer or employee;

 One form of marketing;

 One business diary;

 One ‘you’.

So do all you can to avoid them. Mr dev lall, laparoscopic upperGI surgeon and director of www. privatepractice­expert.com

40 use Gp liaison teams

GP liaison teams in private hospitals can assist with securing opportunities for consultants to engage with GPs, by way of facilitating continuing professional development (CPD) or by attendance at practice meetings, although this is also the responsibility of the individual consultant. Best results are achieved when the two work in tandem.

These teams can be quite large, so it is important for consultants to make the effort to meet with them on a regular basis. Getting together just once a year and expecting them to know who you are, what you do and when you are available is not enough.

With the team having quite literally hundreds of consultants to support, you need to keep your name out there.

But bear in mind that it really does boil back down to the amount of time and effort you are prepared to put into your own practice too.

Also, encourage your secretary to meet up with the GP liaison teams or speak to them on a regular basis. It is good practice and helps to raise your profile. sue o’Gorman, independent development consultant, Medici Marketing

41 Make time for yourself

Define how many hours and days per week to work in your practice and how flexible you are prepared to be.

Be very specific about the patients you wish to see so that you get suitable referrals. When

you offer something unique, people know when to refer.

Deal with emails once or twice a day only. See your patients at their appointment time and have satisfied patients at the end of the consultation, so start on time, be aware of the length of the consultation and develop effective techniques for ending.

Identify your personal timewasters to eliminate or reduce them.

Do paperwork and other admin during working hours; don’t take it home.

dr susan e Kersley, The Doctors’ Coach

42 Giving a refund

While refunds and goodwill payments are a feature of complaints in independent practice, there is no guarantee that this kind of goodwill gesture redress will settle a complaint or avoid a future negligence claim. In addition, it may be a mistake to assume that a complainant is only interested in getting a refund.

Patients who make a complaint generally want an explanation of what happened, an assurance that steps have been taken to try to prevent it happening again to them or anybody else, and an apology and remedial treatment by the doctor.

For this reason, it is important that any complaint response addresses each issue or concern the patient has raised.

Offering a refund may even appear insensitive, unless you can also demonstrate that you are taking their complaint seriously.

➱ continued on page 24

Members who wish to make a goodwill gesture payment should seek advice on wording the letter.

dr catherine Wills, MDu deputy head of advisory services

43 network Networking is essential. I would strongly advise anyone setting up their own practice now to become involved in a couple of well-chosen medical societies such as The Indees (part of the Independent Doctors Federation) or the Chelsea Clinical Society. You really need to keep going to events to meet people.

I had always done so because I enjoyed the social aspect and also because I wanted to meet the people I was referring my patients to.

dr samina showghi, Harley Street GP

44 update partnership agreements

Rising numbers of consultant group bust-ups are costing specialists vast sums of money because they have never bothered with a proper practice agreement.

Many partnerships formed during the surge in group growth have set up their structures on a basis of trust.

Lawyer Chris Inson advises: ‘Problems can be avoided, or at least mitigated, by ensuring that partnership agreements are comprehensive and up to date.’ independent practitioner today news story

45 avoid tax evasion

Tax evasion can only be expressed in one way – illegal. This is when you deliberately and knowingly defraud the tax authorities. It may land you in

the holidays. A good rule of thumb in the majority of cases is to aim for around two-thirds of your normal NHS annual income.

simon Bruce, managing director, Cavendish Medical, a fee­based independent financial practice helping doctors in private practice and the NHS

47 Beware of professional isolation

Some private practitioners work in quite a solitary way and may not have the regular meetings with peers that their NHS colleagues may have.

As well as not having as many opportunities to meet up and discuss clinical issues and promote learning in this way, the biggest impact when working in isolation is not having a colleague on hand with whom to share the experiences and frustrations of the day.

Talk to other colleagues and try to arrange a peer support or learning group to prevent isolation and encourage team learning.

dr rachel Birch, medico­legal consultant, Medical Protection Society

48 choose between adverts or pr advertising attributes

☛ You pay for the mention;

☛ Full control over copy;

☛ Less credibility;

prison, it will certainly cost you in taxes lost, interest owed and penalties charged.

Similarly, overly aggressive tax avoidance may result in the same action if you lose in a battle against HM Revenue and Customs.

vanessa sanders, partner with Stanbridge Associates, an accountancy, finance and tax advisory service specialising in the medical profession

46 consider your retirement needs

The first step to achieving a realistic savings pot is to think about how much you will need to fund your lifestyle when work has ceased.

Most doctors have no realistic idea of how much this is and it can come as a surprise, particularly if you have left it to others to manage the household and book

☛ Date it appears is established by you;

☛ Only expert/clinic included is yours;

☛ You can include photos, logos;

☛ Final ‘proof’ is provided before print;

☛ Is not affected by external events.

v editorial (pr) attributes

☛ The coverage is free;

☛ You don’t control what’s written;

☛ More trust from the public;

☛ You may not necessarily know when it comes out;

☛ Other experts may be quoted;

☛ Will rarely, if ever, include logos;

☛ You won’t know how it looks or its context;

☛ Space depends on other news. tingy simoes, managing director, Wavelength Communications

➱ continued on page 26

49 research financial support

Very often, grateful patients want to give something back when they have received great care and we are hoping that we can help direct those philanthropists to invest in our research. We have already had some success in this area.

dr paul Glynne, co­founder, The Physician’s Clinic, Devonshire Street, London

50 how to end up before the GMc: 1

Neglect your own health, commit a crime – and forget to tell the GMC about it, decide to take up a new area of practice in which you have no experience, be rude to patients and colleagues and don’t listen to their concerns.

dr claire Macaulay, medicolegal adviser, Medical Defence union

51 how to end up before the GMc: 2

Turn to drink or drugs, tell a few white lies, keep poor notes, date a patient, keep your mouth shut. as above

52 don’t ruin your appraisal

Why appraisals go wrong:

1. Poor preparation;

2. Use of unsuitable venue;

3. Not leaving time for appraisal; 4. Attempting to have a mate do it;

5. Having meeting in middle of busy schedule;

6. Not taking appraisal seriously;

7. Technical problems;

8. Mistaking the end of the interview as the end of the process;

9. Not keeping your appraisal portfolio up to date;

10. Not keeping focused on the appraisal structure.

dr paul Myers, director, Doctors Appraisal Consultancy

53 first impressions are vital

The front office is first point of contact for a client, whether by phone or in person. This first interaction makes the first impression and is critical.

The phone must always be answered, preferably by a realtime nice human being.

When the client enters the clinic, they must always be welcomed and the staff should be aware if they have previously attended or not. They should not have to ask the client.

Your investment in staffing must permit this. If the staff take a call when you are busy and say that you are going to call them back, then call them back as soon as possible.

The client needs to know that you care.

Mr donald Gibb, consultant obstetrician and gynaecologist, The Birth Company, 137 Harley Street, London

54 ten steps to consider when responding to subject access requests

1. Identify whether a request should be considered as a subject access request;

2. Make sure you have enough information to be sure of the requester’s identity;

3. If you need more information from the requester to find out what they want, then ask at an early stage;

4. If you’re charging a fee, ask for it promptly;

5. Check whether you have the information the requester wants;

6. Don’t be tempted to make changes to the records, even if they’re inaccurate or embarrassing…

7. …But do consider whether the records contain information about other people;

8. Consider whether any of the exemptions apply;

9. If the information includes complex terms or codes, then make sure you explain them;

10. Provide the response in a permanent form, where appropriate.

Source: information commissioner’s office

55 selling and buying a practice

The selling consultant needs to consider:

 The reputation of the purchasing doctor;

 His or her personality;

 Their ability to work together;

 Their commitment;

 The time frame for the transfer and ultimate sale of the practice.

The purchasing consultant needs to consider:

 The available practice performance;

 Reputation;

 Turnover;

 Medical insurance recognition;

 Practice profile;

 Location;

 Security of tenure;

 Operating facility arrangements;

 The time frame of transfer;

 The purchaser needs to make a commitment to the new practice that will give enough time to exploit its potential.

Maitland cook, director, Maitland Cook Medical Management Company Ltd and The Cadogan Clinic, London

56 agree terms before writing insurers report

Doctors who are asked to do medical reports they expect to get paid for are being warned to agree terms or risk going unpaid.

The advice came after a disgruntled consultant neurologist told Independent Practitioner Today that an insurer failed to pay his fee for writing a lengthy response to its request for more information.

He explained he was asked to provide ‘a somewhat in-depth report on a patient with a new chronic condition’.

But when he invoiced the company ‘as I would anyone requesting a specific undertaking’, it ‘refused to pay, stating it was not “policy” to do so and not something they would do with any consultant’.

The doctor argued that by specifically writing to him – to see if the patient’s condition was within or outside the cover – the company had created a direct contract and was responsible for associated costs. He claimed he had been treated unreasonably and unfairly.

Specialist medical accountant Ray Stanbridge said: ‘This is all to do with offer and acceptance. If there is a contractual relationship between the consultant and this particular insurer, then it must pay.

‘But if it was a casual request for a report and there was no formal agreement, then the insurer is right. The moral for doctors is not to do casual reports for insurers, if requested, unless the terms are agreed.’

news story

57 entrepreneur inventors, get a patent!

Crucially, the invention must remain secret until the filing of a patent application if you are to obtain a valid patent.

So, it is important to seek professional advice early in the development of an invention prior to any public disclosure, including any testing of the device or publication in a trade journal.

Kate lees, European patent attorney, Harrison Clark Rickerbys

58 use a log to record all business miles

Following a long-awaited tax case ruling, we now know that:

➲ Travel by consultants to undertake itinerant work – for example, home visits to patients – is taxdeductible;

➲ Travel expenses for journeys between places of business for purely business purposes – such as two private hospitals – is taxdeductible;

➲ Travel expenses for journeys between a location which is not a place of business – for example,

an NHS hospital – and a location which is a place of business (such as home or private hospital) is not tax-deductible;

➲ Travel expenses for journeys between home (even where home is used as a place of business) and places of business – for example, private hospitals – are generally treated as not tax-deductible.

ray stanbridge, partner, accountancy, finance and tax advisory medical specialists

Stanbridge Associates

59 update your website

Your website is all about promoting your story. When you have something to say, say it.

If you have performed a groundbreaking procedure or you have been mentioned in an article, then put this on your site.

Website content is not meant to be static; it is meant to evolve and should be updated regularly.

sarah Bakker and holly Broadway, Merchant Healthcare Marketing

60 Work with your pa

In many cases, relationship problems start during the recruitment phase because the usual job specification has been trotted out without a great deal of forethought.

Essentially, the candidate is doomed to failure. Take time to consider what their role will involve.

Ask yourself: Why did the last person leave? What was wrong? Find it, then fix it and write the right job spec.

More often than not, you will find that your employee wants to do more than you originally expected, but if you don’t ask or they don’t tell, you may be missing out.

Having the right tool for the job is as right for the medical professional as it is for their PA.

