May 2014

THE BUSINESS MAGAZINE FOR DOCTORS WITH A PRIVATE PRACTICE

Today INDEPENDENT PRACTITIONER

In this issue

Partnerships

What you should do when your line-up changes P25

Your guide to finance

So what next for private doctors’ finances? We review the state of play after a year of change P42

Bupa pushes hospitals for 15% fee cut

By Robin Stride

Bupa is to push private hospitals to cut their prices by at least 15% in the wake of the competition inquiry.

Announcing the move to consultants and GPs at the BMA’s private practice conference, the insurer vowed it would use the money saved to give insured patients better value and to grow the market ‘for the benefit of all participants’.

Bupa Health Funding managing director Dr Damien Marmion said it would chase significant reductions from hospitals found by the Competition and Markets Authority (CMA) to be charging ‘excessive’ rates and profits.

He said: ‘It is an absolute priority of ours to address this – and to secure the agreement of current and future private hospital owners for significantly lower fees.’

The amount would vary by hospital group, but in some cases the insurer wanted a 15% cut or more.

Asked how Bupa arrived at the

In association with

15% figure, a spokesman told Independent Practitioner Today: ‘This has been carefully calculated based on the relative pricing of some of our hospital providers, compared to others – for example, where some hospital operators charge significantly more than others, with no evidence of better quality or patient outcomes.’

In a lengthy speech, Dr Marmion defended policies that have angered many specialists, claiming these were needed to reverse the decline in the market. But he argued that the results showed greater retention of customers and were attracting new corporate clients.

He admitted relationships between doctors and insurers were ‘badly strained and in serious need of repair’, but he and other key speakers called for all parties to now work together to resolve issues.

Responding later to the ‘15% plan’, BMA private practice committee chairman Mr Derek Machin questioned if hospitals would try

and recoup losses by charging other insurers more. He said hospitals might cut back on their staff as a result of having to find 15% efficiencies and that would be a safety issue.

At the main event, The Federation of Independent Practitioner Organisations (FIPO) criticised the CMA for not taking account of private medical insurers’ (PMIs) ‘overwhelming powers’ nor the paradox of fixed fees imposed by insurers on clinicians in what it said should be a competitive market.

Chairman Mr Geoffrey Glazer warned that, with insurers’ power unchallenged, the UK private health care sector would go the way of the US.

He said: ‘Instead of having a private healthcare system that provides care management, we are going to have one where care is managed by the PMI providers restricting cover, benefits and choice. And that is a disaster we are about to sleep­walk in to.’

FIPO supported the CMA’s call for doctors’ fee estimates, quality

outcomes data and banning unethical incentives to clinicians.

But he believed consultants’ transparency should be matched by insurers, who he claimed failed to clearly explain policies and what they covered.

Mr Glazer argued that fees were fixed by insurers, making a nonsense of the inquiry’s requirement for consultants to publish consultation and standard procedure fees to patients.

He called the proposed system of monitoring ‘very bureaucratic’ and said the CMA had ignored the fact there was unlikely to be any financial or clinical benefits for patients through the proposed hospital selloffs.

Mr Glazer also claimed there was no evidence that any resulting small savings would make private medical insurance cheaper.

Some doctors in the audience expressed further criticism of Bupa, but Mr Machin observed: ‘We either work together or we hang together.’

➱ continued on page 3

SUPER-DOC: Dr Kate Hersov is a private doctor with a comic business. Read all about it on p22

May 2014

www.independent-practitioner-today.co.uk

nHs could be the winner perhaps the competition inquiry could be a boon for nHS private patients units? P12

doctors whose idea made a kersploosh an entrepreneurial duo publish medical comic books to educate children P22

How to create your own surgical clinic

Want to realise your vision of a surgical clinic designed to your own ideals? P28

an uneven playing field for inspection new cQc fees show the uneven playing field between private sector and nHS P36

when others ask to see medical notes

Some timely medico-legal advice to deal with an increasing demand on doctors P38

a private doctor’s guide to finance

We review the state of play in the fiscal world after a year of changes P42

Plus our regular columns

Business Dilemmas: ethical conundrums answered P46

Doctor on the road: BMW X5 P50

Profits Focus: dermatology and oncology P52

ediTorial commenT

Inspection fees like toothache

The author of Independent Practitioner Today ’s guide to CQC registration highlights a number of areas this month that have been bugging private doctors for a long while (see p36).

It hurts many to have to pay anything at all to the watchdog, but when the fees are blatantly unfair on independent practitioners, then they are understandably seriously miffed.

High-running feelings on this subject were clearly displayed at this year’s Independent Doctors Federation meeting.

As if they did not have to pay enough for the annual round of registrations and certifications,

private doctors are being forced to cough up more than their NHS GP counterparts. To cap it all, dentists have got away with no fee rise this year.

As Martha Walker points out, not only is there an inexplicable difference in annual fees but the categories of classification are also puzzling.

It’s a shame then that only 111 independent providers responded to a recent CQC fees consultation paper.

The CQC wants to listen and take on board your comments. So start talking to get fairer treatment – and do let us know what you tell them.

Tell us your news Editorial director Robin Stride at robin@ip-today.co.uk

Phone: 07909 997340 @robinstride

To adverTise Contact advertising manager Margaret Floate at margifloate@btinternet.com Phone: 01483 824094

To subscribe lisa@marketingcentre.co.uk Phone 01752 312140

Publisher: Gillian Nineham at gill@ip-today.co.uk Phone: 07767 353897

Head of design: Jonathan Anstee chief sub-editor: Vincent Dawe

Circulation figures verified by the Audit Bureau of Circulations

Pension limit cut plan would harm doctors

by leslie berry

A Government think-tank has sparked fears that doctors could lose thousands of pounds under a new pensions shake-up.

It called for the tax-free lump sum payable upon retirement to be removed and said there should be a reduction in tax relief for higher-rate taxpayers.

The Centre for Policy Studies’ report, Retirement Savings Incentives, urged the Government to scrap the tax-free lump sum and replace current tax relief levels on pensions with a 33% flat rate for all savers.

While this move would benefit basic-rate taxpayers who now receive only 20%, senior doctors are among those who will face a substantial cut from their present tax relief of up to 45%.

The report also suggested ISA and pension savings should share an annual combined contribution of just £30,000, compared with the current joint allowances of £55,000 – just one month since the Chancellor announced the

ISA annual contribution limit would rise to £15,000.

These proposals come after pensions minister Steve Webb recommended reducing the tax relief limit to a flat 30%, stating he ‘would like to see the benefits of pensions tax relief spread much more evenly’. And he would also like to remove the lifetime allowance limit.

Simon Bruce, managing director of specialist financial planners Cavendish Medical, said: ‘After the good news for pensions revealed in the Budget, it is disappointing that speculation is already mounting as to the next round of changes and cuts that higher taxpayers might face.

‘However, it remains to be seen whether these proposals will become reality; removing the taxfree lump sum would be a bold move for any politician so close to the general election.’

 Mr Webb also suggested providing savers with an estimate of life expectancy based on health factors and place of residence to help with later-life financial planning.

Bid to promote Harley Street

Plans to develop two imaginative new initiatives to promote the ‘Harley Street’ and the ‘London’ brand to overseas patients have taken a step forward with a further meeting for interested parties.

Twenty representatives of leading medical businesses in the area met for follow-up talks this month following a sell-out summit meeting in March which created support for the project.

Summit organiser Keith Pollard of Intuition Communication Ltd said there had been strong support for an opportunity to discuss the way forward and share ideas.

He told Independent Practitioner Today: ‘We have another meeting scheduled for June in partnership with Healthcare UK which will discuss a joint initiative to develop, brand and promote London and UK private patient units.

‘And we have held one-to-one follow-up meetings with a couple of businesses who may help us to drive things forward.’

The initiative aims to combat growing overseas competition around the world which is hijacking thousands of potential patients who might otherwise come to see consultants in the UK.

Queen’s award for HCA

by charles King

The hospital group fighting the competition inquiry’s attempt to force it to sell off two of its London hospitals has hit back by winning the Queen’s Award for Enterprise in International Trade – for a third time.

One of the highest awards for British business goes again to HCA for outstanding achievement in investment and growth of overseas business.

The company was recognised for continuous overseas sales growth.

Over the last six years, it increased overseas turnover from 26% to 35% of total turnover. In the same period, the group has more than quadrupled its employees.

The Queen’s Award also recognises companies’ investments in innovation, and HCA was praised by the organisation for major investment in new equipment and technologies totalling over £500m in the last ten years.

tremendous achievement and testament to the expertise and dedication of the leading consultants and specialist teams across HCA’s network of hospitals.

HCA president and chief executive Michael Neeb said: ‘To win this award for the third time is a

‘Our ongoing investment in the latest technology and medical research combined with the capabilities of our highly experienced medical teams make a sizable contribution to the reputation of London as a centre of medical excellence.’

He said HCA’s hospitals were privileged to have ‘some of the

most distinguished consultants and physicians in the world’ and many patients travelled to London to access their skills.

HCA was often competing in a global healthcare market, facing alternatives including Germany, the US and Singapore.

Mr Neeb added: ‘Our hospital group strives to provide not only the best treatment and outcomes, but also the best overall service for patients, in the knowledge that it must maintain the highest standards and best quality of care every day of the year.’

Spire declines to scotch sell-off rumours

Hundreds of independent practitioners working in Spire Healthcare’s 38 private hospitals were unclear as we went to press about future plans for the company.

Over the last few weeks consultants have been hearing rumours of possible buyers for the group, but parent company Cinven declined the chance to comment on a possible sell-off.

A spokeswoman would only tell Independent Practitioner Today: ‘I’m

Inquiry

is a wake-up call

➱ continued from front page

The boss of the biggest private hospital group issued a rallying call at the private practice conference. BMI Healthcare group chief executive Stephen Collier said later he was ‘very encouraged’ by the high level of agreement at the main meeting on many of the issues facing the sector. ‘There is more than one issue. We need to sort them all out together.’

He told doctors the competition inquiry had held a mirror up to the sector, delivering a ‘wake-up call’ over how private healthcare operated. There was now a clear opportunity to co-operate for improvement and growth.

afraid that we cannot comment on the recent media speculation on the sale of Spire Hospitals.’

Spire Healthcare had been expecting to have to sell some of its hospitals as a result of the competition inquiry into private healthcare. But, before the final report last month, it knew it had escaped this threat, saying it welcomed recognition it was not anticompetitive.

Referring in our February issue

Mr Collier said: ‘We’ve got to be more open as to who we are, what we do and why we are better.’

At a later session, Bupa medical director Dr Annabel Bentley said she wanted to listen to consultants’ concerns and work with them to make it easier to do business with the insurer.

There were now seven different ways to bill online, the insurer’s Consultant and Facilities Finder website would be enhanced with more marketing and promotion, plus help with appraisal and access to patients’ feedback.

But she said she recognised there was a lack of trust between some consultants and insurers –displayed at the conference – and Bupa aimed to tackle this.

She hoped consultants would give feedback and suggest ways to raise quality and reduce costs.

to the possible enforced sale of hospitals owned by other operators, it said: ‘If a hospital came up for sale, we would consider it carefully as an integral part of our long-term strategy.’

Then, in April, it said: ‘With the conclusion of this period of regulatory instability behind us, we believe the outlook for UK private healthcare and Spire in particular is encouraging. As a sign of our continuing commitment to the

private healthcare sector, since the start of the CMA inquiry – i.e. since April 2012 – we have invested over £100m in our hospitals.’ Senior consultants with the group have seen their hospitals change hands before. Spire was formed only seven years ago from the sale of Bupa Hospitals, for which it paid £1.44bn. The network grew with the addition of Thames Valley Hospital and ten former-Classic hospitals in 2008.

Doctors look at appealing against competition probe

The BMA and the Federation of Independent Practitioner Organisations (FIPO) are looking at the legal possibilities of an appeal over aspects of the Competition and Markets Authority (CMA) inquiry into private healthcare.

BMA private practice committee chairman Mr Derek Machin told Independent Practitioner Today that lawyers were looking to see if there were any grounds for appeal, specifically around the way in which evidence was assessed and judged, but not the findings.

He admitted: ‘This is a very technical area. It is by no means certain there is a case by any common-sense observations. But we

are not talking common sense. We are talking competition law and the rules under which the competition body was discharging its duties.’

Mr Machin expected to hear the verdict near the end of May.

He added: ‘If we feel there’s a reasonable prospect of success, we will pursue it.’

An appeal could easily cost the profession a hefty six-figure sum. Doctors’ leaders could have access to ‘hundreds of thousands of pounds’ in a defence trust, but Mr Machin said money was not the issue.

‘The issue is – have we a case with any prospect of success?’

michael neeb

Anaesthetists hit out at higher fees for surgeons

By a staff reporter

Anaesthetists claim that higher fees paid to some surgeons for operating on NHS patients in private hospitals are likely to exceed many other ‘inducements’ to consultants now being banned in the wake of the competition inquiry.

The Association of Anaesthetists of Great Britain and Ireland hit out over payments in its response to the Competition and Market Authority’s (CMA) investigation into private healthcare.

AAGBI President Dr William Harrop-Griffiths said: ‘An increasing volume of elective NHS surgery is being performed in private hospitals as a consequence of the Health and Social Care Act 2012.

‘But some groups of consultants are being paid substantially higher hourly rates for treating NHS patients in private hospitals, and we believe this acts as an inducement to bring lucrative, privatelyfunded work to those hospitals.

‘This is an abuse of public funds that adds many millions a year to NHS costs. These extra payments to consultants are likely to exceed the scale of many of the other inducements now prohibited by the CMA.’

The association, which repre -

sents nearly 11,000 anaesthetists, referred to a CMA statement that payments for treating NHS patients in private facilities should not be ‘excessive or disproportionate such that they constitute a concealed incentive for private patient referral’.

Dr Sean Tighe, chairman of its Independent Practice Committee, said: ‘We would like further clarification on how this principle will be implemented. At the moment, consultant surgeons in many private hospitals are being paid considerably higher hourly rates than other consultant groups to treat the same NHS patients.

‘Pay parity for consultants of all specialties is a fundamental principle of the NHS and these significant differentials constitute both

an inducement and a waste of badly needed NHS money.’

Anaesthetists urged the CMA to go even further to promote patient choice and encourage greater transparency from hospitals and private medical insurers.

AAGBI said this included further clarification on how the Government will prohibit the use of public funds for the payment of inducements to consultants.

It strongly supported specific measures in the report to prohibit private hospital operators from providing inducements to clinicians ‘to treat or refer patients for tests at its facilities’.

And it welcomed the inquiry’s finding that structured anaesthetists’ groups working together to provide private healthcare have no adverse effect on competition and can improve the quality and safety of patient care.

The association said it was one of the first professional associations to publish guidelines on good practice for anaesthetists providing private healthcare and was strongly committed to enhancing patient choice through transparent treatment information. It endorsed the CMA’s measures on publishing information on consultants’ fees and performance.

But it expressed disappointment that the CMA’s report did not fully address the role of private medical insurers. It had hoped to see measures to limit their market power and their moves to restrict patient choice.

The AAGBI agreed with other professional groups that insurers’ action to oblige consultants to charge only the fees set by PMIs was limiting competition.

Dr Tighe said: ‘Patients should be able to “shop around” for consultants on the basis of cost and quality. If fees are set by PMIs, there can be no cost competition and less incentive to compete on quality. If this is not addressed, the fee and information remedies will be grossly disproportionate.’

Dr Harrop-Griffiths said the association believed insurers should be forced to publish comparative tables of benefits so patients knew exactly what their policy covered. ‘They should also be stopped from dictating treatment on the grounds of maximum costs, as the treatment that each patient receives should be based on clinical decisions, not how much money the insurers are willing to pay out.’

The AAGBI said it was keen to continue working with the CMA.

Costs rise for sacking staff unfairly

Doctors’ law firm Hempsons has warned that the maximum compensation award for unfair dismissal has risen to £76,574, or 52 weeks’ gross pay, if lower.

The new awards affect those whose employment terminates on or after 6 April 2014.

The limit on a week’s pay – for statutory redundancy and basic award calculations – has increased from £450 to £464.

And the level of statutory mater-

nity/paternity pay and statutory adoption pay has gone up to £138.18 a week and statutory sick pay to £87.55 a week.

Partner Fiona McLellan said important changes to employment law would have an impact on how employers handle Employment Tribunal litigation in particular. From 6 May, individuals who wish to raise tribunal proceedings – subject to limited exceptions – must make contact with

ACAS first. ACAS must then take steps to promote a settlement.

Potential claimants have to supply basic information to ACAS to kick-start the process, specifically their name, address, phone number and details of the potential respondent, following which, for a month-long period, ACAS will endeavour to achieve a resolution with the parties.

More information and guidance can be found on the ACAS website

www.acas.org.uk/media/pdf/h/o/ Early-Conciliation-explained.pdf.

Ms McLellan said Employment Tribunals can now, in claims issued after 6 April 2014, issue an unsuccessful employer with a financial penalty in circumstances where there have been one or more aggravating factors in the case. The maximum fine for each head of claim is 50% of the compensation awarded, subject to a maximum of £5,000.

Dr William Harrop-Griffiths

FOOD FOR THOUGHT: Complementary medicine was big on the talk menu when consultant Dr Ken Ward-Atherton was invited to attend a reception at St James’s Palace in London to meet HRH Prince Andrew Duke of York and members of the Saudi Royal Family. Dr Ward-Atherton, who holds the titles Lord of Little Witley and Hurcott, Worcestershire, discussed the clinic services he offers at Spire Liverpool Hospital, which include a range of complementary therapy interventions for diet-related health issues and a newly introduced Food Intolerance Screening service.

Spire produces hip guide

A new 63-page guide to private hip replacement tells patients what’s involved, what to consider when considering particular surgeons and hospitals and what they need to take into account

before and after the operation. It is sponsored by Spire Healthcare and is available free from www.privatehealth.co.uk/hospitaltreatment/find-a-treatment/ hip-replacement-surgery/guide.

Innovation bill is causing confusion

Considerable confusion among doctors is likely if the draft Medical Innovation Bill becomes law, a medical defence expert has warned.

Dr Michael Devlin, head of professional standards and liaison at the Medical Defence Union (MDU), claimed the proposed legislation might impede medical innovation.

This was because doctors thinking of using a new approach or procedure would have to consider the effect of the Bill, which would be an additional process.

Dr Devlin said doctors’ calls about innovation to the union’s 24-hour advice line showed doctors were not, as the law stands now, being deterred from innovating .

‘We see no need for new legislation and are happy to reassure

Forcing sale of units ‘will hurt growth’

By Charles King

Competition and Markets Authority (CMA) plans to force HCA to sell-off two of its London hospitals have been criticised by professional services consultancy Mercer.

It expressed concern over the impact of the divestiture ruling and the effect this might have on the private medical market’s ability to provide an affordable and efficient service.

The CMA’s findings, reported extensively in Independent Practitioner Today last month, aim to open the market up to greater competition.

But, according to Mercer, they may instead lead to greater industry uncertainty, ultimately stifling growth.

It said: ‘It is of concern to the consultancy that the group is being penalised for achieving such a high status within their respective clinical areas.

Naomi Saragoussi, principal in Mercer’s Employee Health and Benefits business, said: ‘Given that approximately 80% of individuals covered by private healthcare are covered as part of an employer-sponsored arrangement, encouraging individual patient choice has the potential to directly affect the dynamic of group schemes.

‘Multiple individual buying decisions may not equate to the same buying decision the employer has historically made for the scheme as a whole, in terms of hospital and consultant eligibility.’

Ms Saragoussi added: ‘It is paramount that, at a time when patients are in emotional turmoil, they are able to easily review all their options. This requires a level of transparency in the market that will prevent clinicians from charging over the typical market rate.

doctors that medical innovation should not leave them open to an increased threat of litigation, so long as they can show they acted in accordance with current legal and ethical principles governing clinical practice.’

The MDU believes the current legal position is clear. It explained that doctors considering innovative treatment need not fear litigation if they apply the following principles:

 Appropriate safeguards should be in place;

 There are good reasons for departing from accepted practice;

 The patient fully understands what is proposed and why the doctor believes it is in their best interests;

 The patient has given consent.

‘This decision, in the short term, is likely to have little impact on the market within London and the South-east other than potentially stifling growth during this period of increased uncertainty.’

Following the CMA review, consultants will be required to be more transparent around their fees, including providing patients with information in a set format made available by the healthcare facility where the consultant practices.

‘It also requires hospitals and consultants to provide details of clinical outcomes before a scheduled review in 2019.

‘We hope this investigation will lead to private medical administrators, hospital groups and clinicians working collaboratively with the patient to achieve better outcomes.’

Mercer welcomed other decisions made by the CMA, but said any differences between hospital groups, private medical administrators and clinicians needed resolving in a practical fashion.

Rebuild for Cambridge hospital

Building has begun on a new Nuffield Health Cambridge Hospital. When completed, it will replace the existing hospital on the same site, which aims to stay open throughout the work.

Maxine Estop, director of the unit in the city’s Trumpinton Road, said the hospital aimed to give over much of the space for green surroundings, but have as much car parking available as before.

Dentists’ group security

By Leslie Berry

Private dentists have been boosting their incomes in tougher times by taking a leaf from independent practitioners’ books and forming groups.

Dentists have been struggling to maintain private revenues during the recent economic downturn, but joining a group has given many a financial lifeline, according to a new report from healthcare analysts LaingBuisson.

t he recession meant many patients attended less frequently, or looked to access subsidised NHS care, leading to a private dentistry contraction of more than a fifth (22%) in real terms since 2009-10.

But the report says most dentistry groups have displayed good growth despite market contraction. And many more new groups have emerged in a new corporate

landscape with different target markets, though most are small and in early stages of development.

Groups of three or more practices now represent as many as 6,950 dentists in the uK.

Meanwhile LaingBuisson expects private dentistry to get a lift from positive stable economic growth over the next four or five years, but believes that changing patient dynamics could transform private dentistry in the long term.

It says market power will inevitably moves further towards patients as dentistry providers ‘compete more actively to attract private customers on price, convenience, and loyalty’.

Report author, economist Philip Blackburn, said: ‘ t he biggest game-changer is the drive towards consumerism as dentists and dentistry groups compete to attract private customers, as the private

Nuffield joins registry to help knee op results

Nuffield Health has announced it will encourage all consultants to participate in the first registry of its kind – the u K’s National Ligament Register (NLR).

t he registry will allow providers, for the first time, to collect and analyse data about anterior cruciate ligament surgery (ACL), allowing surgeons to identify trends, track new developments and identify the best-practice techniques.

t he NLR, initiated with the agreement of the British Association for Surgery of the Knee, the British o rthopaedic Sports trauma and Arthroscopy Association and the British orthopaedic Association, has been developed by a group of surgeons with the aim of having doctors manage the data they input.

Nuffield Health’s medical director Mr Geoff Graham said: ‘ t he purpose, as with any registry, is to increase and enhance the quality

of care we are able to offer our patients and therefore we will be encouraging all Nuffield Health surgeons to get involved.

‘ o ver the next few years, the audit will allow us to identify best practice in surgery, provide better quality data to patients about the types of procedures which will provide the most benefit to them, and also whittle out those procedures that are perhaps not providing the best results.

‘Long term, the benefit to our patients will be significant and I hope, on this basis, that all providers and surgeons from both NHS and the private sector will get on board.’

to take part, surgeons need to register both their own details and the details of their secretary or assistant responsible for booking patients. See the NLR website www.uknlr.co.uk, which also provides information to patients on ACL injury and rehabilitation.

dentistry pie is smaller than it was and dentist supply is greater than it’s ever been.

‘Changes are already happening, as a number of dentistry groups provide services from retail outlets with ambitious expansion planned around customer convenience, and there is a stronger industry focus on customer benefits, including keener pricing, value for money, loyalty rewards and the highest-quality experience.

‘In turn, movement towards consumerism and a retail environment for dentistry providers is expected to energise growth.’

on NHS dentistry, Mr Blackburn added: ‘the Government has its work cut out to deliver wider NHS access and clear improvements in oral health without any significant real spending increases going forward. As a central purchaser,

NEW RECRUIT FOR WIMPOLE CLINIC

Holistic GP Dr Sohère Roked has joined the Marion Gluck Clinic, the bio-identical hormone therapy clinic based on Wimpole Street, London. She said: ‘Dr Marion Gluck is one of the UK’s top 250 private doctors. To work with her and bring my holistic approach to this prestigious practice is another landmark moment in my career.’

Dr Roked also has a clinic at the Therapease outlet near Cardiff city centre, specialising in health and wellbeing.

NHS England is looking to generate commissioning efficiencies, and the new dentistry contract –which could be rolled out in 2016 or 2017, focused on a prevention care pathway – is being introduced to deliver net pay-offs in the long term.

‘While these may be achievable on paper, there remains an underlying scepticism that any model based on more patient time with a dentist also means more money must be spent. And, at the moment, the NHS’s primary care dentistry budget doesn’t support this.’

 Dentistry UK Market Report –fourth edition (2014). Price: £825 for the hard copy and £1,185 for the digital package (hard copy, PDF and Excel files) from LaingBuisson. Phone: 020 7833 9123. Website: www.laingbuison. co.uk

Pop-up theatre allows hospital to be flexible

Consultants at Spire Liverpool Hospital will continue working in a mobile surgical unit, brought in to increase capacity, until next May. the temporary operating theatre from Vanguard Healthcare is linked to the hospital building via a corridor and has been used since october 2011.

Hospital director Alison Peake said: ‘the mobile theatre has supported our ability to deliver specialist surgical services. Having an extra ultra-clean-air theatre means we can increase our capacity for putting in joint replacements and artificial material into patients, minimising the risk of infection.’ Vanguard’s chief executive Ian Gillespie said the ‘pop-up hospital’ service was flexible and could be used from days to years. ‘Private hospitals sometimes use our facilities to assess the feasibility of building a more permanent solution while business case approval is sought.’

interview with new iDf presiDent

The submariner looking for subs

The new president and chairman of the Independent Doctors Federation is pushing for a membership boom. Robin Stride reports

So juSt where is the Independent Doctors Federation going?

‘From strength to strength,’ says its new president and chairman, Dr Peter King-Lewis.

With the NHS finding itself ‘more and more strapped’ to provide what people want and expect, he sees a big future for private practice in the u K and his organisation.

What turned out to be his future as a private GP, though, was an unexpected career move. today he practises at the King-Lewis Family Practice in Chelsea Consulting Rooms in Lower Sloane Street.

But, back in his 20s, it looked like he would be spending a lifetime working under water as a submariner. He only started in medicine at the age of 29 after spending ten years in the Navy as a navigator and diver.

When he left he got a place at Bart’s and constructed his own GP training scheme. Psychiatry became a special interest and he then trained in the specialty as a registrar at the Priory, Roehampton – which he loved.

Soon he met private GP and a former IDF chairman, Dr Martin Scurr, at an IDF meeting – the ‘F’ stood for Forum in those days –and joined a weekend rota of private GPs before starting up in private practice in the mid-90s.

When Dr King-Lewis surfaced as an independent practitioner, he started out in a flat ‘with a desk, couch, chair and phone’. He

recalls: ‘As the removal men were going downstairs, my first patient was coming upstairs. She was a model on the front page of Harpers & Queen and had been referred to me by Martin Scurr.’

He built up the practice, doing ‘hotel work’, as much on-call as he could and ‘living by the crumbs that fell from other people’s tables’. Word-ofmouth proved a valuable ally.

Right now he is looking for ‘a bright young entrant’ with a view to partnership who will possibly ultimately take over the practice when he retires.

He advises anyone starting out: ‘Get to know as many people as you can. Let them know what you want to do and find out from them how you ought to be going about it. And enjoy it!’

founding father

Dr King-Lewis joined the IDF not long after he became a private GP, having attended a talk at the Cromwell Hospital on ‘the joy of private practice’ by IDF ‘founding father’ Dr Stuart Sanders.

‘He was so inspiring – and loved what he was doing. that’s when I made the decision.’ o ther IDF members gave him good support too.

that was back in 1994. two decades on and the ‘joy of the private GP’ is still clearly a long-term condition. He says: ‘I still walk in here most mornings thinking “I’m the

luckiest bloke alive”. I love the people I look after and work with.’ this year sees the federation celebrating its silver jubilee with a fast-growing membership now at a record high. With nearly 1,200 members, it saw a 4% increase last year: 36% work outside London, 32% are under 50, and 25% are GPs.

t he IDF will have to update its website’s record of membership strength even faster in future if Dr King-Lewis gets his way.

inclusive philosophy

In the old days, he says, the body was exclusive and for doctors in purely private practice. Now it is ‘inclusive’ and he hopes his term will see any doctor who has any significant private practice joining up. ‘the larger the army, the louder the voice.’ that takes us back to where the IDF is going. It is not a trade union and while it can give members advice, he explains that it does not have the resources to take on doctors’ individual battles.

But it has to be a reactive organisation, he says, and there are important roles to develop in education, conferences and breakfast meetings. It is hoped to have more gatherings outside of London in the future.

He also hopes the IDF will have open and co-operative dialogue

with hospitals and insurers. one of the difficulties in the past, he believes, is that insurers’ representatives keep changing, but he is looking forward to a series of meetings in the near future.

t he issue of whether consultants in private practice would become employees of private hospitals over the next few years was raised at the federation’s annual meeting in March.

Does he think this is likely? Dr King-Lewis says: ‘there’s a danger they could be and that would be a great loss. they would lose their independence.’

talking of the current initiative in London to do more to promote Harley Street and the capital to patients overseas ( Independent Practitioner Today , February and April 2014), he thinks it is something to broadly welcome ‘as long as it brings the focus onto the excellence of private practice in the uK and shows its ability’.

Mention of Harley Street reminds him of an old consultant colleague who once warned him: ‘You have to remember, old boy, Harley Street is an address, not a qualification.’

Dr King-Lewis says he has passionately believed in the IDF from the first day he joined.

Now in his new role, he is ‘just thrilled at having a chance to help it to grow and evolve in an ever rapidly changing world of medicine – and to help it promote excellence in the independent medical sector’. 

Dr Peter King-Lewis, new IDF chief

Dr Martin Scurr

competition inquiry

Watchdog remedy is hard to swallow

Keith Biddlestone (right), group commercial director at HCA International, spells out why the Competition and Markets Authority’s remedies – good and bad – will matter to consultants

Following the Competition and Markets Authority (CMA) publishing its final ‘remedies’ at the end of its investigation into the l ondon private healthcare market, it’s easy to see why healthcare providers like hCA are concerned.

As readers of Independent Practitioner Today will know, hCA has strong concerns about the analysis of the competition authorities, particularly relating to the logic of forcing the divestment of hospitals, and we’re unsurprised to see the analysis has faltered under scrutiny throughout the investigation.

however, there are also ‘behavioural’ remedies that the CMA is proposing. here are the top reasons why i believe the remedies matter to consultants as well as to hospital groups:

First, the CMA is shaking up the use and transparency of quality data in the private sector, for both doctors and hospitals.

Specifically, quality data will be collected in a way that is comparable to the nhS and will be made public from April 2017 onwards. the intention is for patients to be able to see doctors’ outcome metrics, not just for their private practice but for their whole specialty.

Also, in the future, there will be much clearer comparisons between private hospitals, allowing doctors and patients alike to make informed decisions on where to treat and be treated.

Second, there will be the introduction of oPCS coding and man­

datory capture of the patient’s nhS number when they register with private hospitals.

t hat means a patient’s treatment will be able to be tracked for the entire episode, allowing for meaningful outcome measurements and continuity.

third, the CMA has introduced a requirement – from the end of 2016 onwards – for consultants to publish their outpatient fees on a central website.

o nce a diagnosis has been made, consultants will need to give patients a range of fees for subsequent treatment as well.

Limited clinical input

Many doctors and hospital groups repeatedly asked the CMA to investigate the insurers and their obliga tions. i t’s disappointing and nonsensical that the CMA excluded insurers from their inquiry rem edies.

Fourth, it’s worth noting that, frustrat ingly, the CMA sought limited clin ical input during the inquiry despite hundreds of doctors proactively writ ing to them to offer their views.

Fifth, on a less controversial note, the

CMA has quite rightly regulated against payments by hospitals to consultants that are based on volume of patients treated at those hospitals.

hospitals and consultants will instead be required to disclose any financial interest that the consultant has in a facility, and any fees paid to them by the facility beyond a diminimishing threshold.

Moreover, the CMA has set a cap of 5% for the maximum equity stake a doctor can have in any healthcare facility. this, too, must be disclosed.

Sixth, to make a lot of this happen, there will be a new ‘ i nformrganisation’ to ome the main source of independently validated inform ation on ity and activity. CA supports the idea that the Private healthcare nformation network (P hin ) is proposed as that

The Shard: HCA still plans to go ahead with the expansion of its London Bridge Hospital into this iconic skyscraper

The CMA sought limited clinical input during the inquiry despite hundreds of doctors proactively writing to them to offer their views

i nformation o rganisation, with membership spanning all private hospitals – including cosmetics clinics and nh S private patient units – insurers and consultants.

So, the remedies undoubtedly have implications for consultants over the coming years. h CA remains concerned that with lim ited clinical input into the inquiry, the CMA has fundamen tally misunderstood elements of the market such as the power of insurers.

we will be vigorously appealing the divestment remedy proposed on the basis that the CMA’s main allegation against hCA appears to be that we are too successful, too efficient and too innovative.

l eaving the CMA aside, h CA has big plans. in the past decade, we’ve invested over £500m in new and existing hospitals and infrastructure and we have plans for £300m more investment over the next five years.

As always, we are looking to work with our consultants to deliver world­class care through our network of hospitals.

Consultants are a vital part of our network, and the world­class care delivered at hCA is only possible due to those doctors who practise within it.

we are at a crossroads in the evolution of our sector, with a number of big changes proposed: some good, some bad.