Every team member needs to understand the goals ahead to achieve success.

Don’t wait until the chips are down to make sure your PA knows what you need.

Michael Bolt, managing director, Need More Time Ltd

➱ continued on page 28

61 plan your succession

Succession documents should reflect the existing partnership agreement in place, but also deal with important provisions relating to partnership property, liabilities – both past and future – and distribution of assets and profits.

A lack of succession documents or improperly drafted succession documents could prove disastrous for the partnership, the remaining partners and potential investors and other stakeholders.

A change of partner composition is often a good opportunity to refresh the partnership agreement of your practice, ensuring your agreement is up to date with the latest laws, regulations and general good practice expected in the private medical sector.

Ensure that notice is given to all relevant organisations and individuals, including the London Gazette , relevant suppliers and customers.

robert capper, a partner, Health and Social Care Team at Harrison Clark Rickerbys

62 use integrated practice management software

Let me be blunt: any consultant running a private practice with annual revenues of more than £50,000 should be using some form of practice management software.

Of course, I would say that, wouldn’t I, but most of the consultants I know would be the first to admit that they are not business people; they’re too busy being doctors.

There’s nothing wrong with that, of course – I’m sure that’s exactly how their patients would want them to be – but it still surprises me how many consultants have never even heard of integrated practice management software, let alone considered using it.

The benefits are numerous, obvious and immediate – and yet I still meet consultants who rely on ancient physical filing systems and ledgers.

Practice management software will save you money, paying for itself in months. It will improve the quality of care you give your patients.

Practice management software will save you money, paying for itself in months. It will improve the quality of care you give your patients

It will make your practice administration much more efficient. It will reduce stress and aggravation. And it will free up your time and your practice manager or secretary’s time to focus on what really matters: looking after your patients and generating more business.

tom hunt, managing director, PPM Software Ltd

63 Get a web presence

In our experience, most doctors seem to write their websites for other doctors and not for patients. Have you stood back and really examined it and felt happy with how it looks? A good website should be a good reflection of how you are in practice. Website designs should ensure that these key factors are a priority: easily accessible and simply explained.

catherine harriss, founder, MultiWorksMarketing.co.uk

64 Boost profile on video

☛ Dress smartly in clothes suitable for meeting a patient in a clinical setting.

☛ Bring along any ‘props’ you think may be appropriate to your specialty; for example, vertebrae of the back or model of the heart. They need to be recognisable to the patient viewing the video, but avoid anything too graphic.

☛ Practise your personal script prior to the recording.

☛ Keep your language simple and avoid jargon.

☛ Arrive at the scheduled time for your video recording. You need to look as good as you can on camera, so avoid running late and arriving hot, sweaty and harassed.

☛ Remember to smile. You may find you concentrate so hard on your lines that you forget the most important thing – smiling.

☛ Put your video on your own website, on YouTube and on the websites of the private hospitals where you practise. Tell patients.

leslie Berry, writer, Independent Practitioner Today

65 embassy work some quick tips:

LOG: It is vital that a letter of guarantee (LOG) is obtained prior to

Most doctors seem to write their websites for other doctors and not for patients

any treatment; this document will vary slightly depending upon the embassy that is issuing the document.

There is normally a set of terms and conditions covering the LOG and you must always submit this document in conjunction with your invoice to the embassy in a timely manner to ensure the best possible chance of receiving payment.

Some embassies also require a medical report along with the invoice and LOG. If this process is not followed, then you run a much greater risk of working without getting paid.

FEES: How much do you want to charge for your treatment needs careful consideration. Your fees could be for consultations such as initials and follow ups, inpatient care, inpatient consultations and intensive care.

Whatever you decide needs to be clearly articulated to the embassies before you start to see their patients to avoid any misunderstanding after the treatment has been carried out – and to avoid dealing with disputed invoices.

PAYMENT: Be prepared for extended payment cycles and allow for this within your practice, particularly where you are likely to be paying tax to the HMRC, even if you have not collected payment. This could have a devastating effect on your cash flow if you have not planned accordingly.

CHASING: Even when all the above is done, you will still need a robust system in place to chase for payment on a continual basis to ensure that your money is collected.

Garry chapman, Medical Billing and Collection

66 consider spouse pension contributions

Making employer pension contributions on behalf of a spouse may be one of the most tax-efficient strategies of all, not only saving tax now but also in retirement. James Gransby, partner, MJA MacIntyre Hudson

67 care for family elders

We are all invariably so busy in our own lives that we tend to put

➱ continued on page 30

• Completely open scanner that is well tolerated by claustrophobic patients

• Weight-bearing scans for spine and joints enable a more precise diagnosis

• Patients who are large or cannot lie down can be accommodated

off making a decision on care until we are faced with an emergency.

Look for the warning signs; for example:

 An increase in the level of forgetfulness where the individual wanders out of the house and can’t find their way home;

 An increase in falls around the house;

 Not eating or drinking properly, leading to weight loss or loneliness and depression.

As a first action, I would strongly recommend carrying out research into possible care even if you don’t need it for months or even years.

Consider the options of hourly care, live-in care or a care home. Explore the costs involved and how to fund care over several years.

Review the need for a Lasting Power of Attorney. Discuss these matters among the family and in particular with the person who may need care to ensure that, wherever possible, they are comfortable with and participate in choosing care for themselves.

Listen to their opinion and act accordingly.

chris Miller, head of development at The Good Care Group, London

68 check out leasing deals

For many, an upfront capital outlay may not be a viable option. Leasing, rather than buying and paying up front, will often prove the most affordable option, spreading equipment costs over a three- or five-year period through regular monthly payments.

What’s more, a cash flow analysis will highlight potential returns on investment – and these can prove substantial.

A lender with good knowledge of the market will be acutely aware of any potential return on investment that new equipment may generate and will therefore be more likely to provide approval.

In certain cases, the equipment will be in place before the borrower has even been required to make a payment, allowing them to immediately reap the rewards from greater revenue streams.

Mike nolan, managing director, Academy Leasing

69 see the price is right

Our experience is that consultants typically do not charge correctly. This is because they have either not done enough research when setting the pricing in the first place or they have not reviewed the pricing on a regular basis.

Garry chapman, Medical Billing and Collection

70 Mediators –cheaper than lawyers

As an independent practitioner, it’s unlikely you will have to deal with workplace conflict very often, but given how destructive such disputes can be, you owe it to yourself to be prepared. While mediation may not be the answer in every case, it is considerably cheaper than instructing a lawyer. Most importantly, it is a great way to initiate a conversation when communication has broken down.

Mike hill, director, Human Connection

71 Moving into aesthetics

Make sure you stand out by offering a special something which defines you and your business and sets you apart from the crowd: What is your unique offering (USP)? Is there something that sets you apart, something that will attract prospective patients? Find it and capitalise on it. If not, you may wish to reconsider your move into aesthetics, as there are many providers who don’t offer anything unique and are simply peddling commodities. Ask yourself: ‘Why should patients choose me instead of X?’ One of the greatest pitfalls of any business – and especially in aesthetics – is trying to be everything to everybody. When you offer too many choices, you ultimately just confuse the patient while reducing your potential profitability. Creating a service menu offering competitive – but not too cheap – prices is essential. But your ultimate goal is to create a solid concept of who you are and what your aesthetics business is, something that maintains your integrity while being marketable. If you want to be really successful, take a step back, look at the

While mediation may not be the answer in every case, it is considerably cheaper than instructing a lawyer

marketplace and ask how you can positively disrupt it. You can disrupt by price, by innovating and charging more (like Apple), by using technology, by sheer quality of service or by becoming a master of marketing.

pam underdown, chief executive, Aesthetic Business Transformations

72 have a social media policy

Clinic and practice staff should bear in mind that any content they post on social media should not:

 Interfere with their work commitments;

 Contain libellous, defamatory, bullying or harassing content;

 Contain breaches of copyright and data protection;

 Contain material of an illegal, sexual or offensive nature;

 Include confidential information about practice patients, expatients, staff (clinical and non-clinical) and other practices and healthcare organisations;

 Bring the practice or profession into disrepute or compromise the practice’s reputation.

Julie price, Medical Protection Society

73 avoid the taxman

This can be done by:

1. Submitting ALL tax returns online and in time;

2. Keeping records for FOUR years;

3. Keeping a diary;

4. Keeping a LOGICAL invoicing system;

5. Identifying debtors at year-end;

6. Having a formal policy for bad debts recovery;

7. Keeping records/invoices for expenses;

8. Keeping a mileage log;

9. Maintaining a business bank account – compulsory for a company;

10. Operating a full PAYE system and maintaining proper records. ray stanbridge, partner, Stanbridge Associates

74 take professional fee protection insurance (pfp)

I always recommend my clients take out PFP insurance, which means that, in the event of a tax inquiry, professional fees, usually

➱ continued on page 32

up to a limit of £50,000, are covered by the insurance policy.

The fees for dealing with a tax inquiry are generally between £1,500 and £5,000 plus VAT, depending on the complexity.

Bearing in mind the premiums are relatively inexpensive – between £200 and £300 a year – it is money well spent.

Most accountants will use a registered scheme that they recommend to their clients.

susan hutter, partner, Shelley Stock Hutter

75 handling complaints

Care Quality Commission regulations specify independent hospitals have an independent review stage for complaints. 98% of independent hospitals in England choose the Independent Sector Complaints Adjudication Service (ISCAS) to provide this independent review.

It is vital to share information in a timely fashion with the registered manager about any complaints made against you and to involve them if you are finding the complaint difficult to resolve. Co-operate with any requests to meet with the patient. ISCAS encourages registered managers to offer to meet with patients to discuss their complaint and the vast majority of complaints are resolved through this means.

It is also important that you make your consultant notes avail-

Ensure

you have a copy of the hospital’s complaints policy and are familiar with its contents

able to ISCAS if requested, with the appropriate consents, without delay.

Ensure you have a copy of the hospital’s complaints policy and are familiar with its contents, particularly around time-scales within which to respond to complaints and how to signpost complainants on if you are not able to resolve their complaint.

disa young, senior adviser, ISCAS

76 Watch out for website turn­offs

 Lack of information to explain treatments;

 General look and feel being outdated;

 Not able to view the website on a mobile phone or tablet;

 Lack of guidance about cost/ price of plans;

 Old-fashioned images;

 Talking in the third person/corporate language;

 Adverts;

 Lack of verifiable/scientific, peer-reviewed, citations;

 Selling the practice rather than giving a balanced view on procedures;

 Slogans.

Joel calliste, co­founder, Smart Medical Web

77 Beware of competition law

If you work as part of a group, it’s vital to check that you’re not discussing or sharing information

that could land you in trouble. This will largely depend on how you work together and whether you are part of the same economic entity.

If you and your fellow group members work as part of a limited liability partnership (LLP) or limited company and only apply your services via this intermediary, then you are part of one economic unit and any discussions you have internally about fees would not be a competition issue.

If you work as part of a group, it’s vital to check that you’re not discussing or sharing information that could land you in trouble with competition law

The situation becomes more complicated if you also work as a sole trader outside the group, as well as being a member of a group, as decisions made internally within the group could then be used to influence your commercial conduct as a sole trader –such as the fees that you may charge for specific procedures. Furthermore, if you do work within a group such as an LLP, you must be mindful of the fact that other LLPs and groups active within the same medical specialism are still your competitors. Any choice about fees or whether you intend to accept an insurer’s or facility’s package price should be made independently and not as a result of discussion with other consultant groups.

ann pope, senior director for anti­trust enforcement at the Competition and Markets Authority

78 Minimise inheritance tax

Whether you choose to pass on some of your wealth now or in the future, ensure you have the full picture of what this could mean in terms of the tax that might be applicable for you and the people you would like to protect. hugh davies, financial planner, Cavendish Medical

79 have an up­to­date will

For the busy independent practitioner who is juggling a heavily congested schedule, making a will can often be overlooked and forgotten about. However, wills remain an essential piece of planning which require careful thought and consideration. edward Jacobs, solicitor, Gross and Co

➱ continued on page 34

80 protect your practice’s goodwill

There are two alternative circumstances in which a restrictive covenant would be considered necessary.

Firstly, those purchasing a practice will want to protect the goodwill they have bought by seeking to prevent the seller from setting up in competition immediately after the sale.

Secondly, those with established practices will want to prevent those engaged in the practice from seeking to take patients away with them if they depart and set up a rival business.

In either case, a carefully drafted restrictive covenant, contained within either the business transfer agreement (BTA) in the former case or within the consultant’s agreement in the latter case, can ameliorate the risk.

Without having a restrictive covenant in writing, the practice

owner runs the risk of their goodwill being diluted if the incumbent – be they the original owner or a consultant, the leaver – leaves the practice and seeks to take advantage of the relationships they have built up direct with the patients while at the practice, with the intent of poaching them. lynne abbess and puja solanki, Hempsons solicitors

81 protect your pension

Take advantage of valuable protection schemes to help safeguard your pension from harsh tax charges.

Every senior doctor is likely to breach the new allowance due to the very nature of making pension contributions into the NHS scheme over a number of decades.

Unfortunately, the pension protections available are nearly as complicated as the pension schemes themselves, so it is a very

Take advantage of valuable protection schemes to help safeguard your pension from harsh tax charges

difficult area for the busy professional to get right.

If you are unsure how to proceed, you should seek help without delay – the tax charge if you breach the lifetime allowance can be a staggering 55%.

patrick convey, technical director, Cavendish Medical

82 adopt a good marketing plan

this includes:

 Analysis of your current situation – PEST / SWOT;

 Objectives and goals of your practice;

 Who are your customers and whom are you targeting? These may differ – for instance, patients/ doctors/general awareness;

 Your brand;

 Marketing your service;

 Defining the product or service you are selling;

 Pricing;

 Geography – where are you promoting yourself;

 Promotional tactics;

 Budget;

 Implementation – who does what, when and how? Is training needed?

 Evaluation. Do you have any metrics in place?

Malcolm Mccoskery, marketing consultant

83 combat fraud against your business

➤ Never divulge online banking passwords or online banking secure codes to anyone on the phone, even if you think you are talking to the bank.

➤ Do not rely on your phone’s caller display to identify a caller. Fraudsters can make your phone’s incoming display show a genuine number.

➤ Be aware that a bank will never call you and tell you to transfer your money to a ‘safe’ account.

➤ If you see unusual screens or pop-up boxes when using your online banking or unusual requests to enter bank passwords, log out immediately and call your bank.

➤ If possible, set up your online banking so that two separate people are required to make any payments.

ian crompton, uK Head of Healthcare Banking Services, Lloyds Bank

84 use liquidation

As a retirement strategy, liquidation gives you an additional lump sum at the cessation of your private practice

And this may be particularly attractive for those in the 2008 or new 2015 pension schemes where the expected retirement age is 65-plus.

Hence, this has been a popular strategy for many consultants who can afford to leave money in the company.

ian tongue, partner, Sandison Easson chartered accountants

85

Get phin fit

The Private Healthcare Information Network (PHIN) is coming. My advice is to embrace the process and all the opportunities it offers.

Like it or not, it’s regulation now anyway. We’d have to collect this information one way or another. Why not let PHIN do it for us?

Ultimately, once all these glitches with the system have been ironed out, collecting information in this way will help improve clinical quality, and it will improve patient information.

It’s going to be so powerful in the future to be able to say to my patients: ‘Look, here’s a link to PHIN’s website giving all the data about my practice. I see X many people a year, no complications, I have a 90% patient satisfaction rate...’

This kind of transparency is going to give confidence to GPs when they are making referrals, and to patients and families when they are making choices. I would say embrace the change and make it work for you.

dr voi shim Wong, consultant gastroenterologist, Highgate Hospital, London

86 don’t miss calls

In a recent analysis of phone calls to the private healthcare sector, we identified that healthcare practitioners are missing the most calls at the beginning of the week, with their lines busiest at 10am on a Monday –followed by Tuesday and Wednesday at 3pm.

This suggests clinics are the most under-resourced at these times.

This strongly indicates that, as the high volume of calls are

The Private Healthcare Information Network (PHIN) is coming. My advice is to embrace the process and all the opportunities it offers

occurring at times when we would expect patients to get in touch –first thing in the morning – many practices are underestimating the number of calls they receive from patients trying to get through to them.

It’s all too easy for a practice to think they have the staff resources to cover busy call times, but many won’t be aware of the number of calls they are missing.

stephanie vaughan­Jones, telephone answering specialist, Moneypenny

87 don’t wait a year for accounts

Ask your accountant for more regular reports in the form of a set of management accounts – for example, monthly or quarterly.

You will be able to make informed decisions which will affect your business within the current financial year.

There are several benefits in tak-

ing this more involved approach, including:

 Better control and understanding of costs;

 Ability to compare year-to-date performance with previous years;

 Forecasting future earnings;

 Boosting cash flow;

 Tax and dividend planning –and much more.

ebert hyman, chartered global management accountant and general manager at London urology Group and 101 Diagnostics

88 stay abreast of GMc confidentiality guidance

The GMC has updated its website guidance with a 76-page document

Confidentiality: good practice in handling patient information. We suggest all independent practitioners ensure they and colleagues familiarise themselves with it and changes affecting them.

➱ continued on page 36

PRACTISING PRIvILEGES NOW AvAILABLE

We can’t detail them all here. Just listing the new bits takes the GMC another six pages. There is explanatory guidance too – and more to come.

But we will pass on the body’s accompanying stark warning: ‘Serious or persistent failure to follow this guidance will put your registration at risk’. editorial comment

89 Know new law on consent to treatment

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

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

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

But Foot Anstey LLP partner Mr Sankey said: ‘Many seem to know little or nothing of the change. The continued use of standardised consent forms suggests practice has not sufficiently changed. Standard forms are unlikely to record the sort of patient-centred advice and discussion the law expects.’ news story

90 dictate accurately and clearly

An outsourced secretarial service relies more readily on the information as dictated by the clinician.

A remote typist, albeit who may work within a case management system, will not have access to clinic data, patient notes, test results or hand-written summaries, so will rely solely on the information dictated by the clinician with regards to which patient the letter is on and who the letter is to.

With the cost-savings of outsourcing secretarial typing, which can be substantial, it is imperative to dictate clear, detailed and concise information on each and every sound file.

stephanie carmichael­drage, www.outsec.co.uk

With the costsavings of outsourcing secretarial typing, it is imperative to dictate clear, detailed and concise information on each and every sound file

91 Get money from lawyers

Your terms of business should always make it clear to solicitors when you expect to be paid for medico-legal work.

The majority of firms are very good at paying their experts on time, but some do need a gentle reminder by way of a phone call. ‘I am expecting a cheque but it hasn’t arrived yet. I was wondering if it might have got lost in the post’.

It’s amazing how many of these cheques arrive the following day. Some firms need a written reminder, but very few, if any, never pay.

Don’t expect to be paid in advance for a report. But it is not unreasonable to expect to be paid promptly once you have submitted your invoice/fee notice. Michael r. young, expert witness

92 install data safeguards

Your practice’s information security policy must include clear guidelines for secure communication and the appropriate use of email. (Healthcode still receives emails which include screenshots of invoices with unredacted patient information).

For example, there should be a requirement to ensure personal information is transmitted securely; restrictions on the use of personal devices and unsecure personal email accounts; checks to ensure new recipients’ arrangements are secure before messages are sent; and disabling email functions such as auto-complete addresses which can lead to personal information being sent to the wrong person.

peter connor, managing director, Healthcode

93 invest in private healthcare facilities

Until the Competition and Markets Authority (CMA) 2015 final order arising from its private healthcare investigation, many doctors never realised they could put money into equity participation schemes.

But Dr Tony Lopez, chief executive and medical director of Incorporated Health, said although the CMA put a prohibition on unfair business relationships between

Your terms of business should always make it clear to solicitors when you expect to be paid for medico­legal work

consultants and private facilities, it also made clear they must not hold more than 5% in these projects.

This meant they could indeed invest and there were now plenty of well-funded new companies who wanted to work with consultants.

He said schemes could be ‘very profitable’ and a typical investment might be £25,000-£70,000.

‘If they had the opportunity, I think there would be about 2,000 doctors willing to get involved. They just don’t know how to do it. But there are companies, as well as mine, who can help them.’ news story

94 sort these financial tasks now

 Do you have a retirement plan?

 Are you on the right pay scale for any NHS work?

 Will you exceed the annual allowance for pension savings? Will you exceed the lifetime allowance?

 Have you protected the value of your pension?

 Are you confident your practice structure is tax- and pension-efficient?

 Are you taking advantage of your available allowances every year?

 How are your investments performing?

dr Benjamin holdsworth, practising medic and business development director of Cavendish Medical, specialist financial planners

95 seek help for professional stress

Stress is often the elephant in the room when it comes to the highperforming health professionals whom I’ve worked with.

I see many medical consultants, some at the very top of their game, struggling with stress, often for far too long.

Many of these doctors have been delaying seeking help, suffering in silence for fear of being found out as not coping or not being good enough at their job.

In their attempt to eradicate stress and avoid any of the nasty feelings that may come with others knowing that they aren’t coping too well, they have engaged in a number of very unhelpful, yet understandable coping strategies

that have made their problems much worse, in the longer term anyway.

dr Michael sinclair, consultant counselling psychologist

96

Be aware of a salaried option

Doctors’ expressions of interest in working on a salaried basis in a new flagship private hospital has gone through the four-figure mark, its chief operating officer has revealed.