Ultimately, we should nurse what’s good about the CMA’s remedies, while getting rid of what’s bad. n

Make sure nobody is left behind

Help prevent shingles disrupting your patients’ lives. There is a 1 in 4 chance of people developing shingles during their lifetime.1 You can help protect eligible patients who were aged 70 and 79 on the 1st September 2013 by vaccinating them under the national shingles immunisation programme.2

ABRIDGED PRESCRIBING INFORMATION

ZOSTAVAX® powder and solvent for suspension for injection in a pre-filled syringe [shingles (herpes zoster) vaccine (live)] Refer to Summary of Product Characteristics for full product information. Presentation: Vial containing a lyophilised preparation of live attenuated varicella-zoster virus (Oka/Merck strain) and a prefilled syringe containing water for injections. After reconstitution, one dose contains no less than 19400 PFU (Plaque-forming units) varicella-zoster virus (Oka/Merck strain). Indications: Active immunisation for the prevention of herpes zoster (“zoster” or shingles) and herpes zoster-related post-herpetic neuralgia (PHN) in individuals 50 years of age or older. Dosage and administration: Individuals should receive a single dose (0.65 ml) administered subcutaneously, preferably in the deltoid region. Do not inject intravascularly. It is recommended that the vaccine be administered immediately after reconstitution, to minimize loss of potency. Discard reconstituted vaccine if it is not used within 30 minutes. Contraindications: Hypersensitivity to the vaccine or any of its components (including neomycin). Individuals receiving

immunosuppressive therapy (including high-dose corticosteroids) or who have a primary or acquired immunodeficiency. Individuals with active untreated tuberculosis. Pregnancy. Warnings and precautions: Appropriate facilities and medication should be available in the rare event of anaphylaxis. Zostavax is not indicated for the treatment of Zoster or PHN. Deferral of vaccination should be considered in the presence of fever. In clinical trials with Zostavax, transmission of the vaccine virus has not been reported. However, post-marketing experience with varicella vaccines suggest that transmission of vaccine virus may occur rarely between vaccinees who develop a varicella-like rash and susceptible contacts (for example, VZV-susceptible infant grandchildren). Transmission of vaccine virus from varicella vaccine recipients who do not develop a varicella-like rash has also been reported. This is a theoretical risk for vaccination with Zostavax. The risk of transmitting the attenuated vaccine virus from a vaccinee to a susceptible contact should be weighed against the risk of developing natural zoster and potentially transmitting wild-type VZV to a susceptible contact. As with any vaccine, vaccination with Zostavax may

not result in protection in all vaccine recipients. Zostavax and 23-valent pneumococcal polysaccharide vaccine should not be given concomitantly because concomitant use in a clinical trial resulted in reduced immunogenicity of Zostavax. Pregnancy and lactation: Zostavax is not intended to be administered to pregnant women. Pregnancy should be avoided for one month following vaccination. Caution should be exercised if Zostavax is administered to a breast-feeding woman. Undesirable effects: Very common side effects: Pain/tenderness, erythema, swelling and pruritus at the injection site. Common side effects: Warmth, haematoma and induration at the injection site, pain in extremity, and headache. Other reported side effects that may potentially be serious include hypersensitivity reactions including anaphylactic reactions, arthralgia, myalgia, lymphadenopathy, rash and at the injection site, urticaria, pyrexia and rash. For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Package quantities and basic cost: Vial and pre-filled syringe with two separate needles. The cost of this vaccine is £109.20. Marketing authorisation holder:

Sanofi Pasteur MSD SNC, 8 Rue Jonas Salk, F-69007 Lyon, France Marketing authorisation number: EU/1/06/341/011

Legal category: POM ® Registered trademark Date of last review: October 2013

References 1. Miller E, Marshall R, Vudien J. Epidemiology, outcome and control of varicella-zoster infection. Rev Med Microbiol. 1993; 4: 222-230. 2. Tripartite letter (Department of Health, Public Health England, NHS England. Gateway Reference Number:00254) “Introduction of shingles vaccine for people aged 70” 12th July 2013.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Sanofi Pasteur MSD, telephone number 01628 785291.

Are you compromising

Leading practice management software providers DGL Solutions and Helix Health recently joined forces, creating the largest provider of practice management solutions to private medical professionals across the UK and Ireland. We

for current and potential DGL Practice Manager customers

Leading Practice manage ­

ment Software providers, dg L Solutions and Helix Health recently joined forces at the end of 2013, creating the largest provider of practice management solutions to private medical professionals across the UK and ireland.

Helix Health has been involved in the development and support of practice management systems for more than two decades, including an extensive footprint in hospital and retail pharmacy, resulting in a wealth of experience and a considerable installed base of consultants and private gPs of over 3,000 customers.

dgL Practice Manager now acts as Helix Health’s flagship consultant product in the UK and ireland.

Howard Beggs, chief executive of Helix Health, said: ‘Our first priority following the acquisition was to ensure our new dg L Practice Manager customers continued to receive the same high standards of customer service that they have become accustomed to.

‘What attracted us first to dgL Solutions was their reputation of friendly support and service, which has been built up over the last 23 years. in addition, the dgL team’s deep product expertise and specialised service capability strongly complement the strength of Helix Health.’

Peter gregory, the founder and previous managing director of dgL Solutions, now acts as head of product development for dgL Practice Manager within Helix Health. He commented: ‘in addition to their strong reputation for

explore what this means

excellent customer service within the healthcare sector, Helix Health brings proven capability and talent in critical areas such as technical innovation, product interoperability and systems’ integration to the dgL team.’

secure access

dgL Practice Manager is used by over 5,000 medical consultants throughout UK and ireland and is currently delivered via a highly innovative, hosted platform, enabling secure system access from multiple locations.

While the market is saturated with generic practice management systems that require you to adapt to follow their workflows, Peter gregory takes pride in the

Once a consultant signs up to DGL Practice Manager, they very rarely leave

fact that dg L Practice Manager was designed specifically for private consultants and practice managers.

He said: ‘We believe our customers shouldn’t have to compromise on their practice man age ment software or adapt to match a software package’s workflow.

‘customer insight is at the heart of our innovation, so we are continually looking at new ways to solve our customers’ business issues and exceed expectations. that’s probably why our customer retention is so good.

‘Once a consultant signs up to dgL Practice Manager, they very rarely leave. We even have a customer who moved to Bermuda and is still using the system! although this wouldn’t have been possible without our new hosted version.’

suiting our needs

Vicki Spence, office manager of Bradford anaesthetic Services, has been using dgL Practice Manager since 2009. explaining her choice of software, she said: ‘at the time, we looked at other systems on the market, but none of them compared to dg L Practice Manager. We felt that they were all very generic, whereas dg L Practice Manager suited our specific needs.

‘now, having a central location for all our patient records and associated paperwork makes our jobs 100 times easier.

‘ t he flexibility within the reporting section within dg L Practice Manager is also fantastic. if a report isn’t already in the system, it can be built – no problem.

Sealing the deal: Helix Health chief executive Howard Beggs (left) and Peter Gregory, head of DGL Practice Manager Development

compromising on your software?

‘the service we’ve received has been consistently excellent and the system adapts to our changing needs.

‘Over the years, we have asked for a number of changes within dg L Practice Manager which have been implemented within a matter of days, making it a bespoke system for our business.’

flexible system

dgL Practice Manager is a flexible system that caters for individuals and groups alike, trusted by a number of large private hospitals across the UK, including H ca , Spire Hospitals, nuffield Healthcare and circle Hospitals.

Helix Health plans to solidify and strengthen relationships with current and prospective dg L Practice Manager customers by continuing to look at ways to enhance their product offering.

One such relationship which has gone from strength to strength is the unique partnership formed in 2011 with g alen Health

Partners, a wholly­owned subsidiary of Hca Hospitals.

g alen Health Partners offer a comprehensive selection of services to support the modern private practice for consultants working within the Hca network. the company works with a number of partners to help take the hassle out of private healthcare, allowing consultants to focus on their primary role: the clinical care of their patients.

as the main aim of galen is to

help private practices run more efficiently to enable them to develop and grow, it was apparent that it needed to partner with a practice management software provider.

initially, a feasibility study was carried out where research was gathered on the top three practice management softwares within the market.

after the initial research, galen and the Hca project management team convened various focus groups of consultants and their medical secretaries in order to evaluate the features and to ascertain the benefits.

they then looked at the ability to integrate key H ca systems within the software.

dgL Practice Manager was then chosen as the preferred vendor and the work on integrating Hca systems – including Medi tech, Patient Keeper, Labs and Pacs –began.

Speaking on the partnership, Jenny ayling, consultant services

officer at galen Health Partners, said: ‘ t he integrations within Hca­Hosted dgL Practice Manager means that consultant practices can access lab results and scans more quickly. new patients can be looked up on the H ca Meditech system, enabling the secretary to copy the details across.

‘ t he system itself allows most actions to take place with the click of a few buttons, which ultimately allows the secretary to spend more time answering the phone, dealing with patient queries and making appointments.

Anywhere access

‘ dg L Practice Manager enables the complete patient record available to consultants wherever they go, as it can be accessed from anywhere with an internet connection. t hey can quickly view all patient records via one portal, saving time within consultations and enabling a more efficient and timely clinic.’

‘H ca­ Hosted dg L Practice Man ager is currently one of the most popular product currently within the galen Health Partners portfolio. d ue to its popularity, we have even recruited an inhouse dedicated Hca dgL helpdesk, as well as an H ca dg L account manager to provide further training and support to new and existing users.’

‘ t he team at dg L and now Helix Health have been very easy and transparent to work with. they are very willing to take on any new ideas or suggestions for integrations to the system to further enhance the system and improve user experience. We look forward to continuing to work with the team and growing the service further.’

Rebecca Ivey, HCA DGL account manager, with Jenny Ayling, consultant services officer at Galen Health Partners

DGL Practice Manager, recently rebranded under the Helix Health brand umbrella

compETiTion inqUiRy: ppUs

NHS could be the

What is the potential impact of the competition inquiry’s final remedies for the private healthcare market on NHS private patient units? Will it prove an irrelevance? Philip Housden argues that, rather than being a threat, perhaps it is an opportunity for growth

Doctors who are members of the IDF become part of an increasingly large and more influential organisation that is better equipped to deal with the many and varied issues facing independent doctors than those acting in isolation.

There are many professional advantages for doctors who are IDF members:

 A council that lobbies Parliament, government organisations, insurance companies and regulatory authorities on behalf of its members

 An active social and educational programme

 An approved appraisal system by trained appraisers for those seeking separate independent practice appraisal

 A Responsible Officer to whom members may relate if they qualify to do so under the DoH ‘Connecting Doctors to Responsible Officers’ flow chart

 An independent complaint resolution procedure for member doctors

 A monthly e-bulletin which keeps members updated on current events of interest and reports on meetings

 Personal profile page on the IDF website

 Mentoring help for those new to independent practice

You can join online via our website www.idf.uk.net, email info@idf.uk.net for a membership application form or call 020 8090 3470

winner

To sTarT with, let’s just recap to last month’s final report on the private healthcare market from the Competition and Markets authority (CMa).

It aims to prohibit arrangements which it decides substantially lessen competition in the relevant local area – and its ‘remedies’ are:

 a restriction or ban on certain benefits and incentive schemes provided by private hospital operators to clinicians;

 a combination of measures to improve the public availability of information on consultants’ fees and of information on the performance of consultants and private hospitals;

 The divestiture by HC a of either the London Bridge and the Princess Grace hospitals or the Wellington Hospital including the Platinum Medical Centre;

 Measures to ensure that arrangements between NHs trusts and private hospital operators to operate or manage a private patients unit (PPU) will be capable of review by the CMa

The report claims that the remedies will improve competition in the private healthcare market. It is London and private hospitalcentric, but, the question is: will these remedies achieve the intended outcomes or will the most lasting impact not be with private hospitals at all?

For PPUs, it demands measures to ensure that arrangements between NH s trusts and private hospitals groups to operate or manage a PPU will be scrutinised closely by the CMa

An irrelevance for the nHS? on one level, the CMa review has little relevance to the NHs. Even with recent growth, total NHs private patient revenues approaching £500m are less than 0.5% of

the NHs budget and 8% of the private market.

The issues reviewed and disagreements exposed are principally an in-house, sibling fall-out between the five major insurers and the five principal hospital operators over who has most power in the value chain.

But the wider picture is of a private healthcare industry with long-term challenges related to the affordability of private insurance and the rising costs of provision in a low-growth economy.

The increasing demands of care quality regulators require investment and better performance management in an ageing private hospital estate portfolio. so if CMa remedies manage to squeeze out some of the identified excess profits of £150m a year from operators, then the sector becomes less attractive for private equity investors.

This CMa review falls well short of a fundamental shift in the

industry dynamic and is a reminder that healthcare insurers and private hospitals are essentially in a symbiotic relationship – each has fundamentally required the other’s geographical and service coverage to have an offering to patients.

In the two-way street between the private sector and NHs most of the traffic is actually one way and now valued at £1.2bn a year. Private hospital groups have long since worked to de-risk their core insurance-funded business with ‘top-up’ NHs activity.

The independent-sector treatment centre (I s TC) programme has been replaced with ‘Choice’ referrals that now make up around 25% of all discharges in some groups and NH s trusts still outsource activity to their local private hospital to help with capacity and access challenges. By contrast, health insurers have been generally slower to ➱

stimulate NH s PPUs to offer alternatives to private hospitals. a lthough there are a growing number of PPUs, far from all NHs trusts provide private patient care, and of those that do, few are recognised by the major insurers.

nHS ppUs today so, CMa review or no review, the ‘closed shop’ of private healthcare in England would appear to go on as now, with the 99%+ of NHs core business similarly unaffected.

But, although the NHs in England is a minority supplier of privately-funded healthcare services, it has an increasing market share. The Health and s ocial Care a ct 2012 that removed the private patient income cap on NHs facilities in England has stirred expansion of NHs PPUs, with reportedly 40 new or refurbishment projects underway.

For each of the four main remedies, there are issues for trusts and their private patient management teams to consider:

incentives

to clinicians

Free outpatient rooms and secretarial services at the local private hospital must now be charged to consultants at a ‘fair market rate’ with transparency of these arrangements for patients. But the free tea, warm welcome and the attractive separateness of the environment will clearly remain.

The incentive schemes that the CMa is concerned about are those that provide a financial reward based on referrals and activity.

r eputedly there are – or have been – many variations on a theme in place within the sector based on revenue value. Will this change? on the face of it, yes, but the essential imperative for private hospitals to attract and retain consultants will, of course, remain – and those consultants have got used to the rewards.

The central question is ‘when is an incentive scheme not an incentive scheme?’ This change is likely, therefore, to give further impetus to the development of consultant chambers.

The commercial arrangements between hospitals and consultants can be made ‘arms-length’ through contracts with limitedliability partnerships and consultant-owned companies.

In this way, while the clinical and quality relationship can remain an individual one, the commercial aspects can be managed by means of a third-party entity.

This remedy is unlikely on the surface to have a direct impact on NH s PPUs – but it goes a small way to levelling the playing field.

For some consultants, some of the time, the removal of private hospital incentives might just swing the balance towards using the NHs private patient facility a bit more – and for ‘chambers’ even more so. s o NH s private patient managers take note: embrace your local chambers.

information on fees and performance

The sector is set on a trajectory towards increasing transparency on performance, as is our society as a whole. Within private healthcare, the trend is witnessed by the establishment by providers of the Private Healthcare Inform ation Network (PHIN), which will develop and co-ordinate this action and other websites.

The ability for patients to find out more about volumes, length of stay, complications and other indicators must be a good thing, particularly where all steps are taken to make this as comparable as possible.

tions of private hospitals and also have practising rights and responsibilities, it should be expected that the same applies.

This requirement should be the least contentious, in so far as it seems to be the easiest to be practically achieved. The principal area in which this requirement will impact is self-pay, where a single price, combining provider and specialist fees, is the norm.

price transparency

The sector is set on a trajectory towards increasing transparency on price, as witnessed by PHIN also taking the lead in this area too.

But what will happen in practice and will it make a difference?

Consultants’ outpatient fees do vary across specialties and consultants, but do these have anything other than a minimal impact on referrals or patient choices?

Healthcare demand is not pricesensitive, except perhaps at the two ends of the spectrum. at the exclusive high end, it may well be there that there is actually an ‘averaging up’ among established consultants anxious to equate price with quality, rather than a market-driven price reduction.

It is also inevitable in our social media age that patient perception and comment will drive opinion and future consumer behaviour. But with such relatively uninformed consumers, this will take some time before it overrides the established order of the three ‘ a’s –availability, affability, ability’.

Private hospital operators will now be required to make consultants provide fee information in standard format as a condition of practising there.

The CMa is also requiring the collection and publication by a new information body of data on the performance of private hospitals and individual consultants. a s NH s PPUs should follow the best-practice governance conven-

glimmers that information on trust performance might drive PPU – rather than local private hospital – growth.

Medical infrastructure, expertise of clinical staff and reputation all scored significantly higher with PPU patients as their reason for choice of provider than private hospital patients. This is where PPUs can be at an advantage in many provincial private markets.

HcA’s divestiture

This is the most high-profile remedy. It is a major issue for HC a , who will legally challenge the CMa, and a sigh of relief for BMI who escaped a similar sanction. But, even within London, it is debatable what impact it will make.

spire’s recent acquisition of st a nthony’s Hospital, Cheam, s urrey, shows that the London market adapts over time. The Cromwell’s availability for sale to other than HC a has been rumoured for a long time.

From an NH s perspective, London PPU earnings top £250m a year too, and are enjoying double-digit annual growth. Where there is distraction and uncertainty, perhaps London NHs PPUs as well as HCa’s competitors can benefit?

But at the other, more commoditised end of the market, things may well be different.

The collective impetus of increased self-employment, raised referral thresholds and the identification of ‘low-priority procedures’ by clinical commissioning groups, together with the difficulty newly appointed consultants are having in getting a toehold into private practice proper – these are all encouraging an ‘affordable selfpay market’.

This is a market that PPUs should be keen to exploit, as specialist niche private providers are doing, and it is also the route for Care UK’s soft entry into private healthcare.

But this does not have to be just a boring process. Deep in the CMa’s patient, GP and consultant surveys appendices, there are

Local private provider-ppU partnerships

More NH s trusts are viewing investing in private patient provision as a way of raising revenue to subsidise their core public provision of care.

Most, but not all, PPUs remain managed ‘in house’ rather than licensed to a partner. But the higher the ambition of the trust and the greater the costs of capital for a new-build, the more likely a trust is to seek a partner. a s PPUs are co-located with NHs hospitals and have access to their infrastructure and support facilities, partnering with a trust may offer a low-risk means of market entry for private hospital operators.

The CM a proposes that the owner of a private hospital in a low-competition catchment – a so-called single or duopoly area –would be barred from partnering with an NH s trust to operate a PPU.

Perhaps it is the NHS, largely unmentioned in the CMA’s review, that could be the main winner from the proposed remedies

This may mean in many provincial markets it leads to less interest from the sector in PPUs, where perhaps the local private operator may be strong enough to deter entry by a second player. Will this reduce the likelihood of a trust developing new PPUs capacity? Probably not, as either a commercial case stacks up or it does not.

It is clearly a commercial risk for a private hospital operator to invest in a joint venture with a trust, but this can be mitigated by length of contract, the treatment of the rewards over the contract life and whether the hospital chain is the finding source. alongside this, the majority of trusts have the potential to enable enhanced internal ‘arms-length’ commercial entities within their own organisations without recourse to a formal, long-term partnership with a third party. The creation and maintenance of a vibrant, empowered in-house PPU management team – often supplemented by specialist consultancy support – has been the route followed by the majority of the high-earning NHs trusts. The evidence is that it is these trusts that are driving higher than average PPU growth.

An increasingly mixed market o n a first read, these remedies seem to be just too centred on London and private hospitals. and will they really facilitate a more competitive market? Time will tell, but there is room for innovative responses that could benefit NHs trusts and consultant chambers at least as much as any hospital group or insurer.

so, perhaps it is the NHs, largely unmentioned in the CM a’s Private Healthcare Market review, that could be the main winner from the proposed remedies, if enacted. 

Philip Housden (left) is a director of Housden Group management consultancy specialising in commercial support across the healthcare sector

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compETiTion inqUiRy: docToRs’ viEw

CMA report is a chance lost

Dr Brian O’Connor

(right),

chairman of the Independent Doctors Federation’s specialists committee, gives his take on what happens next

The IndependenT doctors Federation (IdF) promotes excellence in the independent medical sector and welcomed the idea of a report into private healthcare initiated by what was previously known as the Competition Commission over the past two years.

Unfortunately, the final report – which lists measures to increase competition in the private healthcare market – is a major disappointment and an opportunity lost.

The I d F, perhaps naively, had anticipated that any measures would be directed at improving patient care.

however, based on careful study of the report and on feedback from many of the most important stakeholders, namely the patients, none of the measures outlined will clearly enhance the patient journey within private healthcare.

The Competition and Markets Authority (CMA), perhaps unsurprisingly, focused on issues of competition, price and rivalry, terms that are alien to doctors and patients alike.

There was no emphasis on the importance of the doctor­patient relationship, which is fundamental to the ultimate measure of good healthcare: the patient outcome.

The inquiry seemed to be disproportionately concerned with divestiture of hospitals. Ironically,

The Competition and Markets Authority focused on issues of competition, price and rivarly, terms that are alien to doctors and patients alike

despite its provisional remedies, the divestiture of hospitals amounts to one organisation, h CA, selling one or two of its major internationally­recognised medical facilities in London.

Our overwhelming feedback, particularly from patients, was that hCA had developed worldclass facilities in London and it could only be to patient detriment if one or more of these facilities were lost.

There is fear that any takeover likely in the current climate will be from a financial institution or private equity group.

They will have little knowledge or interest in the fundamentals of healthcare nor the nuances and complexities of the medical profession and interaction with patients. This would only lead to diminution in standards to the detriment of patients.

In short, the feedback from patients and colleagues was that any loss of h CA expertise and investment would have a negative impact on delivery of healthcare.

Transparency on fees

Universally, there has been a welcoming acceptance of the measures designed to highlight performance of hospital providers and of consultants as well as transparency about hospital charges and consultants’ fees.

Any system that demonstrates the quality of care delivered by

doctors in hospitals can only be to patients’ benefit.

e qually, patients will be in a position to make more informed choices on the assumption that transparent publication of consultants’ fees will be an effective reflection of true costs to the user.

We are in agreement that a more transparent market will allow patients to make choices that matter to them and will influence positive change.

incentives schemes

The IdF abhors incentive schemes for doctors and is supported without exception by all IdF members with whom this was discussed and, indeed, other relevant stakeholders.

The CMA omitted to take any remedial action on the incentives made by private medical insurers for consultants to become preferred partners and, perhaps more worryingly, the cash offers to patients to switch their care to the nhS.

The main difficulty that has been voiced by primary care and hospital specialists and, most importantly of all, patients was the lack of any remedy concerning the influence that the insurance companies bring to bear on private healthcare in the UK. Many submissions were made by consultants as individuals, by professional organisations, by

members of the public and by patient organisations highlighting the difficulties experienced in the past five years with major private medical insurers (pMIs).

Two of the leading p MIs exercise a duoply (approximately 65%) of the market and, in my view, exert undue influence and market power in relation to patient choice, restriction on consultant access, investigations, procedures, access to hospitals, length of stay in hospitals and to consultant fee structures.

The omission of a remedy for this, in the words of one very senior and knowledgeable patient, ‘raises concerns about the focus and function of the CMA in delivering this report’.

The feeling among patients we have encountered is that they are extremely concerned at the CMA’s tacit acceptance of ‘open referral’. p atients have indicated they were disappointed the CMA did

Healthcare is all about patient-doctor interaction and the doctor-patient relationship has always been sacrosanct. This was not mentioned in the report

not make any reference to the changing conditions of patients’ policies.

Some patients also feel ‘trapped’, unable to transfer from their current insurer because of a pre­existing condition. And some think this report will not address the issue of decreasing benefits in the face of rising premiums.

The overwhelming view of consultants we have heard from since this report was published indicates that patient benefit is unlikely to accrue from this. h ealthcare is all about patientdoctor interaction and the doctorpatient relationship has always been sacrosanct. This was not mentioned in the report.

chance to appeal

doctors and patients as individuals and as groups made submissions between the publication of provisional findings and the final report, yet were denied a fair

opportunity to have these submissions listened to in a meaningful way.

Obviously, hCA will appeal the measure demanding they divest one or more of their hospitals in London. Whether doctors groups and patient groups will be in a position to appeal is uncertain.

Younger consultants feel particularly aggrieved that the CMA did not take more positive action to address what they see as the anti ­ competitive stance of the insurers in demanding that newly appointed consultants can only adhere to a fixed and uneconomic fee structure in order to be ‘recognised’ to see insured patients.

Some older consultants have also expressed disappointment that the CMA did not intervene against the extraordinary and asymmetrical dominant power of the pMIs to compel consultants to a certain fee structure for fear of derecognition.

Adapt to survive

Yes, independent practitioners can adapt to new surroundings. peter Connor assesses the impact of the Competition and Markets Authority’s report for consultants

Much attention has focused on divestiture of hospitals in London in the wake of the competition and Markets a uthority ( c M a ) report, but the repercussions are not just for the big beasts of private healthcare.

From the private doctors’ perspective, the crackdown on hospital incentive payments and the drive to make more information available about consultant fees and performance are likely to have a considerable impact.

a nd their ability to respond positively to new challenges will determine their success.

clinician benefits

i n banning direct incentive schemes provided by private hospital operators to clinicians, the cMa acknowledged that the major hospital groups have already ended cash ­ based payments to doctors for referring patients.

it concluded that indirect incentives such as equity participation schemes were acceptable – subject to certain conditions – as were the provision of certain ‘low ­ value’

benefits, including basic workplace amenities, general hospital marketing and services that are integral to the hospital’s operations, such as administration systems and billing where the consultant’s fee is part of a package price.

h owever, it said higher value services, such as ‘the provision of consulting rooms, secretarial and administrative services and contributions to indemnity insurance [for] private patients’, should be charged at their fair market value and made available to all clinicians with practising rights rather than allocated selectively. the market cost of providing a secretarial service would be based on the full cost to the hospital operator of employing the secretary, together with any overheads such as it costs. hospitals will be expected to publish these services and the prices charged for each on their website.

While the c M a accepted this decision would ‘increase costs to clinicians’ who had previously benefited from free or subsidised service, this consideration was

outweighed by the benefit of removing the potential influence on referral behaviour.

i t also refused to allow any exception for schemes which offered free or discounted consulting rooms to new consultants for a limited period.

o f course, the impact of this remedy is likely to depend on whether you had been eligible for these subsidised services, but i believe a level playing field benefits everyone in the long term.

undoubtedly, many independent practitioners will continue to use the secretarial services available at their hospital, but at least there is now an incentive to shop around for administrative services or practice management software which meets their needs.

in taking a more active approach to procurement, consultants might therefore find ways to manage their own practice more efficiently and cost­effectively.

in reality, the writing has been on the wall for direct incentive schemes for some time, because doctors have an existing ethical duty not to ‘ask for or accept –from patients, colleagues or others – any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients’ (paragraph 80, Good Medical Practice, 2013).

t he c M a warns that it will notify the GMc of any incentives that it believes are incompatible with ethical guidance.

The information age everyone in private health provision accepts the pressing need for comprehensive data about quality and treatment outcomes. in fact, the sector was once a pioneer in this area: patient ­ reported outcome measures (PR o Ms) were actually introduced in the private sector in 1998 and did not appear in the nhS until 2009.

More recently, healthcode has worked with the Private healthcare information network (Phin) to collect hospital episode statistics for an industry­wide project that gives patients an online resource to search for local independent hospitals which perform particular procedures and view information such as average length of stay.

there is still much to be done to allow patients to exercise effective choice. But the information remedies set out in the report provide useful direction and momentum, not least the creation of an i nformation o rganisation ( io ) responsible for providing appropriate guidance; verifying data; and processing and publishing it in a meaningful way, including risk­adjustment where necessary. the cMa has indicated that Phin would be a suitable io, subject to certain conditions.

i n the report, the onus is on hospital operators to disclose the necessary information about the volumes of inpatient procedures, average lengths of stay, mortality rates, patient feedback (set out in paragraphs 11.570 and 11.571 of the final report). Much of this

data will be provided in code and the cMa’s remedy means providers will need to use multiple coding systems (see box below).

But independent practitioners have an important part to play in recording sufficient detail about patients’ diagnosis, co­morbidities and treatment, so the hospital can submit correctly coded data to the information organisation.

they are also directly affected, because the data provided by hospitals about each patient episode is expected to include the responsible consultant’s GMc number.

the cMa envisages that data will be comparable with that collected by the nhS so the io can report performance measures across the whole of the consultant’s nh S and private practice.

i n addition, consultants will now be responsible for providing written fee information to patients before they attend an outpatient consultation using a standard template letter provided by their hospital.

t hey will also be required to publish their current list prices on the io ’s website – allowing for legitimate variation.

a gain, this requirement is in

line with the GMc’s latest ethical standards which state: ‘ i f you charge fees, you must:

a) tell patients about your fees, if possible before seeking their consent to treatment and;

b) tell patients if any part of the fee goes to another healthcare professional’ (paragraph 4, Financial and commercial arrangements and conflicts of interest, 2013).

For their part, hospital operators must ensure patients treated at their facilities are fully informed of the consultants’ fees.

Advertising prices

the cMa recognises there will be an administrative cost to consultants who are not currently providing written fee information, but it added that this would be minimal given the introduction of template letters and assuming secretarial support.

Besides publishing their prices on the io website, we expect doctors will choose to make their list prices available to patients on their own website, that of their hospital and other online directories, but they will need to ensure this is consistent and up to date. to reduce the administrative

Coding CoMpliCations and Mapping

the CMa remedy means private hospitals must record their treatment using multiple systems of clinical coding:

 the Clinical Coding and schedule development group (CCsd) system will continue to be used for billing.

 the office of population Censuses and surveys (opCs) coding classification will be required for procedure coding for submission to the new information organisation (io). it is already used in nHs records of patients treated in private hospitals.

 Hospitals must also provide diagnosis coding ’to an internationally recognised standard such as iCd-10 coding’ including patient co-morbidities. the CMa expects the io to agree the appropriate system with members which would need to be comparable with the nHs (which uses iCd-10). the private sector typically uses a version of iCd-9.

 private hospitals must now address the challenge of accurately recording all activity using CCsd and opCs coding classifications for both billing and clinical purposes. this means clinical coding must become integral to their day-to-day operations. But they will be able to take advantage of existing code-mapping tools from Healthcode which translate between the different classifications.

 Mapping is already being used in the analysis and publication of clinical activity and quality indicators by pHin to convert hospital episodes recorded using the CCsd codes into opCs. We have also developed a mapping tool to convert iCd-9 codes to the iCd-10 system and vice versa.

 Meanwhile clinicians in independent practice who need to provide coding information would only need to hold a list of the appropriate ‘maps’ to cover their most common procedures.

Consultants’ ‘to do’ list

You may think you have plenty of time, but i strongly encourage you to acclimatise yourself to the new private healthcare landscape rather than stand on the sidelines until the CMa’s remedies are implemented.

For example, those now benefiting from subsidised administrative services could check what arrangements their hospital is going to make and research the alternatives.

also review your fees now to see how they compare with others in your specialty. Collate fee information and contact details for the specialists you work with such as anaesthetists and radiologists – if these are charged separately.

Work with the hospitals where you have practising privileges to understand exactly what will be involved in gathering performance data for the io this issue directly affects clinicians and it is important you are involved in delivering the solution.

burden involved, h ealthcode is developing a solution which will enable consultants to take control of their published list prices.

a greater worry might be that encouraging patients to shop around on the basis of price as well as quality could exert downward pressure on fees, while some insured patients could be deterred from choosing a consultant if their prices exceeded the amount that would be reimbursed by their insurer.

Research carried out for the c ompetition c ommission and quoted in the cMa’s final report suggests 29% of patients considered the likelihood of their private medical insurance covering a consultant’s fees to be an important reason for choosing a consultant. however, it’s doubtful that price considerations are more important for most patients than the quality of the treatment provided. Perhaps more reassuringly, 36% said they had discussed the consultant’s reputation with their GP and 29% said quality of care was one of the most important reasons for choosing a particular hospital.

For high ­ achieving practitioners, the use of risk­adjusted performance measures should help them build their reputation and their practice. and, more broadly, it will give consumers a real insight into the excellent care available, helping to improve the status of private sector provision.

it’s also true that the availability of more detailed information about quality and outcomes will further drive up standards by encouraging practitioners to reflect and by stimulating competition. i t should also give useful

insights into the risks and benefits of different treatments, perhaps even providing an evidence base for new procedures.

A five-year plan

While there remains the possibility of legal action on its divestiture remedies, the c M a expects the statutory orders implementing its final proposals to be made by october 2014.

the requirement for consultants to provide patients with fee information and the ban on direct incentives will then come into effect immediately. But the cMa has recommended a deadline of a pril 2015 for other benefit schemes to be modified to meet its criteria.

it also recognises that the collection of performance data will take time, calling for this to be published in stages over three years following publication of its report, with all data available from april 2017. it is committed to reviewing the situation again in april 2019. i have long believed the lack of meaningful information about quality and outcomes is one of the greatest challenges facing the private health sector. it is a challenge for the nhS too. healthcode has already developed a number of tools which can help providers submit data in the correct format without the need for expensive system overhauls and we want to play our part in helping independent practitioners adapt to their changing surroundings. 

Peter Connor is managing director of Healthcode, a leading provider of online solutions to the independent healthcare sector

ACCOUNTANT’S CLINIC

You can spend to save

Expenses: are you claiming back all the areas of your business? Susan Hutter (right)

finds a lot of

independent practitioners are missing out on some generous tax breaks

Many Medical practices will be aware of obvious expense claims, such as travelling and use of home as office when they submit their annual tax return.

yet, there are some areas which doctors are still in the dark about and could be claiming far more back to reduce their tax bill.

RESEARCH & DEVELOPMENT (R&D) TAX CREDITS

i have met a number of doctors who were unaware of making an extra claim for their work in research and development. This is an omission which potentially could have cost them tens of thousands in unclaimed tax credits – and even more in some cases.

R&d tax relief for medical professionals trading as a limited company is very generous, although this relief is not available to unincorporated businesses.

i n order to obtain this special relief, the expenditure must be on a project which seeks to ‘achieve an advance in overall knowledge or capability in a field of science or technology through the resolution of scientific or technological uncertainty’.

This is complex jargon as set out by HM Revenue and customs and not easy to understand. Therefore, to help you to decide whether or not the expenditure will qualify, it is recommended that you take specialist advice.

you can take this advice before making a decision whether or not to spend the money. if the expenditure does qualify, for every £100 spent, your company can claim an additional £125 of deduction against profits.

This is known as R&d tax credit. For example, if your company

spends £100,000 on qualifying R&d, not only will it receive tax relief on that £100,000, it will also receive tax relief on an extra £125,000 – a total of £225,000. This results in a corporation tax saving at 20% of £45,000!

Many of you may be carrying out qualifying R&d expenditure, which incidentally includes directors and employees’ salaries, without even realising it.

Obviously, you are claiming tax relief on the salaries, but if the work carried out qualifies for the extra tax credit, the tax relief –as you can see – is enhanced enormously.

Furthermore, if you have not made a claim until now, but subsequently discover that you have been carrying out qualifying R&d work, you can, in fact, go back for two years to make the claim.

EXPENDITURE ON PLANT AND MACHINERY –CAPITAL ALLOWANCES

Unlike R& d tax credits, capital allowances are available to all doctors, whether they are sole traders, partnerships or limited companies.

The main tax relief on your expenditure on fixed assets is known as a nnual i nvestment a llowance ( aia ) and effectively provides 100% tax relief on expenditure on qualifying plant and machinery costing up to £500,000 in the year of purchase from 1 april 2014.

Prior to that, the maximum was £250,000.

The allowance will reduce to a maximum of £25,000 on 31 d ecember 2015 – so if you are thinking of spending relatively large sums of money on plant and

machinery in the not too distant future, you should definitely do so before that date.

any expenditure in the year to 31 March 2015 will attract aia on £500,000. any expenditure over and above the aia limits would be subject to an annual writingdown allowance which, in most cases, is 18% of cost, less the aia claim.

you will also need to consider rental weighed against outright purchase and how to structure the funding accordingly. But £500,000 is generous and most consultants are unlikely to spend more than that on plant and machinery.

Best time to spend money on the business?

a s far as timing of business expenditure is concerned, the rule of thumb is the sooner you spend the money, the sooner you will obtain tax relief.