Mr Keith Hague said London’s Cleveland Clinic, due to open in two and a half years’ time with an initial 200 beds (29 ITU), had sparked interest from ‘thousands.’ His remarks came in response to a challenge from a representative of the Independent Doctors Federation (IDF), whose members have voiced opposition in recent months to a private salaried service model. news story

97 collect feedback from patients

Certain aspects of a practice can be hard to measure in hard data – such as how well staff communicate with patients and how patients feel about the service they receive. So consider collecting feedback from patients – this will give you the chance to understand things on a more personal level. Jane Braithwaite, managing director, Designated Medical, secretarial support services

98 avoid undercharging

A mistake we found was a consultant’s secretary had charged all insurers at one insurer’s rates, not realising different insurers will accept different fees for similar work and procedures.

In some cases, there was up to a 100% differential, costing the practice tens of thousands of pounds over several years.

Another common mistake we find is the incorrect billing of multiple procedure codes because each insurer has their own specific rules about how the invoice total is derived.

If these are misunderstood, you could be missing out or billing incorrectly – and that can cause you problems with the insurers. findlay fyfe, managing director, Medical Billing and Collection

99 send out fee letters

Are you aware? Under Article 22.2 of the Competition and Markets Authority Order arising from its long-running inquiry into private healthcare, consultants must send patients written fee information before outpatient consultation (operative by 31 December 2017) and prior to further tests or treatment – by the end of February 2018. news story

100 carry on reading us!

You’ve come with us this far –thank you!

Now make sure you don’t miss the big issues, and much more, that we will be covering in exciting future editions of Independent Practitioner Today

Every subscription will help us continue bringing you important coverage in the fast-changing world of private practice. Subscriptions for our ten issues a year are only £75 for doctors if you pay by direct debit. See details on page 22.

 All writers above held the posts quoted, and worked for the companies/organisations mentioned at the time of publication. Every effort has been made here to cover still relevant advice on ongoing issues. Readers should act on it only after checking with appropriate sources and/or advisers if in any doubt.

CREATing yoUR own pREMisEs

When opening day

Using a case study, Maurice Citron (right) has sketched out some important issues and processes you will need to consider if you decide to acquire, develop and trade from your own clinical property.

Now, in the final article of his series, Dr Ian Drever – the entrepreneurial consultant psychiatrist behind the project – is in business! After almost four years, he was delivered a welcoming, truly state-of-the-art new psychiatric day clinic

EshEr GrovEs is, I believe, the UK’s first purpose-built specialist clinic for depression, anxiety and stress. There are four consulting rooms and one group room, which can accommodate six patients and a therapist.

The clinic in Esher, surrey, is serviced by two toilets, a reception area and a spacious garden room where day-patients will be able to relax and eat. There is also a goodsized administrative office accommodating three members of staff.

Esher Groves provides a very comfortable, modern and attractive therapeutic space with air conditioning throughout. Attention to detail is impressive.

Client confidentially is very important in this type of consulting context and higher specification fire doors have been installed to provide additional sound proofing for the consulting rooms.

All the rooms have been carefully designed to be of a certain size with dimmable lighting to allow the therapist to create an intimate and cocooned-like ambience. Top specification CAT 5 Ethernet connectivity is supplied throughout the building, allowing super-fast access to the internet in every room.

Consultants will be able to book consultation rooms at Esher Groves and, in time, this will be done via a fully automated online booking system.

Consultancy rooms are charged between £17.50 and £20 an hour with preferential rates available when bundles of time are booked.

Therapists will be asked to sign a letting agreement and will also be required to provide copies of their professional qualifications, evidence of professional indemnity/ insurance and to present their track record for approval.

The demand for this type of clinical space is already apparent, so much so that a local cosmetic practice offered Dr Drever a premium rent to lease an entire floor.

There is clearly a gross undersupply of clean, modern, warm consultancy space in the local area, but Dr Drever believes Esher Groves will provide more than just attractive space for therapists.

It will also act as a support network for like-minded practitioners and will provide a community hub for discussions, lectures and continuing professional development. Local therapists will be able to feel part of a team connected via the physical space.

Marketing the business

Building sites have a reputation for being messy and unattractive, but they can provide marketing opportunities too.

During the latter part of the build, a giant building banner hung from the scaffolding at the front of the building advertising the spe-

cialist clinic. It proved to be very popular and earned Esher Groves many ‘likes’ on its LinkedIn page.

The business has rolled out several pieces of marketing material including a website and printed brochure. however, resources will be used to engage with therapists directly.

Fortunately, Dr Drever has over 20 years of experience as a mental health practitioner and can access a wealth of connections nurtured over that time. he has received a huge amount of goodwill and support from his professional network, several of whom have expressed a serious interest in using the premises.

Dr Drever will now develop a network with primary care practices in the local vicinity to build on the interest. It is believed GPs will be a vital source of therapists and clients and the primary source of referrals.

There are 17 GP surgeries with 122 GPs within a five-mile radius of the clinic. he has a straightforward strategy: knock on the GPs’ door and try to get ten minutes of their time to pitch the clinic and the services it offers.

Therapists will bring their existing clientele to Esher Groves and the clinic will market itself internally to these patients with a weekly newsletter and advertising posted in the waiting room and reception.

Psychiatrist Dr Ian Drever pictured in his new clinic’s waiting room

Scaffolding during building work provided an advertising opportunity

day arrives

Time to reflect

Now that that clinic has been delivered, Dr Drever can reflect on the journey to date. We caught up at the clinic and talked about his thoughts and experiences on developing his own clinical premises.

he says: ‘I’ve learned that there is something powerful about having a vision and consistently executing against that and grinding it out; the power of grit and determination. It gets you somewhere and even

if the steps are small and the process is slow, over time, that adds up to something really meaningful.’

I asked him how he will feel when the business starts to perform: ‘A massive accomplishment and vindication for what we’ve been doing,’ he tells me.

‘I’ve always been very comfortable that we had a strong business concept, but it hasn’t been tested and once we get some customers through the door and start mak-

ing money, that will feel incredibly rewarding.’

After all the trials and tribulations, did the doubts ever start to weigh him down? Was there ever a point he wanted to walk away?

‘I never got to the point that we thought it wouldn’t open,’ Dr Drever responds. ‘I didn’t know when we were going to open; it was taking such a long time. I stayed focused on what we were doing and that there was a need for the clinic.

‘It was building on what I know and the years of experience I have accumulated. It never felt like I was doing something alien or completely off the wall. It’s been a marathon, but we’re here and ready to go and its very exciting’.

How much more does he now know about property?

It’s been a marathon, but we’re here and ready to go and its very exciting

‘My background has been medicine and psychiatry, so learning about finance and property has been really stimulating and very rewarding. It keeps you on your toes, motivated and inspired. so, yes, I’ve enjoyed that.

‘ h owever, the real work only starts now; providing the services, developing the policies and processes. There’s a steep learning curve and many new responsibilities.’

I will finish by congratulating Dr Drever and his team on a very successful property project and wish him all the luck for the future as he reaps the rewards of his hard work and dedication. 

Maurice Citron is director of Citron Singer Property Finance, a commercial property finance broker specialising in the healthcare sector

 Tell us about your building project! Get in touch by email at robin@ip-today.co.uk

Above: The reception area

Left: The new entrance

Below left: The waiting room

BillinG AnD cOllEcTiOn: invOicinG

Let experts do the bill

So you’ve still not been paid?

Well, sending the invoice is the easy bit. Findlay Fyfe (below) shows why

WE OCCASIOnAllY find doctors who wonder why their secretary might want or need to outsource their billing and collection.

When this happens, the first thing that springs to mind is the fact that the specialist may be unaware of all the demands arising from running a modern successful practice.

This is fine, as their focus should be on the delivery of excellent patient care, but a consultant should never underestimate how time-consuming and often awkward the billing process can be in private healthcare.

A good secretary or practice manager who can manage the day-to-day running of the practice and everything it brings as well as the billing and collection is worth their weight in gold.

The heavy workload is also

multi-faceted, so some secretaries who are good at dealing with patients are often not as good at asking for money. not everyone is comfortable having these conversations, especially if there is a difficult patient to deal with.

So let’s consider the various parts of the billing and collection process and the issues these bring.

. Getting hold of patients

A lot of our account managers’ time is spent contacting patients by both emails and phone calls. This can take many attempts before contact is made and can be for many reasons such as the collection of outstanding payments, notification of excesses and shortfalls or clarification of patient information such as correct insurance and contact details.

. Dealing

with private insurance companies

Insurers increasingly expect billing information to be sent online or through a portal like Bupa online or Healthcode.

This makes perfect sense in terms of speed of payment, cost and accuracy to the insurer, but can result in many problems with invoices failing or being rejected. You need to put strong procedures in place to ensure these errors are managed effectively.

When a secretary has been used to sending these invoices by post and then has had to switch to electronic transfer, we regularly find a practice in distress from errors. And, in some cases, they were not even aware of the problem.

Each insurer has its own pricing policy and rules about invoicing and these need to be understood

Findlay Fyfe is managing director of Medical Billing and Collection

bill chasing

and followed. Some insurers limit the times when you contact them to raise queries and how many queries can be raised on each occasion. This causes bottlenecks in busy practices or where staff look after more than one consultant.

. Reconciliation

By this we mean matching payments against individual invoices. Payments can come in from various sources such as insurers, patients, solicitors, embassies and hospitals. These can arrive individually or can be

combined, reflecting remittances relating to multiple invoices.

Our account managers carry out this function as part of their dayto-day activities, which means these payments are identified and applied to the relevant invoice.

If we find a balance outstanding, then an invoice needs to go out promptly to the patient to inform them of their liability. This can be a time-consuming job requiring ‘quiet time’ which is difficult to find in a busy practice. So, unfortunately, this tends to mean it gets put off. That means

the aged debt can rise. The problem escalates as staff find it a Herculean task to resolve and this cycle just repeats until you take action to break it.

Often when we take on new clients, this becomes a major part of their onboarding process. We call it intensive care, a process of ensuring this backlog of outstanding debt is identified, invoiced and chased.

. Obtaining patient information

When a practice takes on a new patient, there should always be a process to get all the relevant information to allow the billing to be managed effectively.

A clear and concise patient registration form can be a good idea if you ensure that this is filled in correctly. Robust processes at the start can ensure the patient experiences a smooth payment pathway through the practice.

. Sending the invoice

Many busy practices think sending the invoice is 90% of the collection process. This is only the first step in this process.

All our calls and patient engagement are automatically diarised by the account manager to ensure maximum effectiveness and provide a complete audit trail for reference should a problem occur.

Sending the invoice is only the tip of the iceberg. Certainly no one would pay without one.

But if you consider all the other demands on a busy practice, from managing emails and calls from patients, scheduling appointments, managing patients’ medical records and letters, co-ordinating diagnostic tests and other hospital services, then its easy to see how the billing function can get put to one side.

Given all the pitfalls of billing and collection in a private practice, outsourcing can be an attractive and cost-effective option. 

pRivATE pATiENT UNiTs

NHS grows sub-brands

In our previous issue, Philip Housden (right) analysed private patient revenue growth for 22 NHS trusts across greater London. This was the first in a series, which this month looks at the 17 NHS trusts delivering acute care services to the southern home counties

AnAlysis of nHs trusts’ 2016-17 annual accounts for this group shows that total private patient incomes rose by 3.2% to reach a new record of £62.4m (figure 1).