The only time that this rule may not apply is when you are trading as a partnership or sole trader and you know that, in the current tax year, your income is likely to be in a tax bracket no higher than 40%, whereas in the following tax year you are likely to be in the highest tax bracket, that is to say: 45%. in this case, it would be sensible to wait until after the end of the tax year before incurring the expenditure, as long as that does not hold your business up. in all cases, to be allowable for tax, the rule is that the expenses have to be incurred ‘wholly and exclusively for the purpose of the trade’. n

Susan Hutter, is a specialist in medical accountancy services at Shelley Stock Hutter LLP

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Doctors whose idea

Medical comic books are big business for these doctor entrepreneurs. Leslie Berry reports

How sHould a GP, surgeon or parent explain to a newly diagnosed child that they are going to need to have radiotherapy? what is the best way of explaining a condition such as epilepsy to a teenager? How should breast cancer or stroke in a parent be explained to a child of five or ten?

The Medikidz have the answer.

Medikidz is the world’s first medical education company for children. u sing a gang of five larger-than-life superhero characters, each representing a different area of the human body, Medikidz produces comic books to explain conditions, illnesses and health issues to children in an accessible and empowering way – think Marvel comics meets medicine!

Conditions covered range from asthma, to bedwetting, to Parkinsons, to multiple sclerosis. In fact, there are currently over 80 peerreviewed titles published, in 30 different languages, with a list of over 300 titles still to produce.

To date, over three million comic books have been distributed globally, helping children in 50 countries worldwide.

Medikidz was co-founded by two doctors from New Zealand, d r Kate Hersov and d r Kim Chilman-Blair, who became frustrated with the lack of resources written specifically for children, in a language that they could understand and relate to.

d r Hersov explains: ‘There exists worldwide an enormous lack of useful material for young people around medicine and health – most of what exists tar-

gets parents only. This realisation was the catalyst which lead us to create Medikidz.’

Medikidz produces comic books to explain illnesses and health issues to children in an accessible and empowering way – think Marvel comics meets medicine!

All Medikidz titles are written by a team of in-house doctors and comic-book writers, peer-reviewed by world-renowned specialist physicians and endorsed by leading patient associations and academic bodies.

There are currently eight qualified doctors among the staff in the london office, working across a variety of roles.

dr Columba Quigley is the chief medical editor. Before joining the company, she was consultant and senior lecturer in palliative medicine at Hammersmith Hospital.

diverse team

she says: ‘As chief medical officer, I am responsible for the medical content of all Medikidz products. I supervise the medical writing process, from the assimilation of relevant and appropriate medical facts for the particular condition,

merging the medical information with the visual content, to signing-off on the final printed or digital product.

‘As a doctor, I love the fact that working at Medikidz necessitates being up to date with evidencebased guidelines on a huge range of medical conditions. My medical knowledge has been greatly enhanced and broadened over the past two years as a result.

‘I also love working with such a diverse team which includes not only doctors, but artists, graphic designers, and comic book writers. This has been a unique multidisciplinary experience, where all team members play equal contributory roles.

‘And when the printed book arrives in the office, the realisation that our work reaches out to children affected by illness all over the world is a truly celebratory moment.’

s ome of the most important relationships that Medikidz hold

Medikidz founder Dr Kate Hersov (above) and her publications’ superheroes with Maddison Andrews, aged 7, the star of a competition ‘Medikidz Explain Eye Tests’, run with Vision Express

made a ker-sploosh!

and build are with patient associations, academic bodies and institutions within primary and secondary healthcare.

d r s elena Audit, previously a specialist registrar in radiology, establishes and maintains these partnerships.

s he says: ‘Medikidz now has collaborations with hundreds of healthcare organisations globally, with new opportunities arising all the time. on an average day, I can be liaising with our partners in Brazil to Germany to China.’

s he also co-ordinates the Medikidz Youth Advisory Board, a group of 30 young people aged 6-16 who review the publications and give feedback on the general content and direction to help the team shape Medikidz to ensure they benefit their target users.

promoting healthy lifestyles

d r Audit says patient education and the communication of health issues have always been a priority for her in promoting healthy lifestyle choices.

she says: ‘It’s incredibly rewarding to be involved in an initiative which engages and communicates with children and young people on a global scale so effectively, reducing the stigma of medical conditions and promoting health.’

Each Medikidz title features a real-life case study who is either suffering from, or has had exposure to, a medical condition.

The books are written from the young person’s perspective, concerning a condition that they themselves are experiencing or one that a parent, family member or loved one is going through.

Kenzie Barry, the 13-year-old star of the ‘Medikidz Explains Eczema’ title and member of its youth advisory board, explains: ‘The comic book is amazing

A selection of comics published by Medikidz, which use a gang of superheroes to explain complicated clinical conditions to young patients

because it helps not only me, but my family, friends and people around me understand what the condition is like.

‘I love visiting the Medikidz office for the youth advisory board meetings and having fun with all the staff as well as the other kids with different conditions. It’s great to know that my story can help others who go through the same things as me.’

The future for Medikidz lies in digital expansion. All content is being transformed to become viewable on digital platforms, alongside creating downloadable apps to assist with such issues as drug programme adherence and

games to encourage young people to become more engaged in their conditions and treatments.

dr Adrian Raudaschl, the group’s digital director and also a practising doctor, says: ‘I’m responsible for innovating and developing new digital applications for children. w hat I love most about working at Medikidz is making a meaningful difference to children’s lives through education.

The new digital platform is a hugely exciting direction for us, as it helps us to positively engage children on a level that they not only are familiar with, but also enjoy.’

Co-founder and uK chief execu-

tive dr Hersov admits it took a huge leap of faith for her, her cofounder and all the doctors that work with them to make the move from practising medicine to a life of comic books and superheroes.

‘However, I am so proud that I have such an amazing team of people who take enormous pride in what we do and are passionate about their role in actively improving the future of children’s health.

‘All at Medikidz work tirelessly to reach our goal of creating a global community of young people who are informed, empowered and health-aware.’ 

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Retirement

Whether you have an outgoing partner leaving or a new partner coming in, it is important the transition is catered for legally and the succession of the practice is dealt with in writing. Robert Capper (right) explains

It Is absolutely vital that partnership documents not only reflect the existing partnership agreement but also deal with important provisions relating to partnership property, past and future liabilities and distribution of assets and profits.

And there are some key retirement and succession documents used in a partnership change: the ‘deed of retirement’ and ‘deed of adherence’, along with other options for partnerships considering a change of partners.

A deed of retirement is used in respect of an outgoing partner. While called a deed of retirement, it can often be used to deal with outgoing partners that have either been expelled or have died. Due to the formalities that need to be taken care of in these cases, such documents are often complex. t he document will deal with several key areas:

 Retirement of the outgoing partner

It should stipulate the date on which the partner will retire –

with reference to the relevant partnership agreement clause, if applicable – and whether the existing partnership will continue and, if so, on what terms.

 partnership property

the formal transfer of all property belonging to the partnership from the individual partner to the remaining partners.

Where such property is held subject to a liability, such as a mortgage, the continuing partners will typically endeavour to release the outgoing partner from such debt.

 liabilities

the continuing partners will typically indemnify an outgoing partner from any liabilities the partnership incurs. While the outgoing partner cannot be released from debts incurred before they leave the partnership, the remaining partners can agree to indemnify any costs incurred by the outgoing partner in payment of those debts.

 payments

t he retirement of a partner will mean that cessation accounts will need to be drawn up to value the outgoing partner’s share. such share will then typically be owed to the outgoing partner, along with any other amounts agreed under the partnership agreement or as a result of negotiation between the parties.

 Restrictions

t here may be restrictive covenants imposed on an outgoing partner. t he extent to which these are reasonable will depend on how enforceable they are.

 notices

In order to discharge future liabilities from the outgoing partner, a notice will usually be placed in the London Gazette to announce that, as of an effective date, a partner has left the practice.

It is also imperative that suppliers, customers and any other third parties that you work with – such as the Care Quality Commission – are also made aware of the changes as appropriate, owing to the joint and several nature of partnership liability.

It is vitally important that all of the above areas are dealt with. Failing to deal with just one element of the retirement of a partner from your practice could be disastrous for the continuing business, as well as for the outgoing partner or other stakeholders in your practice, particularly if giving them an indemnity or release of liability from the partnership.

Deed of adherence

A deed of adherence is used in respect of an incoming partner. Often enough, these will be fairly simple documents to state that the incoming partner agrees to be bound by the terms of the existing partnership agreement. t here will also be important provisions relating to:

 capital

If the partner is bringing in capital to the partnership, such a clause will set out the amount being brought into the practice and how such capital will be paid, including the time-scale for an injection of such.

if your partnership agreement has not been updated in a number of years, there is good reason to do so on a change of partner

 profits and losses

With the new partner entering into the partnership, the profit and loss shares will need to be adjusted according to the partners’ wishes. s uch a clause will vary the existing agreement.

Whatever the distribution of profits and injection of capital that the new partner will join the partnership with, it is important to ensure that the incoming partner is effectively bound by the existing partnership agreement.

Having a properly drafted deed of adherence is therefore vital in achieving this and can save many complications further on in time

by taking the correct action from the outset of appointing a new partner.

An alternative to deeds –new partnership agreement

Of course, deeds of retirement and adherence are not the only way of removing and adding new partners to the practice. It could be that a technical dissolution of the partnership takes place on the retirement/admission of a new partner, with a new partnership agreement being implemented on the change.

A technical dissolution means the end of the original partner -

Top TipS foR SuCCeSSion planning

 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

ship and the start of a new one. this type of dissolution does not therefore result in a winding up of the business, but essentially stops the business at the date of the ‘dissolution’, distributes the assets –or liabilities – among the partners in the ‘dissolved’ partnership and reforms a new partnership with the continuing partners, their assets and the new partner. to document such a circumstance, the partnership accounts are drawn up to reflect the situation on the last day before the new agreement is entered into. t he partner would then join/ leave the practice and the new partnership agreement will be entered into.

this is often a good opportunity to refresh the partnership agreement of your practice and, certainly, if yours has not been updated in a number of years, there is good reason to do so on a change of partner. t his will ensure it is up to date with the latest laws, regulations and general good practice expected in the private medical sector. 

Robert Capper is a partner in the health and social care team at legal firm Harrison Clark Rickerbys

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How to create your own surgical clinic

Want to realise your vision of a surgical clinic designed to your own ideals? Maitland Cook (left) examines the dream – and the reality

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• Weight-bearing scans and variable patient positioning enables a more precise diagnosis

• Truly open system is a solution for claustrophobic patients without compromise in image quality

The imposing door opens automatically, you walk in to the reception and a pretty, smartly dressed receptionist welcomes you with a ready smile and a cheery greeting.

everywhere is clean, tidy, pristine. The newspapers are neatly folded. You arrive at your consulting room where the patient list is ready, the computer is turned on, an equally elegantly presented nurse welcomes you with coffee and an offer to help with all your needs throughout the day.

The theatre manager calls to confirm all is ready for your first operation in 30 minutes … how marvellous!

Then the alarm wakes you … it really was a dream!

m any consultants dream of owning their own clinic. s ome attempt the task, few make the reality and even fewer make the reality a commercial success.

Why have your own surgical clinic? By doing so, you combine all the difficulties of your clinical work with the problems of running a hospital.

Combined, they present major challenges in both the creation and the operation. h owever, if you have the overwhelming desire to work in an environment that is created to your vision, this will be the way, as very few pri ­

vate hospitals will tailor their offering to your total desire.

The preliminary questions that need to be answered before making any decision to build your own facility are:

 Location: What facilities currently exist? is there a need for an additional private facility?

 Private medical insurance: What recognised providers exist in the area? Will the insurers register further providers nearby?

 Planning: Will the local council give approval for additional medical use in the area? if yes, will they approve the scheme as presented? Will there be restrictions in hours of use and noise generation? o nce these basics have been answered positively, the major decision that will affect every aspect of the dream and it becoming reality is whether your establishment offers general anaesthesia. This decision is key to the complexity of the design, layout,

construction, registration and oper ation of the unit. The engineering input for a general anaesthetic unit is much more complex than with local anaesthesia, but gives you the chance to carry out much more complex procedures.

never-ending fees

At this point, the matter of the property in which to house ‘the dream’ may start to be considered and, with this, the financial clock begins to tick.

The fees for professional advisers start to be incurred very early on in the project – and never end! Firstly, lawyers have to be appointed to handle the conveyancing of any property transaction. Architects will be required to design the scheme in principle for submission to the local authority for planning approval. possibly a planning consultant will also be needed. it is preferable to appoint archi­

The fees for professional advisers start to be incurred very early on in the project – and never end!

tects and the relevant engineers who have hospital design and build experience. The Care Quality Commission (CQC) will need to be shown compliance with all hospital build criteria before they will consider registration. This will require yet another consultant. in all probability, although all these professional advisers are running up costs, there is still no finite project. if one is a busy successful consultant with a thriving practice, there will probably be the necessity to appoint a project co­ordinator so that the clinical work is not compromised.

All these consultants should be tied in to a pre­agreed fee structure; nevertheless, the costs being incurred will be significant. initial discussions with the bank or other financial institutions will usually have commenced, ideally with the practice bank. For this to progress, a business plan will need to be prepared and considered to ➱ p30

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be viable for both the lender and for the clinic to survive and prosper commercially.

This plan can be produced with input from the accountants, but, in today’s economic environment, will need to be detailed, with much evidence to back up the assumptions and show trading forecasts for three years.

While all this is going on, the property decisions will need to be made. n ew or existing? Where?

The relatively minor considerations of parking and public transport become major if not taken into account.

The simple but most expensive route will be a new build. The layout will be to your exact wish in every aspect. But the cost of land acquisition and then construction may be prohibitive and the chances of the availability of land for such a project in the ideal location are slim.

in all probability, the building

chosen will require conversion, providing the planning authorisation for medical use can be obtained. Leasing the building is normally the best solution from a financial standpoint.

colleagues’ commitment once this is sorted out, the anaesthesia decision can be made; also the number of theatres, how much recovery area, how many overnight beds and consulting rooms. Before committing to the project finally, decide how many consultant colleagues are needed and how much clinic income will they generate.

The business plan should have answered this, but check it again and also the commitment of your colleagues. have they signed up? i f not, do not rely on them. promises can be broken. get firm contracts of commitment. You cannot build a facility unless you have consultants to make it viable.

every point raised so far has to be answered. o f course, there is an enormous choice of solutions: from very small, to a unit with three or four consulting rooms and one or two local anaesthetic treatment areas, to a large unit with multiple consulting rooms, theatres and beds.

i n general, if the correct location can be found, the easiest conversion can be carried out to an open­plan office building.

These buildings, very often on a small business park, have incorporated modern design techniques with false ceilings, raised floors, loads of ducting, air conditioning and high specification iT installations.

They also give complete flexibility for the partitioning and the engineering services can be easily housed in the shell of the building.

The ‘dreamer’, more conventionally known as the potential clinic owner/developer, has now

reached the point of no return. p roviding all the points previously considered have been answered satisfactorily, the project can proceed.

no turning back h owever, do not unless you are confident, in a cold logical, unemotional way, that all bases have been covered – project viability being the most crucial. There is no point in building ‘the beautiful dream’ if bankruptcy results. o nce you ‘cross the Rubicon’, there is no turning back. i f the project is a small to medium­sized project, the architect can co­ordinate the build programme, providing that all agree to weekly site meetings to progress matters and discuss all ancillary points. There also must be a gant Chart analysis with timelines through to registration and opening. in harness with the build programme, all non ­ construction

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aspects of the project have to be planned, agreed and implemented. included in this ancillary programme of works and attention are the following prerequisites to opening for business, all of which are the ongoing management issues and administration that is essential to underpinning a successful operation:

 A management structure, including nursing, theatre and nonmedical management, a staffing structure including hR function;

 All surgical equipment, including diagnostic, and specialist requirements to support the speciality the clinic offers;

 An appropriate i T system, to whatever complexity is planned.

 All relevant alarm systems and patient call back­up;

 Design and layout of all administration areas, furnishing of all such areas and linking to clinical iT system;

 Financial management, includ­

ing invoicing and payment system, also linked to the iT system;

 s ervice ­ level agreements to cover every aspect of the operation to particularly include the pharmacy and equipment sterilisation requirements;

 All non ­ clinical service ­ level agreements;

 Building maintenance and appropriate contracts;

 on­call arrangements to cover 24/7 every day of the calendar year;

 supplier contracts and agreed pricing of all hospital supplies.

Registration requirements

Then there is the CQC and registration. All the policies and procedures will have to have been written specific to the unit, each will have to be checked against the physical layout of the clinic and to the relevant staff and consultants working in the clinic.

The documentation for submission regarding the registration will have to have been submitted some weeks prior to the registration inspection, by which time all key staff will need to be in place, and preparing for the opening.

i t is essential to appoint a project leader to handle and coordinate all the above tasks. Co­ordinating is the most important quality, the timing of which is absolutely key. no equipment

can be delivered until the building is completed.

no staff can be employed until they have somewhere to work, and something to do. Conversely, no clinic or hospital can open until all these inputs have been co­ordinated together.

The policies and procedures must relate to the actual building to be registered, so they have to be tailored to the actual service to be offered in the actual location.

it is a mammoth task which will need a great deal of fortitude and discipline, especially while ensuring the practice does not suffer.

i f you still want to build your own surgical clinic after digesting all the points raised, then good luck. o h, and don’t forget the opening party. 

Maitland Cook is director of The Cadogan Clinic and also founder/ director of Maitland Cook Medical Management Services Ltd

Simple but effective

There is a dirty little secret to marketing your practice, according to surgeon Dev Lall. The secret is that effective – in other words, profitable – marketing is actually very simple. Formulaic, even

Eff E ctiv E mark E ting boils down to just four elements:

❶ the right message;

❷ Presented in the right way;

❸ to the right person; ❹ at the right time.

Successful marketing is just a matter of getting these four things aligned in the right way. a nd when you do so, the results can be staggering. When you don’t get it right, however, you lose your marketing budget, lose your hair and you lose sleep.

a llow me to prove it: imagine trying to sell cigars to non-smokers, or pork sausages to vegetarians. n o matter how expertly rolled by cuban maidens or slowburning and fragrant your cigars; no matter how wonderful the free-range, organic pork in your sausages, you ain’t going to sell any if you get the market wrong.

Yet while it’s simple, it’s not always easy.

many things will come along to derail you – not least criticism from your competitor colleagues and your own uncertainty and fear of getting it wrong.

Over this series in Independent Practitioner Today i’ve talked about a large number of different marketing channels – or doorways, as i call them – ways in which potential patients can find you. for instance, i’ve written about g oogle a dWords, forums, facebook, Pr and writing articles. and i’ve talked about your website and the importance of demonstrating your expert status in the mind of potential patients.

But, really, i’ve gone about this backwards – and quite deliberately. Because i wanted to demonstrate that there is a multiplicity of methods of reaching out to your potential patients. m ost doctors think the only way to get more private patients is

through gP referrals, and perhaps visitors to the website of the private hospital where they work seeing their name in the hospital directory. i hope with this series of articles – and also with my free guides published last year on 100 Ways to Grow your Private Practice (July-august and September 2013) – i ’ve proven to you that this is not even scratching the surface of what is possible.

The three-legged stool of marketing

i’m going to borrow shamelessly from marketing guru Dan kennedy here, because his desc ription of the process is hard to beat.

He describes your efforts at marketing to be like a three-legged stool, with each of the legs representing:

 Message – what you say to your potential patients to get them to consult with you;

 Market – the potential patients out there you could be seeing and treating;

 Medium – the method by which you reach out to these people (the ‘doorways’ described above).

Like a three-legged stool, no one leg is more important than another. and also like a three-legged stool, if any of these legs are missing, you’re going to fall on your gluteus maximus.

Why most people get this marketing thing wrong

n ow, the reason this series of articles is back to front in comparison to reality, is because most doctors’ approach to marketing themselves – the very few that do so, anyway – is to look at the ‘medium’ first and try and shoehorn the message into it and hope it reaches the right market.

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structure the thing is to ask yourself where your market is to be found first of all – then to decide on the medium to reach out to them.

for example, if you are an ophthalmologist and wanted to get more patients with cataracts, promoting your expertise and skills with an advert in The Beano is probably not going to help you very much.

i’m being facetious, of course, because sometimes you have to look at these things sideways.

While The Beano is probably a poor publication to place an advert for an ophthalmic surgeon, because clearly the readership is of the wrong age group, placing an advert in Woman’s Own magazine might be a very good idea. although the demographic is still wrong – median age of readership is 55 – many of these women will have parents who are elderly and likely to have cataracts.

So, paradoxically, Woman’s Own magazine might be a very good place to promote your services as an ophthalmic surgeon looking for patients with cataracts. Women would read your articles and steer their mum or dad to see you.

Patients are looking for someone to treat the symptoms or consequences of the condition, not the condition itself

often clinch the diagnosis before you lay hands on them.

and this information is of vital importance in crafting your message – the words you use in your copy on your website, print advertising, P r pieces, on the radio, whatever.

Because people are looking for solutions to their problems. and their problems are seldom what we think they are.

a gain to use cataracts as an example, patients are not looking for someone to treat their cataracts. n ot really. Some are, because they’ve already seen an ophthalmologist and been given a diagnosis, but in the main they are not looking for a cataract surgeon.

Which highlights the fact that while, in the end, marketing is amenable to common sense, you really can’t know if it’s going to work until you try it. Personally, i think Woman’s Own might be a great place to promote an ophthalmologist looking for cataract patients – but it might fail dismally. You’d have to test it to find out.

So while there is a certain amount of educated guesswork before you start, you can be sure of one thing: the market always, but always, gives you the right answer.

getting your message right

One thing we get repeatedly told throughout medical school is the pivotal importance of listening to your patient – of taking a good history.

more important than examination, more important than any test you might care to throw at them, is taking a careful history, guided by your own experience and what the patient has to say. a s we all know a throwaway phrase used by the patient can

t hey are looking for someone to treat the symptoms due to the cataract. t his is an enormously significant point which bears repeating. Patients are looking for someone to treat the symptoms or consequences of the condition, not the condition itself.

truly get this and you’ll never have a problem again communicating with your patients. Use this in your private practice promotional efforts and you’ll never have a problem attracting patients to come and see you privately.

Talk about the symptoms

So, instead of talking about cataracts, what they are and how you deal with them in your promotional efforts, you should be talking about the symptoms people present with and how you can alleviate them. t his might, of course, be cataract extraction. and better yet, you should use the very words they use to you back at them.

So talk about difficulty driving, especially at night. talk about halos around bright lights such as street lights. talk about washedout colours. talk about the fact that their new glasses don’t seem to have helped their vision at all. talk about difficulty in reading. talk about their eyes getting tired more easily.

these are, of course, characteristic if not pathognomonic of cataracts. remember, the point is not to make a diagnosis at a distance but to get them in to your clinic as a paying patient to be seen and assessed.

If ever anyone uses the word ‘brand’ when talking to you about marketing your practice, treat them like the mugger they are: kick them in the soft parts and run away. Fast.

The importance of testing if there is a secret to success in private practice – or any business venture – it is testing.

Because although you can make an educated guess as to whether a particular promotional strategy is going to work, you can never actually know until you try it out. a ccepting and understanding that in itself is a recipe for success. You’ve got to get rid of the wholly irrational fear of doing this stuff. if you can get over that fear, you are almost certain to succeed eventually – if for no other reason than because something you try has to work sometime, and when it does succeed in generating patients, you’ll keep doing it! Direct response marketing is the only rational type of marketing it is certainly the only type of marketing you should ever be involved in. if ever anyone uses the word ‘brand’ when talking to you about marketing your practice, treat them like the mugger they are: kick them in the soft parts and run away. fast.

Because while ‘brand awareness’ might have some value to the likes of coca-cola and nike, it is a sure way to penury and disappointment when it comes to growing your own private practice.

Because the only rational way to run a marketing campaign is with some sort of feedback so you know if it’s working or not. if you know that, for example, your google or facebook advertising campaign is generating more income for you than it is costing you to run, you should keep doing it. if it isn’t doing so, you try and improve it or try something different.

there is no excuse for not tracking the results of your promotional campaigns. it doesn’t have to be difficult and, in some cases, can be as simple as ensuring the person who books your appointments for you asks each patient where they heard of you.

Whether you are actively marketing your practice or not, you should be doing this at the very least.

Dev Lall (left) is an upper-GI surgeon and runs a specialist private practice consultancy. He is the owner and director of www.PrivatePractice Expert.co.uk

An uneven playing field for inspection

New Care Quality Commission fees highlight the uneven playing field between the independent sector and the NHS, warns Martha Walker (right)

So we now know the annual fees for 2014-15 for all providers of health and social care in england registered with the Care Quality Commission (CQC).

oK, the 2.5% rise facing independent doctors, along with other healthcare providers including NHS GPs – but excluding dentists who overall have not had a fees increase – is not great in the scheme of things.

But this is yet another area that highlights the disparity between private doctors and their colleagues in NHS primary care and dentists in both the NHS and the independent sector.

The percentage may be the same, but in monetary value the gap is considerable and the basis for arriving at the fees is different for each group of clinicians.

summary 2014-15 fees:

Independent doctors are classed as a Community Healthcare Service and fees are based on the number of locations:

 1 location

Fees 2014-15 = £1,540

 2-3 locations

Fees 2014-15 = £3,075

NHS GPs are classed as Primary Care Services (Medical). If the NHS GP practice has one location, fees are based on the number of registered patients ranging from:

 Up to 5,000 patients

Fees 2014-15 = £565 to

 15,000-plus patients

Fees 2014-15 = £870

Dentists are classed as Primary Care Services (Dental) and there is no differentiation between NHS and private.

If the dental service has one location, fees are based on the number of chairs, ranging from:

 One chair

Fees 2014-15 = £600 to

 Six-plus chairs

Fees 2014-15 = £1,300

If fees are based on services, workload for the inspectors and risk, which would seem a logical rationale, then are we saying, in general, an independent practice is a bigger workload for the CQC

A cynic may think the independent sector is subsidising the NHS

and poses a greater risk to its patients? A cynic may think the independent sector is subsidising the NHS.

Not only is there such an inexplicable difference in annual fees but the categories of classification are also puzzling.

NHS GPs and dentists are categorised as Primary Care Services while independent doctors are put into Community Healthcare Services. Surely independent doctors should be classed alongside dentists? As the CQC does not differentiate between NHS and private dentists, why exclude independent doctors from Primary Care Services?

Among documents the CQC published in relation to fees is a very detailed summary of the responses to the Fees Consultation paper, explaining how it reached its decision to raise fees and the comments made by providers from across the sectors.

Six per cent of independent providers responded to the consultation, but what percentage of those providers were doctors was not

indicated. However, 6% equates to 111 responses. were you one of the responders? Interestingly, 6% (449) of dentists and 8% (610) of NHS GPs responded.

Unannounced inspections

Alongside the gap in fees and the different categories for classification, there is the ongoing concern about the timing of unannounced scheduled inspections.

Until now, dentists and NHS GPs have been given 48 hours notice. Independent doctors are given no notice. In March of this year, the CQC announced that NHS GP practices would be given two weeks’ notice to help practices raise standards.

You can do a lot of raising standards with two weeks’ notice. It was also announced recently that dentists could expect a scheduled inspection once every two years. Independent doctors

Independent doctors will still receive unannounced visits once a year, with no notice. The unlevel playing field is beginning to seem more like a ski slope

will still receive unannounced visits once a year, with no notice.

The unlevel playing field is beginning to seem more like a ski slope.

how to level the playing field

The CQC has taken on board the comments made in response documents and through other avenues by providers. In the last year or so, it has shown it wants to engage more positively with independent-sector providers. It has

invited providers to partake in reference groups in the design and reduction of the countless forms required and in formulating the inspection structure and recruiting clinical experts to be part of the inspection teams.

Following providers’ feedback –including part-time private doctors – in the Fees Consultation, the CQC is looking at ways fees impact on some small businesses, and has invited several small providers who responded to join in helping it develop proposals.

The message is that CQC will listen, but you have to talk. So:

 Join the CQC online community;

 Take part in the web-chats with senior CQC staff;

 Complete a post-registration survey if you are a new provider;

 Respond to the consultation documents;

 Attend the workshops and

events held around the country;

 Consider becoming a clinical expert in an inspection team;

 write to the chief executive David Behan and lead inspector for primary care Prof Steve Field. It is only by showing that the independent doctors have concerns and opinions that this sector will be listened to. Being passive is not an option.

Independent doctors just want to be treated the same as their NHS colleagues and their dental counterparts. After all, every clinician follows the same standards, is registered for the same activities and delivers the same services.

 For further reading Go to www.cqc.org.uk and follow the links to fees for service providers.

Martha Walker, a medical management consultant, specialises in CQC registration and compliance. Go to www.cqcconsultancy.co.uk

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When others ask to see medical records

Dealing with a rising amount of third-party requests about patients’ medical records is an increasing problem for many doctors. Dr Naeem Nazem (right) gives some timely advice

As reported in Independent Practitioner Today last month, we at the Medical and Dental Defence Union of Scotland (MddUs) have been seeing a sharp rise in calls from members seeking advice on disclosing medical records to third parties.

In 2013, we received a 65% rise in the number of calls or emails looking for third-party related advice compare to the previous year. A large number of these advice calls came from members who were unsure whether to comply with requests from third parties such as the police or insurance companies.

third parties can make a request for access to a patient’s medical records. However, there are a number of other considerations to take into account.

doctors recognise their primary duty of confidentiality to patients and therefore should generally seek patient consent before disclosure of any medical information to a third party.

Common third-party requests we encounter include fathers without parental responsibility wanting access to their child’s medical records, police seeking records for a criminal case or relatives requesting a patient’s records after death.

the MddUs has also received a number of calls for advice from members relating to the disclosure of third-party information

contained within a patient’s records.

t he d ata p rotection Act 1998 allows patients to access their medical records, but information relating to some third parties cannot be disclosed without their consent.

While the basic principle of providing patients with access to their own medical records seems fairly straightforward, in reality there are a number of things doctors must carefully consider before granting access. t his is reflected in the number of calls we receive on the subject.

Access to own records

When a patient requests access to their own records, doctors should remove identifiable third-party information, other than from other healthcare professionals acting in that capacity. the exception to this position is if the third party provides their consent to the disclosure.

Likewise, if the record contains personal sensitive data which is likely to cause serious physical or psychological harm to either the patient or third party, this should be removed if appropriate.

According to the Information Commissioner’s o ffice (IC o ), third-party information can be disclosed under the d ata p rotection Act when consent has been attained or when ‘it is reasonable in all the circumstances

to comply with the request without the individual’s consent’.

the ICo also states the decision to disclose will ‘involve balancing the data subject’s right of access against all the other individual’s rights in respect of their own personal data. If there is no consent, you must decide whether to disclose the information’.

Here we look at a couple of examples of common requests from a third party looking for access to records:

Estranged parent requesting access to his child’s records some doctors may approach such requests with caution. It is, of course, possible that an estranged parent seeks a copy of their child’s records in an attempt to obtain information or gain advantage over their former spouse. However, doctors should be minded to consider the request as being entirely appropriate.

An estranged father may, for example, want information on a prescription while their son or daughter is staying with them for the weekend or over a holiday. But do all fathers have a right to access their child’s medical records?

the key element to consider is parental responsibility. While all mothers are automatically deemed to have parental responsibility, it is not the same case for all fathers and is dependent on their circumstances.

A father acquires parental responsibility if he is married to the mother of the child at the time of birth – or conception in s cotland. An unmarried father only has parental responsibility if he is recorded on the birth certificate at registration – and the child is born after 1 december 2003 in england or Wales; 15 April 2002 in Northern Ireland; and 4 May 2006 in scotland.

An unmarried father can also acquire parental responsibility by legal agreement with the mother or by applying for a court order. the same law applies to step-parents and civil partners.

If the father’s name is not on the birth certificate and he has not been granted parental rights by agreement or by court, then he is not entitled access to the child’s records.

s ome doctors encounter difficulties when the mother of a child states she does not want any medical information disclosed to the estranged father.

However, it is important to consider GMC guidance on access to medical records which states: ‘divorce or separation does not affect parental responsibility and you should allow both parents reasonable access to their children’s health records’. (GMC’s 0-18 years guidance)

doctors should ensure that, by granting access to the records, they are not going against the child’s best interests. In the case of a child who has reached sufficient maturity, doctors must also consider the need to obtain the child’s consent to the disclosure.

Access to records by an estranged parent can risk drawing a doctor into difficult and complex family dynamics. MddUs recommends that doctors emphasise the need for effective communication between all parties, including the parents, to enable the child’s best interests to be preserved.

Police requesting access to records

the police might make demands for access to specific medical records or ask a doctor for information regarding a particular patient. depending on the conditions of the request, even confirmation that someone is a patient could breach that patient’s right to confidentiality.

the police have specific powers to request records under section 29 of the data protection Act during the course of a criminal investigation. However, this provision enables a doctor to disclose medical information to the police rather than imposing an obligation on them to do so.

d octors should be minded of the GMC’s guidance Confidentiality, which states ‘you must not disclose personal information to a third party, such as solicitor or police officer, without the patient’s express consent, unless it is required by law or can be justified in the public interest’.

s o it is important to consider the benefits of making a disclosure without consent in the public interest weighed against the patient’s right to confidentiality.

Case stuDy: Father’s request to see reCorDs

a father contacts a surgery in england where his child is a patient.

he and the child’s mother are unmarried and now separated, and he wants access to the child’s medical records. the mother also contacts the surgery to ask he be denied access. What action should the practice take?

d octors may consider disclosing information without the patient’s consent in certain circumstances – for example, if there is a possibility of death or serious harm to a patient or someone else or where disclosure may assist in the detection, prevention or prosecution of a serious crime.

t he existence of a lawful warrant or court order also allows doctors to disclose specified information and protects them against breaching the data protection Act or the GMC’s guidance.

While all mothers are automatically deemed to have parental responsibility, it is not the same for all fathers and is dependent on their circumstances

answer. It transpires that the father is recorded on the child’s birth certificate and the date of birth (DoB) is in august 2005. this means that, by law, he does have a right to access his child’s medical records. Note that the location and DoB are important here, as legislation varies among home countries. the mother is informed of this and insists that her own address not be disclosed in the records. MDDus advises that this and any other potentially sensitive thirdparty information should be removed from the notes before being released to the father. The Association of Independent Specialist Medical Accountants is a national network of firms advising over 3,000 medical practices across the UK.

However, doctors should carefully check the content of any warrant and supply only the information requested. the identity of the requesting police officer should also be confirmed.

‘If a patient’s refusal to consent to disclosure leaves others exposed to a risk so serious that it outweighs the patient’s and the public interest in maintaining confidentiality, or if it is not practicable or safe to seek the patient’s consent, you should disclose information promptly to an appropriate person or authority. You should inform the patient before disclosing the information, if practicable and safe, even if you intend to disclose without their consent.’ (Confidentiality, GMC) With any police request for access to records, doctors are reminded to keep notes of any discussions with police and seek advice from their medical defence organisation. 

Dr Naeem Nazem is medical adviser at UK­wide medical defence organisation Medical and Dental Defence Union of Scotland

Let others do the bill chasing

Doctors who audit the true cost of doing their own billing and collection could

in for a shock, says garry Chapman

The number of consultants who have outsourced their medical billing and collection is growing as the process becomes more complex and time-consuming.

INDEPENDENT

Dramatic market changes over the past few years mean specialists must cope with an everincreasing downward pressure from most insurance companies on their fees for both procedures and consultations.