This represents 1.01% of these trusts’ total revenues, a percentage that has remained static for the past several years. The combined national average including london is 1.1%.

These 17 acute trusts can be divided into three groups based on analysis of private patient revenue growth and by percentage of overall trust patient incomes (figure 2):

1. Growing: s even trusts have grown by more than 10% in the past three years and private patients now account for over 0.5% of revenues. There is a concentrated cluster of trusts that are growing private patient earnings in Hampshire and surrey;

2. Static: f ive trusts have held steady through recent years;

3. Falling: The final group is made up of the five trusts that have between them £1.5m a year lower revenues than in 2014-15. The top three trusts by both overall earnings and % of turnover are f rimley Health, Royal surrey and Western sussex. frimley Health has built on the

long-term success of the 37-bed integral inhouse-managed private patient unit (PPU), the Parkside s uite at f rimley Hospital, by recently incorporating the Paragon suite at Wexham Park, slough, into the Parkside brand.

The brand is to be further enhanced by additional private capacity at Heatherwood Hospital, Ascot. f rimley is ranked 11th highest private patient earners in the nHs, and top outside london (figures 3 and 4).

Niche services

Royal s urrey at Guildford has grown by 50% to £6m in 2016-17, principally by concentrating on complex surgery and niche services that the local independent hospitals cannot provide, and are not dependent on designated PPU beds.

These services include radiotherapy, nuclear medicine, brachytherapy and robotic surgery. southampton is similar in having no private patient inpatient beds but instead provides a range of day case and diagnostic capability, including chemotherapy.

This is a style delivered by Brighton too, where the trust has held steady at £4.5m a year despite local competition from spire and

Figure 1

Figure 2

Figure 3

Figure 4

nuffield, which essentially leaves only niche high-grade surgery available for the PPU.

Maidstone, too, has a strength in private cancer care, but has been hit in recent years by the opening of KiMs private hospital, also in Maidstone, with trust revenues falling by £3.3m (40%) in the last three years, and this despite the high-quality facilities provided within the Wells suite within the nHs’s first all-single-room hospital.

Western s ussex Hospitals also earns £6m a year through a range of acute services out of the 26 beds at st Richard’s, Chichester, and the five rooms at Worthing.

The trust has explored a number of potential routes to expanding capacity at Worthing without yet bringing these to fruition. Along the coast, Portsmouth Hospitals has exploited its substantial clinical strength and quality infrastructure to integrate private care and complex nHs activities such as robotic cancer surgery and bariatric surgery

in a 14-bed PPU ward that has delivered 50% growth in the last two years to around £3.5m revenues. in Basingstoke, Hampshire Hospitals’ investment to open the Candover suite in 2013 has paid off. The 22 inpatient beds and a range of supporting outpatient and diagnostic services has enabled the quadrupling of revenues in this time from £1.4m to £5.8m last year.

Own brand

What the above trusts all have in common is that their private patient activities are trust-owned and managed. There are a group of other trusts that have some form of partnership or local arrangement that may mean the true value of private patient activity is underplayed within their annual accounts.

East Kent Trust owns s pencer Hospitals, a subsidiary company managing PPU services of varying size out of Margate, Ashford and Canterbury. The trust lost out on

developing the Ashford market when one Healthcare invested in its first hospital, but still has opportunities to exploit through future trust site and service reconfiguration.

s pencer provides n H s Choose and Book services and was the first multi-site PPU ‘chain’ brand, since followed by Parkside ( f rimley), lindsay (lincolnshire) and nash (south Essex).

it is too soon to know whether nHs sub-brands is a trend that will be embraced more widely by trusts, but it seems to offer some commercial opportunities for the nHs in support of private patient expansion.

Epsom has recently announced a partnership with one Healthcare who assume operational control of the Coombe Wing from BM i later in 2018. This is a prelude to further investment, it is believed, but, interestingly, the tie-up is taking a different line to other trusts that have recently absorbed part-

nership PPUs or called off potential joint ventures.

of the others working with partners: BMi Runnymede Hospital is similarly located on the st Peter’s Hospital site, Chertsey; there is a s pire Hospital at Hastings and Horder Healthcare runs the Mc i ndoe Centre at the regional burns and plastics centre at Queen Victoria Hospital, East Grinstead. of the others not mentioned so far, none are known to be investing for growth: Eastbourne’s PPU delivers a flat £2m or so and i sle of Wight’s Mottistone s uite PPU is limited by the island’s population and geography. But market opportunities for PPU growth remain and it may be that any or all of East surrey, Dartford and Gravesham or Medway seek to invest in additional capacity in the future.

 Next month: the northern home counties

Philip Housden is a director of Housden Group

ThE hisToRy oF mEdicinE

The grim days of body-snatching

Medical historian Suzie

Grogan (right) delves into the profession’s pressure to obtain corpses for

dissection

Obtaining a cadaver for the purposes of dissection had caused considerable hand-wringing in both the legal and medical professions for centuries.

as long ago as 1541, the royal company of barbers and Surgeons – the predecessor of the r oyal college of Surgeons – lobbied for, and had conferred upon it, a licence to dissect four executed criminals per annum, increased to six by charles ii

t his not only offered the first opportunity for a legal supply –albeit a tightly regulated and restricted one – of dead bodies for dissection, but also began the perception of dissection as something degrading, perpetrated only on those at the bottom of the social scale.

this was the legal position for some 200 years.

in 1752, george ii passed what became known as t he Murder a ct, for ‘better Preventing the horrid c rime of Murder’; it offered an additional deterrent to the act of murder: ‘the crime of murder has been more frequently perpetrated than formerly… and…it is thereby become necessary that some further terror and peculiar infamy be added to the punishment of death.’

Judges were given the discretion to substitute ‘donation for dissection’ in place of ‘gibbeting in chains’.

both additional punishments, to occur after death, were designed to deny the murderer the comfort of a decent burial.

t he horror of dissection was thus increased, as the removal of a

body to the r oyal c ollege of Surgeons – the only official recipient of the cadaver – prevented the felon’s family from giving their loved one a christian burial. a nyone attempting to rescue the bodies of their loved one from this grim fate, which also denied pagan beliefs, was liable to transportation for seven years, with early return also punishable by death.

Superstitions about death and the afterlife were rife at this time, and there were frequent gatherings at executions, determined to ‘rescue’ the body of the dead criminal and ensure the surgeons did not get the chance to take the corpse to pieces.

Fear of dissection

i n fact, the riots and threats of revenge were a contributory factor in the decision to end the spectacle of public execution and take the carrying out of the final act within the prison walls. the fear of dissection is closely linked to that of the ultimate punishment introduced by the tudors, that of hanging, drawing and quartering, which also denied the right to observe custom and practice and offer the chance for redemption in the afterlife.

Key figures in the development of the study of anatomy in the eighteenth century are the brothers William and John Hunter. William Hunter thought of the body as useful not only to anatomists but to artists as well.

i ndeed the flayed corpse of a murderer, still in the r oyal academy collection, was nailed to

a cross by sculptor thomas banks and painters benjamin West and richard cosway, to illustrate how far previous artistic depictions of c hrist’s crucifixion were from anatomically accuracy.

i n 1831, the year before the anatomy act, only 11 bodies were released to the c ompany of Surgeons and were legally available for dissection in London, far too few to meet the need of the anatomy schools, which were growing to meet the needs of men who wanted to train as physicians or apothecaries alongside the practice of surgery.

the importance of anatomical study was all the more significant, as the profession was beset by surgeons ill-equipped to pass on their meagre skills to the growing number of medical men training in the period 1750-1850.

Little finesse

if a patient was told they needed surgery, they knew they were in danger of losing their life. Surgery was more a case of hacking off, or out, parts of the body believed to be diseased.

there was little finesse and the surgery was undertaken as quickly as possible to prevent the unanaesthetised patient dying of shock and blood loss.

Postoperative infection was almost certain, as there was no knowledge of the need for cleanliness, antisepsis or antibiotics. For many years, the position of surgeon was offered by means of nepotism and social standing, rather than skill.

The desperate need for dissection

before the 18th century, however, a medical education did not require a physician to study anatomy by practical demonstration. in fact, it was thought a waste of time, offering little in the way of valuable information.

the industrial revolution created a middle class that was increasingly wealthy and expected the best medical treatment their new money could buy, and doctors maintained that progress could not be made without a better knowledge of anatomy.

the progress made was of greatest use in the treatment of gen -

Dissection also offered the only way in which a medical student could learn how a female body functioned

The last in Hogarth’s 1751 series of morality-tale engravings entitled ‘The Four Stages of Cruelty’. It shows the anti-hero on the dissecting table after being cut down from the gallows, having been convicted for murder

A mortsafe: an iron coffin designed to protect a corpse from bodysnatchers

eral, and solely male, medical matters.

Middle-class women, even under the hands of the most skilled of doctors, were to be treated with a respect that may, in some cases, have meant that the true nature of her illness could not be properly identified.

doctors were required to examine and treat ‘blind’, rummaging about under the covers, averting eyes from genitalia and learning to ‘feel’ for the different vital organs by memory.

dark affair

d issection also offered the only way in which a medical student could learn how a female body functioned, as no such niceties had to be maintained.

the dissecting room could take medical knowledge forward, but the obtaining of the necessary specimens on which to practise was a dark affair.

t he a natomy a ct of 1832, which extended the supply of cadavers by allowing the dissection of the poor, unclaimed souls who died in the workhouse, effectively made dissection a punishment for poverty.

i n fact, dissection had been undertaken on those who were poor, and at least nominally unclaimed, for many years.

Surgeons working in charitable hospitals, even in an ‘honorary’ position, could perform what was, ostensibly, a dissection, in front of fee-paying students, simply by taking a post-mortem further than was necessary to establish the cause of death.

e ven after the a natomy a ct came into force, the demands of the dissection room regularly outstripped the supply of the unwanted poor and, although much reduced, body-snatching was to continue into the twentieth century.

The Anatomy Act 1832

it is remarkable to think that an a ct, originally drafted to thwart the activities of the body-snatchers or ‘resurrection men’ and to provide an official source of human bodies upon which a surgeon or student of medicine could undertake research, remained in force until 2004, when it was at last replaced by the Human tissue act of 2004.

t he a natomy a ct 1832 was passed at a time when newspapers were focusing on an outbreak of cholera and on parliamentary reform. So, as in the twenty-first century, contentious legislation could be passed with barely a flutter of interest from the newspapers. the act gave the hospital medical schools and private schools of anatomy an official means of access to the bodies they required for research and learning. the bodies of lunatics and paupers, those left in workhouses and

hospitals with apparently no one to mourn them or pay for a funeral, could be bought from the Poor Law Unions and from those owning eligible institutions, for the purposes of medical research. there was significant opposition to the bill, as it appeared to make a crime out of dying poor and alone, and deprived a person of their right to a burial in their parish. a death in a workhouse, for example, would, if no one came to collect the body within seven days with the means to pay for a decent funeral, be recorded in the parish register and taken to the medical schools without any act of burial taking place.

t his provision goes some way towards explaining the particular dread many had of the workhouse; in addition to separation from family, harsh conditions and the stigma, there was also now the fear of dissection after death, something only previously

allowed on the bodies of convicted criminals.