On top of this, the practice has to deal with the increased yearon-year costs of running a business, making it harder to earn a reasonable profit.

Throughout this period, the number of consultants entering private practice has grown considerably at a time when there has been a big drop in the number of people taking out private health insurance. This makes it harder to maintain market share within the specific specialty of the practice.

The focus should be on making sure invoices are raised in a timely manner, that every procedure is billed correctly, taking into account the nuances of each insurer and invoicing with the correct Clinical Coding and Schedule Development (CCSD) group codes combined with the correct fee schedule for each one.

If this is all carried out correctly, then the invoices must still be

chased to ensure the money is collected and any issues delaying payment are resolved.

Due to the recession, there has been a growth in the different types of insurance policies available, with many different levels of cover, which has resulted in a growth in the amount of money the patient has to pay in terms of each course of treatment.

This would typically be in terms of an increased excess on the policy, reduced benefit limits for a type of cover such as outpatient, reduced level of cover for specific treatments and or co-share policies where the patient has agreed to pay a percentage of each invoice.

chasing shortfalls

That has meant more work chasing and retrieving, resulting in shortfalls for the practice that does its own billing and collection. Where practices do it themselves, it is typically left to one person, often the consultant in what little spare time they have available.

As administration is not typically part of a consultant’s core skill set, it inevitably ends up being done late at night or at weekends. This impacts on other aspects of family life and, in many cases, results in billing delays and a

knock-on impact on the finances. If it is not the consultant, then it is left to the secretary, who is often the busiest person in the practice and whose focus is on making sure all other aspects of the practice revolving around the patient are running smoothly.

So, again, the process gets relegated to being done when time permits, resulting in delays, cash flow problems and bad debts. e ven if done in-house and on time, I would, of course, argue that it is worth assessing the costs of doing so by including the hours involved. running costs seem to increase year on year, with accumulated inflation of 14% over the past four years. There has been an even bigger rise in postage costs from the royal mail.

If you add in bad debts, then the cost of doing it in-house really escalates. From our experience, bad debts run at between 5%-10% and, in some cases, far more – an awful lot of money to give away.

Another thing to consider is that the insurance companies are now starting to put pressure on consultants to send invoices electronically to them (see my article in Independent Practitioner Today , page 8, march 2014). So if you do not have the facility to do this, then you need to spend even more money on putting the infrastructure in place to facilitate this.

Financial audit

To find out how much your own billing and collection is costing:

 establish how much time you and your secretary spend a week on all aspects of raising invoices, reconciling payments, chasing outstanding invoices and dealing with queries from patients/insurers that relate to outstanding invoices. Then work out the cost of the time based on the salary paid;

 Calculate how much you spend on weekly postage relating to billing;

 See how much you spend on weekly phone calls and what percentage of that relates to billing;

 Take into account all of the associated stationery costs;

 If you take credit/debit card payments, work out your monthly bill and the cost of banking;

 Find out how much bad debt you have incurred in the past four

years and then compare that to your revenue over that period to provide an average percentage of bad debts a year.

Some costs vary depending on practice location and circumstances, but check out my estimates of a financial audit on a practice with a £300,000 turnover (see box).

Outsourcing medical billing and collection to a specialist organisation allows practices to maximise the time spent with patients without the finance issues clouding the relationship.

It will also enable the practice to have steady reliable cash flow combined with minimal bad debts with maximum revenue generated for the work performed. using a specialist organisation means the practice receives the maximum amount they are entitled to for the patients’ treatment and also keeps the administrative costs as low as possible.

The consultant will not have to spend valuable time learning and keeping abreast of the changes in the private medical insurers’ schedules, which will allow them to maximise time for their patients, which, in turn, generates further income.

Typically, the fee charged for this service includes all of the associated labour costs, phone calls, stationery and postage, so not only do you get all the benefits listed below, but you save money by reducing the costs of running your practice

outsourcing brings:

➀ The expertise in ensuring that all the relevant information is present and correct when raising the invoice, which means there are no delays in the insurer or the selfpayer accepting the invoice.

➁ The resources to ensure there are no delays in raising the invoice, which, in turn, means the invoices can be chased in a timely manner, ensuring that the practice enjoys consistent cash flow.

➂ The resources combined with an efficient process for chasing unpaid invoices, following up on shortfalls and dealing promptly with any problems with claims, improving cash flow and minimising bad debts.

➃ A variety of management and tax reports which can be tailored

Cost of annual self-ColleCtion in

a praCtiCe with £300k turnover

 the secretary spends a minimum of two days a week on the billing and collection = annual cost £9,000

 postage calculated at 50 documents a week including invoices, letter chasing and receipts = £1,600

 administration cost of phones and all related stationery attributed to billing and collection = £25 a week, £1,300 a year

 payment of £1,000 a week was taken by credit card = £52,000 a year. with a transaction fee of 3% = annual cost £1,560 plus annual fee of £240: total £1,800. Bank charges for handling all of their other cheque payments amounted to £1,000 a year, giving an annual total of £2,800

 Debt for this practice: 7% over the last four years = £21,000 a year. so even allowing for the tax write-offs, this still represented a minimum loss of over £10,000 a year

aDDing all of the aBove Costs: £25,000 a year

to the requirements of each practice, including having online access to your own data.

➄ Freedom from any disruption caused by a a secretarial absence for sickness or holiday.

➅ The ability to raise electronic invoices to the insurance companies, ensuring a speedy payment process as well as compliance with their rules and regulations. 

Garry Chapman is managing director at Medical Billing and Collection

Review and protect your wealth with a financial health check...

Ihave considerable expertise in providing specialist, tailored financial advice to NHS Professionals, GPs and Consultants and have worked with many medical professionals to construct robust financial plans for them. I have the experience to help you successfully secure and enhance your financial future by offering specialist advice in a wide range of areas including:

• Investment planning

• Tax and estate planning

• Annual & lifetime allowance

• Retirement planning

• NHS pension scheme

For further information, or to request your complimentary guide to wealth management, contact:

MIKE WILLOUGHBY Associate Partner

Tel: 07583 013928

Email: mike.willoughby@sjpp.co.uk

Web: www.mikewilloughby.co.uk

UndERsTAnding ChAngEs To TAx lAw

A private doctor’s guide to finance

So what next for independent practitioners’ finances? Simon Bruce reviews the state of play after a year of change

In the past year, doctors have witnessed a merry-go-round of changes to their finances. With the Budget aftermath still settling and with political events on the horizon, where should today’s independent practitioners focus their attention?

Plus ca change, plus c’est le même chose?

the pensions industry is still reeling from the substantial changes to pension savings that the Chancellor George Osborne announced in this year’s Budget.

For once, it seems ce n’est pas le même chose

the first 25% drawn from a pension will remain tax-free and, instead of turning the balance into a guaranteed lifetime income in the form of an annuity, senior doctors aged over 55 will have complete access to their pension savings from April 2015.

In practice, this is likely to be of

greater benefitx to the spouses of doctors where pension funding has been made from partnership earnings or limited company funds and where their marginal rate of income tax is likely to be much lower in retirement than their higher-earning partner.

Doctors drawing their nhS pensions have already had more access to their personal pension pots than the general public due to qualification for the ‘minimum income requirement’, allowing unlimited access to pension income where a base level of secured income can be demonstrated.

h owever, the Chancellor’s announcement to lower the minimum qualification limit from £20,000 to £12,000 a year in the period prior to April 2015 will be helpful for those with less valuable nhS Pension benefits.

In a welcome move, a reduction of the 55% tax charge on draw -

The third of the annual planned rises to NHS Pension contributions was introduced in April and is now in force

down lump sum death benefits was proposed. t his will make it more attractive to keep pension funds invested for the long term, with the possibility of these being passed on to family members in the future after a lower rate of tax has been applied.

nhs Pension contributions

For active members, the third of the annual planned rises to nhS Pension contributions was introduced in April 2014 and is now in force. Doctors with an income of £111,376 or higher will see an increase in contributions from 13.5% to 14.5% of monthly gross pay – with Added Years contributions on top for some.

But do not mistake a 14.5% contribution on your pay slip with your total ‘deemed contribution’ under the Annual Allowance legislation. the two are related but are not the same thing at all.

➱ p44

Celebrating our 22nd year in Business

www.medbc.co.uk

Come and join the hundreds of other consultants who use MBC and experience the following benefits:

• Bad debts of less than 0.5%

• Increase in net income by up to 25%

• Freedom for the consultant and secretary to focus on the medical side of the practice

• 24/7 online access to both your financial and practice management data

• Having a service tailored to your needs with your own Account Manager

• Our fees are only charged on the money that we collect for the practice and NOT on what we invoice which means we share the same objectives

Special offer:

To celebrate our 22nd year in business we are for a limited period of time offering all new clients an introductory discount of 20%*

Further information:

MBC – More than just a billing company

Please visit www.medbc.co.uk for more detailed information or phone 01494 763999 and speak to Garry Chapman to establish how we may assist your practice.

*Terms and conditions apply

the Annual Allowance restricts the availability of tax relief on pension contributions in any given year. the new allowance is just £40,000.

the nhS Pension Agency sent Annual Allowance statements to many members in October 2013 detailing their accrual for the 2011-12 tax year.

Unfortunately, many of these statements were incorrect, which led to much anguish and expense for those left to sort out their affairs before an arbitrary December 2013 deadline for the nhS Pension Scheme to cover any subsequent tax liability.

expect more of the same in the future.

Calculating the allowance for the nhS pension is not straightforward, so ensure you or your adviser are looking at the same final figure as h M Revenue and Customs (hMRC).

the onus is on you to calculate and declare any excess contribution on your self-assessment tax return. Remember that if you do have an excess – for example, due to an increase in pensionable pay or clinical excellence award – you can look back to the previous three tax years to see whether all of your allowance has been used this is known as ‘carry-forward’. If there is no allowance to ‘carry forward’, then the excess is treated as taxable income in the year it was accrued, meaning that independent practitioners will have to treat it as income earned and pay up to 45% tax.

t he only alternative is for the nhS Pension Scheme to pay the tax for you. however, this means a debt accruing against your pension scheme and reduced future pension benefits.

new nhs Pension scheme 2015

In a year’s time, the new nh S Pension will be introduced. n o longer based on final salary, it will run as a career average revalued earnings (CARe) scheme and have a much later normal retirement age. Approximately 75% of existing nh S employees and all new employees will join ‘2015 nhSPS’. In general terms, medical professionals born after 1962 could be affected and will automatically

move to the new scheme for their future service only.

Individuals born before this date will either be exempted altogether and remain members of the 1995 or 2008 pensions or will be subject to ‘tapering protection’. they will still have to join 2015 nhSPS, but their joining date will be delayed, depending on how close to their normal pension age they were on 1 April 2012.

Under the terms of the new agreement, 1/54th of pensionable earnings will be added to the individual’s pension account annually and, each year, the total accrued pension account will be revalued in line with inflation – currently the Consumer Price Index – plus 1.5% to reflect a measure of pay growth. the normal pension age will be the same as the person’s State Pension age. tax-free lump sums will only be available by giving up valuable index-linked pension income at retirement.

For younger members, this adds complexity and means that more needs to be added to the retirement pot now if you want to be financially independent and retain some control over your own retirement age.

Protecting the value of your pension fund

Since April 2012, the overall limit to Lifetime Allowance of a pension has been reduced by 30.5% from £1.8m to just £1.25m with a cut in the overall available tax-free lump sum of £137,500 (from £450,000 to £312,500).

If you are affected by the reduced limit to tax-free pension savings, you may have already applied before the April deadline for Fixed Protection 2014 to safeguard the higher allowance of £1,500,000.

It may now be useful to apply for the Government’s new protection plan, Individual Protection ’14 (IP14), if the value of your pension rights exceeds £1.25m.

t he scheme will allow you to protect your current pension fund value up to £1.5m. Importantly, you will still be able to accrue benefits through both the nh S and private pension schemes without losing the protection.

Applications for IP14 will be open shortly and, following industry feedback, h MRC has

effecT of dIffereNT TrAdINg STrucTureS

In light of the new flexibility of pensions, it is more important for you to check that you are making the most of opportunities presented by your practice’s trading structure.

You may well have considered the advantages of becoming a partnership or limited company, but are you really maximising the efficiencies that these can provide?

If your spouse is a formal partner and sharing some of your practice income, it is likely that he or she will be paying higher-rate income tax now but may not be in the future.

A typical pension contribution strategy takes advantage of this, particularly where total income exceeds £100,000 a year, as this is the level where your tax-exempt personal allowance, now £10,000 a year, is at risk.

Is there excess cash on your company’s balance sheet which could give better long-term returns if directed to pensions and investments?

A limited company can contribute ‘pre-taxed’ company income to a pension. If you are a higher-rate tax payer, instead of declaring the income as company profit and taking the income as a dividend, you can put the sum straight into a personal pension for a spouse if they are employed in the business.

Similarly, rather than holding excess cash earning little interest, you could be making contributions to a corporate investment account.

If you are trading as a limited company, your accountant and adviser should have joined-up thinking over your income requirements now and your future exit strategy.

do you intend to go for a formal liquidation and hope that entrepreneur’s relief will apply or will you convert to an investment company and extract dividends for a number of years post-retirement from clinical practice?

The decisions you take now will have a big effect on your future income stream. Too many independent practitioners are focused on the short-term income tax issue without an eye on the future.

do your current adviser and accountant meet to agree a coherent plan or do they have different objectives?

The Individual Protection 2014 scheme will allow you to protect your current pension fund value up to £1.5m

agreed to allow doctors holding ‘enhanced Protection’ to apply. t his is a key area to get right. Unfortunately, we have helped many new clients who have previously been poorly advised in the area of pension protection – either because their former advisers or accountant do not consider it or do not wish to advise on the complex nhS Pension.

Beware: it is essential to monitor your annual accrual of pension benefit if you remain an active member of the nh S Pension Scheme and have applied for Fixed Protection ’14.

You may find that normal service is enough to invalidate your pension protection and will leave you subject to the standard Lifetime Allowance of £1,250,000 and a reduced tax-free lump sum. the decision to stay in the scheme or opt out will depend on a number of variables that are personal to you.

Managing investments

t he R e IS a tendency for many people to consider ‘investments’ separately from ‘your financial future’, writes Simon Bruce. What are investment returns for if not to help protect your current lifestyle for the rest of your life or to achieve your dreams post-medicine?

Retaining multiple investment managers in the hope of diversification and risk reduction or sticking with a big name who doesn’t consider your nh S pension can create confusion and actually increase risk.

Return of the ‘isA millionaire’ e ven after the Budget changes, the fact remains that many senior doctors will not wish to maximise their own pension savings

because of the caps on Annual and Lifetime Allowance.

Instead, the Chancellor’s surprising decision to raise the annual individual savings account (ISA) limit from £11,880 to £15,000 from July 2014 will make this tax-exempt allowance even more popular.

As an example, if a doctor and his/her spouse invested £30,000 every year for the next 15 years and achieved a 3% real return after charges and inflation, the final fund will be £668,222 – from which tax-free withdrawals can be taken without restriction to supplement the nhS Pension.

t he new ISA ( n ISA) will also allow savers to enjoy more flexibility and move money from

NHS pay freeze

the GOveRnMent’S decision to reject the pay Review Body’s recommendation to reward all nhS staff with a 1% rise has received widespread criticism.

In March, h ealth Secretary Jeremy hunt revealed that more than 600,000 employees – more than 50% of nhS staff – will not receive the rise in remuneration because they are already receiving a ’progression pay’ rise, which automatically increases in line with service.

With inflation running at 2% (as measured by the Consumer Price Index), even a modest 1% rise will be a pay cut in real terms. In addition, around 400 very senior nh S managers will miss out on the pay rise altogether as they ‘continue to show leadership in the exercise of pay restraint’, according to the official ministerial statement.

One consolation is that doctors holding Fixed Protection on their pensions’ savings will retain the protection for longer – although it is still likely to be ineffective over the course of the whole tax year. Fixed Protection ’14, which restores a lifetime allowance of

£1,500,000, can be negated if you remain an active member of the nhS Pension and your benefits go up by more than inflation.

on the horizon

these are unlikely to be the last ‘adjustments’ doctors will face in the year or two ahead. Potential changes to the current consultants’ contract are still being debated, with a major focus on pay progression, clinical excellence awards and seven-day services.

Any proposed amendments to progression pay will, of course, have a sizeable impact on pensions.

When faced with near-constant fluctuations in the external environment, it is more important than ever to ensure your own financial plan is sufficiently flexible to roll with the punches and is geared to achieving your personal goals. 

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

existing cash ISAs into investments and back again, which can prove useful if your financial situation or attitude to risk changes.

Capital gains exemptions

It never fails to amaze me how few individuals go beyond ISAs to maximise their annual capital gains allowance of £10,900. t his allowance provides great scope to harvest investment gains every year totally free of tax. even when compared with income tax, capital gains are still taxed at 18% for basic-rate income taxpayers and 28% for those on the higher rate. With proper stewardship, you can both build a good-sized portfolio before you need to worry about capital gains tax.

How do I tackle domestic

Dilemma 1

A pregnant wife is being pushed

QI am a GP working in independent practice. A pregnant patient recently came to see me and admitted that things had been strained between her and her husband. They had an argument resulting in him pushing her against a wall. What should I do?

AIt can be difficult to know what to do when faced with possible domestic abuse. While doctors may pick up on signs that it is taking place, patients may be reluctant to confirm their doctor’s suspicions.

All members of the healthcare team have a duty to be alert to the symptoms of possible domestic abuse. It is important to be aware and follow any local and national guidance.

For example, the RCGP issued guidance in 2012 advising on the development of a practice policy for managing cases of domestic abuse.