The horrors of the dissecting room

For many, the horrors of the dissecting room disgust and intrigue in equal measure.

For young doctors, their first terrifying experience of the dissecting room gradually fades as their continued work inures them to the subject as a person; the flesh and organs under their scalpel simply there to give them the opportunity to learn, first hand, the wonderful workings of the human machine.

For many, however, that loss of a natural response to death and human bodies was one that awakened in them the sense that they were about to lose something precious, which they resisted, and which persuaded them medicine was not for them.

Hector berlioz, the 19th-century

composer, originally intended to be a doctor and was sent to study medicine in Paris in 1821. His situation is not so different from that facing the poet John Keats, or any young man training to be a surgeon-apothecary in the early years of the 19th century.

His experience of the dissecting room convinced him that his life should be spent in the creative arts, rather than the wards and operating theatres of the big cities. i n his memoirs, b erlioz offers a graphic description of his first experience of the hospital dissection room:

‘When i entered that fearful human charnel house, littered with fragments of limbs, and saw the ghastly faces and cloven heads, the bloody cesspools in which we stood, with its reeking atmosphere, the swarms of sparrows fighting for scrapings and rats in the corners gnawing bleeding vertebrae, such a feeling of

horror possessed me that i leapt out of the window, and fled home as though death and all his hideous crew were at my heels.’ clearly, there was a market for the bodies of the dearly departed, and thus ‘body-snatching’ became an opportunity for those sufficiently entrepreneurial, and strong of stomach, to make a very good, if far from respectable, living. 

☛ 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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Free legal advice for independent Practitioner Today readers

independent Practitioner Today has joined forces with leading healthcare lawyers hempsons to offer readers a free legal advice service.

we aim to help you navigate the ever more complex legal and regulatory issues involved in running and developing your private practice – and your lives.

hempsons’ specialist lawyers have a long track-record of advising doctors – and an unrivalled understanding of the healthcare system as a whole.

call hempsons on 020 7839 0278 between 9am and 5pm monday to Friday for your ten minutes’ of free legal advice.

Advice is available on:

Business structures (including partnerships)

commercial contracts

disputes and litigation

hR/employment

Premises

Regulatory requirements and investigations

KEEp iT LEgAL: BAnding TogEThER

For the benefit particularly of all our new readers, Hempsons solicitor Kirsty Odell (below) looks at limited liability partnerships, limited liability companies, expense sharing arrangements and traditional partnerships

Groups are a motley bunch

Consultants are increasingly joining together to work more collaboratively. This can ease the burden of working alone and being solely responsible for all costs and expenses. Working together can alleviate some of that pressure and assist in moving a business forward.

There are many different business vehicles for this, each with different advantages and disadvantages.

Limited liability partnerships

A limited liability partnership (LLP) is a corporate entity.

Members benefit from limited liability – so they cannot lose more than they invest. Unlike a traditional partnership, an LLP has its own legal status and can therefore enter into contracts in its own name.

There is flexibility as to how profit shares are arranged and it may be akin to that of a traditional partnership. The member receiving the profits is taxed on those profits – as opposed to the LLP being taxed on them.

An LLP has the additional advantage of being more flexible to exit and it can largely decide itself how this will be dealt with.

It is registered at Companies House and has reporting requirements. For example, membership and accounts must be filed and they are publically available.

A consultant will need to consider whether they are required to be a designated member. A designated member has many administrative duties, similar to that of a company secretary.

Limited liability company

Consultants may also choose to work together via a limited company, most likely a company limited by shares. As with an LLP, this creates a separate legal entity and must be registered at Companies House.

Its constitutional documents

will be accessible to the public and statutory registers must be maintained. A limited liability company also has filing requirements, including annual accounts and confirmation statements.

There are two distinct sets of people who run a limited liability company: the directors and the shareholders.

The directors are those who have control over the day-to-day management of the company. They must comply with statutory duties and therefore act in the best interests of the company.

Shareholders are the owners of the company and their liability is limited to what they agreed to pay for their shares. They have the right to make certain statutory

ExpEnsE sharing

This is where a group of individuals retain their own fees but share the expenses of running their practices, such as staff, equipment and premises rent. They can therefore choose to work as much or as little as they would like, depending on how much they want to personally earn. Each practice is independent and is responsible for its own business.

There is a risk that an expense sharing arrangement may be viewed by the outside world as a partnership. Expense sharers must therefore be very careful as to how they describe themselves to the outside world – avoiding use of the term ‘partnership’ and demonstrating that they do each have separate and independent businesses

it is quite common to see one lead expense-sharer who will enter the relevant contracts on behalf of the group. The lead individual would then have to rely on the others to make their respective contributions.

some of the risks of an expense share arrangement can be circumvented by having a robust expense sharing agreement in place, clearly setting out the requisite liabilities of each party and who shall enter into contracts.

decisions and additional decisions that may be reserved for them pursuant to the company’s Articles of Association.

A consultant who becomes a shareholder of a limited liability company may receive a dividend in respect of the profits of the company. It is important to note that, as with profits of an LLP, the member will be taxed on their receipt of profits. However, unlike an LLP, the company will also be taxed on its profits.

Traditional partnership

Some consultants may work together in the form of a traditional partnership, although this is less common.

Legally, a partnership is formed

by individuals working together with a view to making a profit. It is therefore quite possible to inadvertently create a partnership by working together with other practitioners.

A partnership offers consultants the opportunity to own a part of the business for which they are working. As well as owning a share of the business, it also means that the partners share the liabilities.

One key distinction between a traditional partnership and a limited liability partnership is that a traditional partnership does not have its own legal entity.

This means that when the partnership enters into contracts, it is the individuals that are doing so in their own names, rather than collectively as a partnership.

The liability of the partners is unlimited and joint and several, so one individual can bear the costs of another individual’s error. If the partnership does not have the funds to cover the liabilities of the business, the partners could have to settle those out of their own personal assets.

Without a formal partnership agreement, a partnership can provide a very unstable relationship and any partner could turn around at any time and say that they wish to dissolve the partnership – this could have a disastrous effect on the business. Where the partnership can be terminated in this way, it is known as a Partnership at Will.

If a consultant is looking to join a partnership, then the consultant needs to consider the current partnership arrangements in place and the cost of buying in –to partnership assets as well as working capital requirements.

Whatever type of business structure a consultant choses to join/set up, advice should always be sought to ensure that they are aware of the liabilities that they are taking on and to assist in mitigating any potential losses.

All of these structures should have a written agreement in place dealing with these issues.

At Hempsons, we have a dedicated team that can advise on the implications of joining different business models and help to negotiate requisite documentation seeking to protect the individual’s interests. 

PROBLEMS WITH THE TAX MAN?

HMRC tax investigations and disputes create difficult and stressful times.

As an award winning firm of tax experts, our highly experienced partners specialise in resolving problems relating to tax investigations and disputes with HMRC.

To find out, in confidence, how we can help call 0800 734 3333.

‘Here to help. Not to judge.’

Monster of charges

£

is real of

As a hard-working doctor, you deserve to enjoy retirement, make the most of your free time and to lead the life you desire. So make sure that you truly understand your own investments; how your funds are performing and how much you are paying for the privilege.

Dr Benjamin Holdsworth (right) explains how EU directives have helped reveal the true costs of some investments

TwO yEARS ago, the Investment Association, which represents investment managers in the UK, published a report dismissing claims that financial products – in particular, mutual funds – could carry hidden charges for investors.

The study by the industry body branded such fees ‘the Loch Ness Monster of investments’ and threw doubt over their existence.

Now MiFID II, the European transparency rules which came into force in January, has revealed that Nessie appears to be real after all.

MiFID stands for Markets in Financial Instruments Directive –a complicated title for EU regulations which govern investor protection and ensure greater transparency across markets.

The original guidelines came into play in 2007, but the updated version is much stricter and extends to some 1.4m paragraphs. Despite Brexit, UK firms must still comply.

Since the new rules became operational at the start of this year, fund managers are required to disclose ongoing fees which could be hidden from investors, often eating into their returns substantially.

In the financial arena, those of us who have been proponents of fee transparency have long known this to be the case, but this obligatory formal disclosure has been an ‘eye-opener’ for many investors.

double the cost

The new regulations state that fund managers can no longer provide the industry standard ‘ongoing costs figure’ (OCF) as a statement of charges. Instead, they must give a clear picture at least annually of the total cost involved, which may include trading, transaction or banking costs as well.

According to recent research by the Financial Times , in 2016, many investors paid up to double the OCF in the UK’s most popular funds once trading costs were included in the final figure. If the platform charges were added in, investors paid up to

four times the OCF that had been disclosed.

MiFID may be proving challenging for financial companies to implement, but it is already reaping rewards for investors.

Financial ratings agency Moody’s reports that this regulatory overhaul will continue the trend of investors moving to lower-cost passive funds. MiFID’s disclosure will make it easier to compare investment products and so high-fee, actively managed funds will be revealed as poor value.

Easier to review

Already the European fund industry has lost some 3,000 funds over the last five years as the Retail Distribution Review made it simpler to view fund performance in relation to fees.

Back in the 1960s, 70s and 80s, active asset management – where a professional fund manager uses

Numerous academic studies have shown over the last few decades that active asset management is unlikely to provide adequate returns after costs over the long term

that active asset management is unlikely to provide adequate returns after costs over the long term.

Prof Fama developed the Efficient Market Hypothesis which purports that trying to beat the return of the market is futile.

Instead, he found that a passive portfolio, which is designed to track an index, market or asset class with significantly lower costs and turnover, makes very good sense.

forming and how much you are paying for the privilege. 

Dr Benjamin Holdsworth is a practising medic and director of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS.

his or her judgement to guess which assets will perform better than average – was the norm. Clients paid substantial fees for investment managers to deliver returns on their portfolios. However, numerous academic studies, particularly those by the likes of Nobel Economic Prizewinner Prof Eugene Fama, have shown over the last few decades

Over the last decade, 83% of active funds in the US have failed to match their chosen benchmarks. From this, some 40% of funds collapsed before the decade finished.

In 2016 in the UK, asset managers suffered their worst year since the start of the financial crisis with just 21% beating the market.

So it’s worth ensuring that you truly understand your own investments, how your funds are per -

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

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

Cavendish Medical is regulated by the Financial Conduct Authority to provide independent financial advice to individuals and businesses. For more information, visit www.cavendishmedical.com

EXPERT ADVICE YOU CAN TRUST

EXPERT ADVICE YOU CAN TRUST

EXPERT ADVICE YOU CAN TRUST

SPECIALIST MEDICAL ACCOUNTANTS

SPECIALIST MEDICAL ACCOUNTANTS

Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.

Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.

Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.

Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.

Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.

Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.

We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:

We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:

We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:

• Setting up in Private Practice

• Setting up in Private Practice

• Setting up in Private Practice

• Developing your Private Practice

• Developing your Private Practice

• Developing your Private Practice

• Tapering of the Annual Allowance

• Tapering of the Annual Allowance

• Tapering of the Annual Allowance

• Lifetime Allowance planning

• Lifetime Allowance planning

• Lifetime Allowance planning

• Personal Allowance planning

• Personal Allowance planning

• Personal Allowance planning

• Reviewing your PAYE Coding Notices SPECIALIST

• Expenses that you can claim and those you cannot

• Expenses that you can claim and those you cannot

• Expenses that you can claim and those you cannot

• Minimising your tax bills

• Minimising your tax bills

• Minimising your tax bills

• Reviewing your PAYE Coding Notices

• Reviewing your PAYE Coding Notices

Wilmslow, Cheshire,

Be patient with notes

Dr Sissy Frank (right) medicolegal adviser at the MDU, explores the ethics of retaining records after retirement

Dilemma 1

How long must I retain notes for?

QI am a consultant urologist who works in private practice and am hoping to retire later this year. I am unsure what to do with the patient records for my work. In particular, I am unsure how long I should retain records?

AClinical records should be retained for at least the minimum periods recommended in national guidance or required by statute. At present, there is no definitive guidance relating to the retention of private clinical records.

The regulations which did cover this in the past, Schedule Three of The Private and Voluntary Health Care England Regulations 2001, were repealed and not replaced in 2010 and are therefore no longer in force.

Despite this, it would be appropriate to follow the guidance outlined by the Information Governance Alliance’s Records and Management Code of Practice for Health and Social Care 2016.

This document states that different retention periods apply to different types of records and provides a detailed schedule setting out how long different types of records should be retained.

It is important to note that the recommended retention periods contained in the guidance are the minimum periods of time which records should be retained. For patients where you are aware of an adverse incident or a complaint,

or in a particularly serious or contentious case, it may be appropriate for records to be retained for longer than the minimum period.

The MDU regularly receives requests for assistance many years after the event in question has taken place and an absence of records can it make it significantly harder to mount an effective defence against any allegations. However, it is also important to bear in mind that retention of records should also comply with the requirements of the 1998 Data Protection Act. The Act states that records should not be retained longer than is necessary.

When the General Data Protection Regulation comes in on 25 May 2018, it is important to comply with this. There are also the practical considerations such as the availability of secure storage space in relation to the retention of private records that may influence the decision to retain records beyond the minimum retention period. It is important to use appropriate measures when disposing of records. These include cross ­ cut shredding, incineration or hiring a commercial company to manage the records on your behalf.

If you opt for the latter, do make sure that the company holds the necessary British Standard or International Organisation for Standardisation (ISO) accreditations to effectively dispose of records.

Finally, although I hope you have a long and happy retirement, you should also be aware that if any records remain in your possession at the time of your death, the executor of your estate may need to seek further advice on how best to store or dispose of these.

Testing and the financial consequences: Dr Kathryn Leask (right) answers another reader’s query

True cost of a test

Dilemma 2

Financial impact of genetic tests

QI am a consultant breast surgeon and have been asked for advice by a patient who is considering having tests to see whether she has a genetic predisposition to breast cancer. She is concerned as to whether this will have any impact on applying for life insurance and other forms of insurance. Her mother and maternal aunt died of breast cancer and she is understandably concerned about this. Before we look into testing further, she wanted more information about the financial consequences of this.

APatients who have a strong family history of breast and ovarian cancer, and some other forms of cancer, may wish to consider genetic testing to see whether they have a mutation in the tumour suppressor genes BRCA1 and BRCA2.

Where a fault occurs, the proteins that help to repair damaged DNA do not function correctly. This results in cells being more likely to develop genetic alterations which could lead to cancer.

The insurer should not ask whether applicants have had a genetic test

It is possible to test patients for the presence of mutations in these genes, generally after the patient has received appropriate genetic counselling. Those who are found to carry a mutation are at increased risk, as compared to the general population, of developing certain types of cancer, including breast and ovarian cancer.

Insurance application forms may ask about hereditary disease that runs in a family. If this information is requested, the applicant must give accurate responses. The insurer should not ask whether applicants have had a genetic test, however.

The Association of British Insurers (ABI) has a code of practice on genetic testing. At the moment, British insurers have agreed to a moratorium which allows people to apply for life insurance up to £500,000 and up to £300,000 of other types of insurance, such as critical illness insurance, without the need to

tell them the results of previous predictive genetic tests.

This includes patients who had predictive tests before the date of the moratorium and those who may have had predictive tests as part of clinical research, such as the 100,000 Genomes Project. It does not apply to diagnostic genetic tests or non­genetic medical tests, such as blood or urine tests.

The only circumstances where a person may be asked for predictive genetic test results is where they are seeking insurance cover in excess of the set financial limits above.

To date, the only disease that this applies to is Huntington’s disease. A patient may wish to tell their insurance company if they have had a genetic test which has revealed a negative result, as this may be taken into account when working out the policy. 

Dr Kathryn Leask is a medico-legal adviser with the MDU

When a pension can ensnare you

Much has been written about the pension annual allowance – but it is becoming one of the most significant financial risks a consultant can face and can lead to unexpected tax liabilities, warns Ian Tongue (right)

T HE TA x deadline in January 2018 saw many people affected by the pension annual allowance trap. But January 2019 is when this nasty and unfair tax will really start to bite.

It is vital that you understand your position to avoid it.

The headline figure is £40,000, but this soon reduces for those with an earnings level over £150,000. It is important to note that the definition of ‘earnings’ is different to taxable earnings and so understanding the methodology is really vital.

For all taxpayers, the starting point is whether the individual’s taxable earnings exceed £110,000, which is known as the ‘threshold test’.

This test refers to your taxable earnings – from most sources –and if you are under £110,000, you will not see a reduction of your annual allowance irrespective of your pension growth level. If your earnings exceed £110,000, you have to be considered for annual allowance tapering (sliding-scale reduction).

An example of how this would work is to consider two consultants. Consultant A has NHS earnings of £100,000 and a private practice profit of £9,000. Consultant B also has NHS earnings of £100,000 but a private practice profit of £20,000.

They were delighted in the year to receive both a clinical excellence award (CEA) point and a pay

increment. As both pay rises are superannuable, this gave rise to pension growth of £75,000 each.

Consultant A has earnings below the threshold level at £109,000 and retains the full £40,000 annual allowance.

Consultant B has earnings above the threshold level at £120,000 and has the pension growth added to his/her taxable earnings which gives rise to ‘earnings’ of £195,000 for the purpose of annual allowance tapering.

As a result, Consultant B has an annual allowance of just £17,500. It’s a big difference in the potential tax charged for exceeding the annual allowance for a relatively modest difference in private practice earnings.

When it comes to the annual allowance calculations, it is all about the numbers.

To allow for spikes in growth, a system is in place to look back three years and, in years where the annual allowance is not exceeded, the unused relief can often extinguish excess pension growth.

But with the onset of annual allowance tapering, this will affect consultants who are tapered to perhaps get them off the hook in one or possibly two years only. Once the unused relief is no longer available, the tax charges bite.

Whom does this affect?

The simple answer is everyone. But the degree of exposure to a tax charge can vary significantly as the initial example highlighted, and those circumstances of colleagues on similar NHS pay having very different circumstances, are common.

More than ever, it has become increasingly important that consultants engage with their accountant to understand their position.

If you have historically left your tax affairs until later in the year, this is a good opportunity of getting into the habit of submitting everything early to ensure you have the maximum time possible to save for any unexpected tax charges.

How is the tax paid?

When the rules around how much you can save into a pension

It’s a big difference in the potential tax charged for exceeding the annual allowance for a relatively modest difference in private practice earnings

changed a few years ago, the concept of the pension scheme paying any tax due and deducting this from your ultimate pension was introduced.

This worked well for those who struggled to pay annual allowances charges. But unfortunately, NHS Pensions has repeatedly refused to allow its members to pay tax charges where they arise from annual allowance tapering. This means they will only pay tax arising on the excess over the headline £40,000 annual allowance limit, potentially leaving the tax due on as much as £30,000 to pay through the normal selfassessment tax system.

The calculations of who pays what can be complicated, but this policy is why many consultants have an unexpected tax liability that they have to pay personally through the self-assessment system.

Where an annual allowance charge is included on a taxpayer’s return, it also increases the payments on account for the next year – adding a further sting in the tail.

For those who work in Scotland, the Scottish Public Pensions Agency has listened to its members’ concerns and has changed its policy to allow the pension scheme to pay any due if a member wants to use that method.

For those consultants working for a university, or eligible for the university superannuation scheme, a new policy has been introduced. This allows members to restrict the level of their earnings for superannuation purposes to help manage their pension growth.

At the time of writing, NHS Pensions has given no indication

of a change in policy, so pressure from the members and bodies representing doctors may be the only option.

Where the tax is paid through a pension scheme or pensionable earnings are restricted, it is important to note that your pension will be lower on retirement and therefore your independent financial adviser should be involved in your decision-making to ensure your retirement planning is still on track.

Risk factors

It is easy to demonstrate situations where a charge can arise using extreme or unlikely circumstances.

However, the following are reallife risk factors for high pension growth, which most consultants are likely to experience periodically:

 An increase in your pay due to an increment;

 An increase in your pay due to a CEA;

 Back payment across tax years of a superannuable pay rise;

 Moving from part-time to fulltime – first ten programmed activities are superannuable;

 No longer having a car under the NHS fleet scheme, thereby ending salary sacrifice;

 Your HR department supplying the wrong information;

 Your total reward statement details being unavailable, which could indicate errors;

 General errors in your record;

 Inflation factors.

As mentioned previously, running alongside the above which can create high levels of pension

growth is your overall level of earnings which will determine how much pension annual allowance you will have for a specific tax year.

Steps to consider

As highlighted, there are a significant number of variables that could lead to an unexpected tax charge.

You should discuss matters with your accountant and independent financial adviser (IFA) to understand your position in more detail.

Often, tax planning can be undertaken to help mitigate the effect of the above. But if you are going to be subject to additional tax liabilities, it is best to know as soon as practical, so supplying your accounting and tax information to your accountant as early as possible after the tax year end is more important than ever.

For some, consideration of continued membership in the NHS Pension Scheme is a reality, but this is a significant step and should only be made after comprehensive assessment of your circumstances by an IFA.

The tapering of the pension annual allowance appears to be here to stay, so engaging with your accountant and independent financial adviser at the earliest opportunity is the best way to understand and help manage your annual allowance position.

 Next month: Strength in numbers – working with other consultants

Ian Tongue is a partner with Sandison Easson accountants

docToR on ThE RoAd: RAnGE RovER vELAR

Off-roader that’s a luxurious cruiser

Our nice car review fella Dr Tony Rimmer (above) meets the oh-so-nice Velar

T HERE IS no denying there is a degree of professional competition among independent practitioners.

A clinic’s or specialist’s reputation can influence client flow and ultimately the bottom line. Reputations can be earned, but there is also a benefit to being associated with an historically established medical brand.

In London, practitioners still vie for space in clinics located in Harley Street, named after The Lord Mayor of London of 1767 and popular with medics since the 1860s. Similarly, Liverpool has Rodney Street and other cities also have their own areas favoured by private practitioners.

In the US, the Mayo clinic, founded in 1863 by William

Mayo, has an international reputation for excellence, so any doctor associated with it will have, by default, an enhanced image.

So what has this got to do with cars? Well, you would be surprised by the amount of time and money spent by car-makers choosing the name of a significant new model.

Global audience

The moniker has to reflect the brand image, appeal to a global audience and ideally have some historical relevance. Just think of the Skoda Superb Laurin & Klement model or the Maybach division of Mercedes Benz.

Hence, when Range Rover was planning a new stylish mid-range model, it decided to name it after the 26 secret development vehicles

Looking more like a concept car than a production car, Jaguar Land Rover has managed to produce an almost futuristic SUV both inside and out

that were built prior to the launch of the original Range Rover in 1970 and were badged ‘Velar’ – after the Latin ‘to veil’ or ‘to cover’.

This mid-sized SUV sits between the Evoque and the Range Rover Sport, but is much more a fullsized Range Rover than the hatchback sized Evoque.

Looking more like a concept car than a production car, Jaguar Land Rover has managed to produce an almost futuristic SUV both inside and out.

Minimalist driver controls and a clean fascia that is dominated by two ten-inch high-definition Touch Pro Duo screens is only challenged by Tesla’s A4 sized touchpad screen for production car modernity.

Externally, a low coupé-like

roofline and a tapered rear overhang give the Velar a really dynamic and classy look. Impressive attention to detail includes flush-fitting door handles: lovely to use and, again, a feature only shared by Teslas.

Light metallic colours work best, particularly with a dark contrasting roof and the new car makes the current full-sized Range Rovers look dated.

Inside, there is much more space than an Evoque and you can carry five adults without cramping any of them. Boot space is a bit bigger than a Porsche Macan and on par with the Jaguar F-Pace.

Massaging function

Trim materials are first class; you feel pampered by your surroundings. The seats are comfortable and, although I initially thought them to be a gimmick, the massaging function on the front seats work really well on a long trip.

There are six engine options for the Velar: two four-cylinder 2-litre diesels, a 2-litre petrol, a 3-litre V6 diesel and two 3-litre V6 petrols. Top of the range is the supercharged P380 and trim levels are the familiar Range Rover S, SE, HSE and R-dynamic.

My test car was an HSE with the 240bhp 2-litre diesel engine. Initial fears that a 2-litre four-cylinder engine would not provide enough grunt for a car of this size were quickly dispatched when out on the road.

Yes, the unit seems to rev hard when accelerating but it never feels strained and, once at a cruise, settles to allow smooth and quiet progress. Start-up and low speed diesel roughness – as

well as current diesel ‘guilt’ –would be cancelled out by choosing the 2-litre P250 petrol engine.

Like Volvo’s XC90, it proves that modern and efficient fourcylinder engines are all we really need in most circumstances, even in big SUVs.

Luxurious cruiser

Out on the road, there is still no hiding from the fact that this is a near two-tonne 4x4 SUV. The eight-speed automatic box makes best use of the available power, the steering is pretty direct and the Velar swoops through corners with aplomb. It is, however, not a sports car.

It is a luxurious cruiser and the ride, helped by the air-suspension on this HSE model, is as good as any limousine. If you want a sporty handling SUV, you will still need to knock on Porsche’s door. On the other hand, it goes without saying that if you want to go off-roading, then the Velar will tackle all challenges with typical Range Rover aplomb.

The Velar is an interesting addition to the Range Rover stable. I am not quite sure why JLR did not just use it to replace the Range Rover Sport, but I expect its vision of global markets has a lot to do with it.

Its relevance for independent practitioners? Well, it is an expensive car, but if you do work in Harley Street and were considering a full-sized Range Rover Sport, you may do better with the new more up-to-date and elegant Velar. 

Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey

Range

The Velar is an interesting addition to the

Body: Five-seat five-door SUV engine: 2.0 litre four-cylinder turbo diesel Power: 240bhp

Torque: 500nm acceleration: 0-60mph in 6.8 secs

Top speed: 135mph

Claimed fuel economy: Combined 48.7mpg on-the-road price: £64,160

The front seats contain massaging panels, which are great for long trips

Range Rover stable

RoVeR VeLaR hSe D240

The flush-fitting door handles are a neat feature shared only by Teslas

Boot space is bigger than a Porsche Macan and on par with a Jaguar F-Pace

All you need to know about accountancy for private practitioners

It’s costing them dear

Our unique benchmarking series finds consultant urologists suffering from double-digit growth in their expenses. Ray Stanbridge reports

In Independent Practitioner

Today last April, we reported that ‘income prospects for urologists look good, given a healthy profit rise’.

Well, there have been good gross income increases for many urologists in private practice between 2015 and 2016, but costs have shown a significant increase. As a result, profits have shown a smaller rise than one might have expected.

Our figures show that private practice income rose, on average, by about 4.4% between 2015 and

2016, from £135,000 to £141,000.

Costs have risen by a surprising 10.4% on average, going up from £48,000 and £53,000.

As a result, profits have grown by only 1.1% from £87,000 to £88,000.

Buoyant incomes

t he market seems to be quite buoyant for urologists in private practice. Insurance company fees have been restrictive and many are working harder to earn the same income.

But some incomes have been

aveRage INCOMe aND eXPeNDITURe OF a CONSULTaNT UROLOgIST WITH aN eSTaBLISHeD PRIvaTe PRaCTICe

boosted by Choose and Book work, particularly out of London.

t his year, it has been cost increases which have been of most interest. Medical supplies/ assistants’ fees seem to have risen slightly, for no obvious reason.

Staff costs continue to show an increase. As we have indicated, there is a correlation between the personal allowance and family member salaries. In addition, some consultants now offer their family employees pensions or other benefits in kind.

competition watchdog rules

We are seeing increases in costs of consulting room hire. t his is almost certainly attributable to the impact of the Competition and Markets Authority (CMA) rulings, meaning that hospitals and providers now need to charge market rentals to their consultants.

Our view is that general market prospects for most urologists continue to be good, despite insurance company fee squeezes

Expenditure

After a period of growth, on average, professional indemnity/ insurance costs have stabilised –in some cases they have actually shown a fall.

there are a number of new providers in the market offering competitive rates against traditional providers. We shall have to wait to determine whether the cover is equivalent.

Most costs broadly remain the same with the exception of ‘other’, which is mainly marketing. Most successful urology practices now spend an increasing sum on professional marketing.

What then of the future? We are seeing an increase in the number of highly entrepreneurial urologists looking to develop their incomes through partnerships with hospitals, acquiring equipment, providing education/training services and consultancy to any firm and others.

non-clinical income is becoming increasingly important to a number of consultants. We expect this trend to continue.

Our view is that general market prospects for most urologists continue to be good, despite insur -

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd.

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ance company fee squeezes. Costs are, however, continuing to rise, although we believe it may not be as high next year as this last year.

In previous commentaries we have reported on the increasing difficulties of obtaining reliable analysis from year to year.

We also cannot stress strongly enough that our analysis is not

statistically significant – and only represents an indicative average of what is happening in a typical private urologist’s practice.

Joining groups

We have reported that an increasing number of urologists are looking to join groups. Others have chosen to incorporate. Yet others

have decided, primarily in the country, to specialise in Choose and Book work where there are fewer costs.

We are also seeing the effect of the insurance company ‘open referral’ policies coming through in a real long-term squeeze on fees.

All of these facts mean it is very difficult to compare figures on a year-to-year basis, as the market is constantly changing.

Our sample of consultant urologists is restricted to those who:

 Have either had on old-style or new-style contract;

 Have been in practice for at least five years;

 Have been earning at least £5,000 a year from private practice;

 May be trading as sole practitioners or as a member of a group;

 May or may not have incorporated;

 Will continue to do at least some n HS work, meaning that they are not in full-time private practice.

 Next month: Anaesthetists

Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates

How ARE YoU doiNg?

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now See what’S in oUr MaY iSSUe: no. 101

Make sure you don’t miss our next issue, published on 17 May. you may not receive every issue if you have not yet subscribed to the journal. Don’t risk missing out on vital topics we tackle next time:

 How the measurement of outcomes is transforming private practice and how this affects your work as an independent practitioner. Dr Tim Williams, founder and chief executive of MyClinicalOutcomes.com, answers questions posed by Independent Practitioner Today

 an employed private consultant versus a self-employed private consultant. What’s best? accountant Ray Stanbridge assesses an increasing dilemma

 The rise of the general practitioner in the private practice income stakes

 It’s the turn of private patient units in the northern Home Counties to come under Philip Housden’s financial spotlight

 Building plans for your practice or home? earlsmarch founder and managing director Philip Mcquillen sets out ten tips to build the best working relationship with your architect and make things go smoothly

 Some important legal considerations on private premises, rooms, leases and ownership

 Still not done anything about general Data Protection Regulation (gDPR)? Check out Jane Braithwaite’s very practical guide for independent practitioners and their managers

 How to handle a partner’s retirement

 The Uk is a popular destination for international patients seeking expert private healthcare. Dr Rachel Birch, medico-legal adviser at Medical Protection, outlines steps to minimising the risks in treating patients whose first language is not english

 News from the BMa’s private practice and expert witness conferences

 anaesthetists’ private earnings, expenses and profits come under the microscope in our Profits Focus benchmarking series

 Doctor On The Road columnist Dr Tony Rimmer tries out the audi RS range

 Business Dilemmas answers doctors and patients’ issues with the Driver and vehicle Licensing authority

 Is there an investment gender gap?

 Plus all the latest news and views

aDveRTISeRS: The deadline for booking advertising for our May issue falls on 20 april

Ipt

Published by The Independent Practitioner Ltd. Independent Practitioner Today is editorially independent and thanks Bupa for its assistance with distribution.

Printed by Pepper Communications Ltd Material is governed by copyright. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form without permission, unless for the purposes of reference and comment. Editorial layout is the copyright of the publishers. If you wish to use it for promotional purposes on websites or for reprints, we would be happy to discuss licensing the copyright to you.

© The Independent Practitioner Ltd 2018

Registered office: 7 Lindum Terrace, Lincoln LN2 5RP

Write to Independent Practitioner Today PO Box 198, Cranleigh GU6 9BB

eDITORIaL INqUIRIeS

Robin Stride, editorial director

Email: robin@ip-today.co.uk Tel: 07909 997340

aDveRTISINg INqUIRIeS

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Email: margifloate@btinternet.com Tel: 01483 824094

Publisher Gillian Nineham Tel: 07767 353897.

Email: gill@ip-today.co.uk

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