Key features of the guidance include electing a named senior person within the practice to identify and engage with local services for victims of domestic abuse, and establishing a care pathway for victims to access these services.

Medical defence adviser Dr Richenda Tisdale (right) answers more of your topical calls for help arising from recent incidents with patients and doctor colleagues

The guidance makes it clear that you must take action where there is concern that a young person is at risk, and you do not need evidence before raising concerns

It is important that GP practices have a clear protocol for dealing with domestic abuse. You may wish to offer training to staff in order to help them explore the issue sensitively with patients. Liaise with local services who offer support for victims of domestic abuse.

Take action

Consider the family as a whole if abuse is, or may be, present in the household. The GMC advises all doctors to be aware of risk factors linked to abuse and neglect. It sets out its guidance in Protecting chil-

dren and young people: the responsibilities of all doctors (2012)

The guidance makes it clear that you must take action where there is concern that a young person is at risk, and you do not need evidence before raising concerns.

You should seek consent before disclosing information, unless there is a compelling reason not to do so. But information can be shared appropriately without consent if you feel that, on balance, the benefits to the child or young person outweigh the benefits of keeping the information confidential.

domestic abuse?

Dilemma 2 Clinical photo makes me wary

QA friend and colleague recently shared an image online on a social networking site. He shared the image so that he could ask my clinical opinion. However, I felt uncomfortable that he shared the image in this way, as it seems risky.

AThere are a number of inherent risks with sharing images or other recordings of patients online, but with so many doctors now owning smartphones with cameras, there may be circumstances where a doctor might consider doing so.

Where a photograph of a patient is taken and then stored on a smartphone, camera or other digital device, it will need to be protected in the same way as other clinical records or recordings.

The MDU advises that such devices used for this purpose are encrypted and if they are not, images are immediately downloaded to a device that is and the original image permanently deleted.

Many risks

When a photograph is taken on a smartphone, the temptation may be to make use of popular or more niche file-sharing apps and websites in order to share photographs with medical colleagues.

Although sharing photos in this way may seem like a useful way to gain opinion or discuss medical conditions with like-minded medical professionals, it comes with many risks which are likely to outweigh the benefits.

With this in mind, doctors should be very cautious about

sharing photographs of patients online. If a doctor is considering doing so, they should contact their medical defence organisation for advice on specific cases.

If a doctor would like to make a recording or take a photograph of a patient, it is important that they gain specific consent to do so.

When seeking consent to record patients as part of their care, explain why it is needed, as well as how it may be used and stored.

If you wish to use it for secondary purposes, such as in anonymised form for teaching, research or other healthcare purposes, this must be explained to patients and their specific consent obtained, making a note of the discussion in the patient’s records.

Specific consent is not necessary to record certain clinical images such as X-rays and images of pathology slides, but doctors should explain to patients, where practical, what is involved when seeking consent for the examination, including that this recording may be used in anonymised form for other healthcare purposes such as teaching.

Think carefully before using a mobile phone or tablet computer to take and store clinical images. If the image should ever fall into the wrong hands, it is unlikely that you will be able to argue that you had taken all reasonable steps to protect its security, given that it contains confidential patient information.

Such devices should be protected with encryption software. If you do decide to take a photograph or recording with a mobile phone or tablet computer, make sure your settings do not allow images to be uploaded to the internet automatically through photo-sharing apps and websites. 

Dr

Richenda Tisdale is a medico-legal adviser with the MDU

Don’t break the tax

There has been much confusion over the annual allowance statements received from NHS Pensions by many consultants and GPs with a private practice in the last few months. Ian Tongue does his best to de-mystify the paperwork

Due TO changes to the limits that a taxpayer can pay annually into a pension scheme, it is important doctors understand their NHS Pension statements to allow effective pension and tax planning and avoid a nasty shock later on.

What is the issue?

The Government made changes to the limit that can be paid into a pension each year and attract tax relief at your marginal rate of tax. The figure has varied considerably over the years, but from 5 April 2011, the amount fell to £50,000 a year and, from 5 April 2014, this is now £40,000 a year.

Of course, many doctors look at their payslips and conclude that they are not paying anything like that into a pension, so they believe they are OK.

unfortunately, this may not be the case, as HM Revenue and Customs (HMRC) has special rules to calculate how much has been deemed to have been contributed. Therefore, the actual payments from your NHS payslip are irrelevant for the purposes of this calculation.

Why does it affect me?

There are two main types of pension scheme: defined contribution and defined benefit, which are fundamentally different pension types.

u nder a defined contribution scheme, you pay £x in and hope it increases in value to give you a good return on retirement.

However, there is no guarantee of the value of the historical contributions made at retirement, as it is exposed to investment risk. Contributions into these types of schemes count pound for pound within the current £40,000 limit.

The vast majority of u K pensions for those working in the private sector are of this type. For

limit on pensions

consultants and GPs, this will be all private pensions plus any additional voluntary contributions (AVCs) and free-standing additional voluntary contributions (FSAVCs) paid.

The NHS Pension Scheme, as with many public sector pensions schemes, is a defined benefit scheme. This means that there is a formula to determine how much your pension has increased each year.

For consultants under the 1995 Pension Scheme, this is 1/80th of superannuable earnings. For GPs, this is based on dynamised earnings.

Therefore, for defined benefit schemes, the growth in one’s pension is the important variable to consider rather than actual contributions into it.

How does it work?

The mechanics for consultants and GPs are different and the figures used vary depending on whether you are in the 1995 or 2008 scheme.

However, let us look at a simple example of an NHS consultant in the 1995 scheme with 25 years’ service at the start of the year whose superannuable pay increases from £90,000 to £95,000. For the purposes of this calculation, allowable inflation is assumed to be 2.5%.

At the start of the year, the individual had accrued 25/80ths of £90,000 as a pension, which is £28,125. HMRC allows this to increase by inflation, so it can rise by 2.5% without any real growth. This takes the pension to £28,828.

At the end of the year, the individual has an accrued pension of 26/80ths of £95,000 or £30,875. Therefore, the growth in pension in this example is £2,047.

The formula to calculate the deemed contribution is 16 times

Many doctors look at their payslips and conclude that they are not paying anything like the £40,000 limit into a pension, so they believe they are OK. Unfortunately, this may not be the case

helps significantly mitigate or even extinguish the excess growth, particularly as many consultants have faced a pay freeze or modest growth in their salaried earnings.

What if i have a personal pension as well as the nHS?

the growth plus the lump sum increase. For those in the 1995 scheme, this is effectively 19 times the growth or £38,893 in this example.

GPs’ pensions are far more complicated to calculate and, as a consequence, so is the deemed pension input. However, similar mechanics apply as for an NHS consultant.

What are the risk factors?

Sudden increases in superannuable pay are the most common trigger for a spike in pension growth and hence exposure to a possible tax charge.

This could come from a variety of sources, but usually from a promotion, increment point or clinical excellence award. However, any increase to superannuable programmed activities or a new salaried post would have a similar effect.

What can be done to mitigate the tax?

When the rules came out, HMRC anticipated spikes in growth and therefore they allow you to look back three years to see whether there is any unused capacity to come to your aid in a year where there is a spike in growth.

Frequently, the unused relief

The most likely scenario is that the amounts you contribute into a separate pension arrangement will be under a defined contributiontype scheme. So any contributions made in a tax year may need to be taken into consideration when calculating growth and any unused relief from earlier years.

It is important that you speak with an independent financial adviser if you are paying into multiple pension schemes and provide your accountant with all the details.

What happens if i have exceeded the limit?

If you have exceeded the limit, you will have a tax charge at your marginal rate of tax. Therefore, if you exceeded the allowable growth after taking into account any unused relief from earlier years by £10,000 and you were a 45% taxpayer, a tax charge of £4,500 would arise.

By default, this tax charge is collected under self-assessment by reference to the tax year to which it relates. It will also have the knock-on effect of increasing payments on account, which may or may not be reduced, depending on the status of your other sources of income.

However, an option exists for an NHS Scheme member to request the pension scheme to pay the tax on their behalf. The amount paid effectively becomes an interestbearing loan from the date that the loan is taken out and your actual retirement date.

The amount of the loan at

retirement is deducted from your capital value in working out your final pension. NHS Pensions has produced a table to estimate the effect of the NHS Pension Scheme paying tax on your behalf based on your age and expected retirement date. This can be found at: www.nhsbsa.nhs.uk/Documents/ Pensions/Scheme_pays_-_factors_ to_estimate_pension_reduction_ v0_1_-_Dec_2012.pdf

If you are wanting the NHS scheme to pay any tax due for exceeding the annual allowance, it is important to be aware of the deadlines to submit claims.

For 2012-13, the deadline to submit an election for ‘Scheme pays’ is 31 July 2014. On first impressions, this may seem generous, but seeing as the final statements from NHS Pensions indicating growth for 2012-13 will not be issued until May/June 2014, there is actually a narrow window.

NHS Pensions has been issuing provisional statements for 201213 since the latter part of 2013, but many of these are expected to be revised when the final calculations are made, particularly for GPs.

It is important that you make yourself aware of the new legislation in force and provide your accountant with any pension savings statements issued by NHS Pensions.

Take the advice of an independent financial adviser in relation to your options and, with a new NHS Pension Scheme on the horizon, it is better to establish contact sooner rather than later.

 next month: Tops tips for accounting and recordkeeping

Ian Tongue is a partner with Sandison Easson & Co, specialist medical accountants

SUV – still ultimately versatile

Independent Practitioner Today’s

motoring correspondent Dr Tony Rimmer tests the third-generation

BMW

If there is one thing that you can guarantee in running a private practice it’s that the business can’t stand still. We live in a competitive world and rivals will always try to overtake you, even though they may have taken on an idea first developed by yourself.

Medical techniques and technologies are constantly evolving, so we have to be open to change. In the world of motoring, it was BMW who was first to offer a large 4x4 sports utility vehicle (SUV) that had excellent road manners and drove like a normal car with a sporty flavour.

In 1999, it launched the X5 and the car was an instant success. taking advantage of the brand’s high-quality and performance image, buyers could transport the whole family in spacious comfort and enjoy the drive too.

fifteen years on and BMW has released the third generation of the X5. the basic design premise is the same but it now has to com-

X5 to see if the original sports utility vehicle still leads the pack

pete with some serious rivals like Porsche’s Cayenne and the latest r ange r over Sport. h ave all the updates been enough to keep it at the head of the game?

Although slightly bigger than the original, the new X5 is instantly recognisable and styling upgrades have kept it looking fresh and up to date. t he BMW family face is shared with the 3-series and 5-series saloons.

clearer interior

t he new interior certainly has enough to satisfy the doctor who values clarity, quality and precision behind the wheel.

t here has been a deliberate move to reduce the number of buttons and many of the hightech features are accessed by BMW’s superb iDrive controller; still the best in the game.

A huge 10.2-inch screen displays the Professional navigation system, which sensibly comes as standard on all models.

Passengers are well catered for with plenty of room for three adults across the back seats and they get plenty of head and legroom.

BMW also offers an extra two seats at the very back as an option, but these are only child-sized so will appeal to the doctor with a younger family – or children with lots of friends! If you need an offroader that can take seven adults, the Land rover Discovery is still probably the best.

Accessing the huge luggage space is really easy and there is a split tailgate like the range rover to make it easy to slide luggage in and out. the quality of the interior fittings is, as one would expect, top notch and although still not quite at Audi level, certainly enough to deliver that feelgood factor on the drive home from a busy session at work.

It is a shame that the ride and noise levels don’t quite match the promise of the interior. the X5’s

suspension is a bit on the firm side, which is great for the driver in a playful mood, but not so good for passengers.

If you opt for ‘comfort mode’ from the Adaptive M Sport suspension, things smoothen out, but this should really be the default set-up.

huge confidence

Although most owners will never muddy the wheels of their X5, the car is very capable off road. Better than a Cayenne but not as good as a range rover, it gives you huge confidence in tricky driving conditions.

On the motorway, wind noise from the large mirrors and road noise from the wide wheels can be a little intrusive. the steering could be better too. there is a slight lack of directness that is at odds with the steering feel normally delivered by BMW products.

What I can’t complain about

though is the choice of engines. Although there is a 2.0 litre fourcylinder diesel in the base model – even available with two-wheeldrive only – most buyers will sensibly go for the 3.0 litre six-cylinder diesel that is a well established and highly regarded unit.

three different power outputs result from the engine having one (255bhp), two (310bhp) or three (376bhp) turbos to boost output. As a keen driver, I tested the triple turbo and was not disappointed. Despite the large size and hefty 2,190kg kerb weight, this X5 fairly

The 10.2” instrument display screen houses BMW’s Professional navigation system, and the company’s superb iDrive controller is still the best in the game

ily commitments and an appreciation of quality products? t he answer is affirmative. Although not perfect, it has a classy image, is very roomy, drives well and can perform all the functions necessary to act as a large family car one minute and an executive express the next. 

Dr Tony Rimmer is a GP practising in Guildford, Surrey

BMW x5 M50d

Body: Five-seat hatchback SUV

Engine: 3.0 litre V6 turbo-diesel Power: 376bhp

Torque: 740Nm

leaps down the road and can certainly embarrass any hot hatch that isn’t concentrating. f uel economy isn’t bad and emissions are much improved over the previous version, model for model. So does the new X5 still appeal to the busy professional with fam-

Top speed: 155mph

Acceleration: 0-60mph in 5.6 secs

Claimed economy: (Combined) 42.2mpg

CO2 emissions: 177g/km On the road price: £63,715

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Doing the physical splits

Independent Practitioner Today’s unique income and expenses benchmarking series produces its first full-year analysis of two new specialties to this series. Ray Stanbridge reports, with additional material by Martin Murray

We made our first attempt to try to record income trends for dermatologists and oncologists just a year ago. Previously, they were included under the all embracing heading of ‘physicians’. as with other specialties, we are finding that ‘average’ income figures are becoming increasingly less relevant. This is because there are significant differences and outcomes by region and between those who are seriously interested in developing private practice and those doctors who are just using

private practice as a means to top up their income.

dermatologists and oncologists are not immune to the dynamic factors influencing changes in the private medical sector. These include the growth of groups, partnerships with hospitals and clinics and incorporation.

For the sake of clarity, we must state that our figures should not be regarded as statistically significant. d etails are extracted from the accounts of a sample of consultant oncologists and dermaaveRage INCOMe

tologists who are not full-time in private practice.

Our sample does have to satisfy a number of standard criteria. Consultants must:

 Have had at least five years’ experience in the private sector;

 Have earned at least £5,000 a year gross in the private sector in the year to 5 april 2012;

 Be seriously interested in pursuing private practice as a business;  Hold (or have held) an old-style NHS maximum part-time contract or new contract;

 Work either as a sole trader, through a limited liability partnership or group, or through the medium of a limited liability company.

PROFITS FOCUS IS THe INDUSTRy BeNCHMaRK

Doctors and their specialist medical accountants use the statistics published in our ‘Profits Focus’ series to look at how their earnings compare with others and see where they can cut costs and boost their income.

Now all this data is available on our website and is free when you take out a subscription. either fill in the subscription form on page 24 or phone 01752 312140 or email lisa@marketingcentre. co.uk. get a discount by paying by direct debit.

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd. Additional information: Sandison Easson and Co

Rash of expenses peel away profits

A 2% rise in income is no emolient for dermatologists, who suffered a drop in profits, thanks to a big hike in their costs

N OTW i THSTa N di N g all the data issues summarised to the left, our view is that the average income of dermatologists in private practice has risen by 2% from £107,000 in 2011 to £109,000 in 2012.

Costs have risen by 9.6% from £31,000 on average to £34,000. a s a result, taxable profits have shown a 1.3% fall from £76,000 to £75,000.

There has been some increase in staff costs, again generally mirroring the effect of the national rise in personal tax-free allowances.

Consulting room hire fees seem to have shown an increase, presumably as private hospitals move away from historic ‘deals’ in the light of the competition inquiry by the Competition Commission, latterly the Competition and mergers authority.

marketing and promotion

There has also been some increase in ‘other’ costs, reflecting, for a number of consultant dermatologists, the increased expenditure they are incurring on marketing and promotion.

What then of the future? generally, the market for dermatology looks strong. However, there has been some re-alignment of costs and reduction of fees from insurers for some dermatological procedures. i n addition, some insurers have discouraged dermatologists from undertaking diagnostic tests, and this has had an impact on their incomes. in general, however, we expect a positive outlook for incomes for dermatologists in private practice at this time.

➱ Oncologists, p54

How ARE YoU Doing?

Use

DeRMaTOLOgISTS’ eXPeNSeS WeNT UP By 9.6%

A power surge in data?

We THiNk there may have been a lack of compatibility in data between 2011 and 2012. This is because seemingly average gross incomes have risen by 22.5% from 2011 to 2012.

This seems highly unlikely in the current market, even though oncologists generally seem to be developing their practices well.

Costs have risen, on average, by 17.9% from £28,000 in 2011 to £33,000 in 2012.

Taxable profits seem to have risen by 24.6% from £65,000 to £81,000 – but please note our concerns identified on page 52.

Staff and consulting room hire costs have risen, probably for the same reasons as they have for dermatologists.

There has been some increase of ‘use of home’, as many consultants do write their reports and undertake work in their home offices.

i n addition, there has been a growth in ‘other’ costs, again representing the fact that an increasing number of oncologists are developing their marketing activity.

Our overall view is that the market prospects for oncologists are good. There are significant inter-

ests, around the country, in the pros and cons of groups and we would expect that the number will increase over the next few years.

Oncologists have yet to fully experience fees re-alignment programmes from insurers as others have, but doubtless this will come. in addition, we expect to see further discussions as to whether some forms of cancer are of a ‘crit-

ical’ or ‘chronic’ nature. This could affect long-term incomes, but as stated above, short-term prospects are good.

 next month: Anaesthetists

Ray Stanbridge runs an accountancy, finance and tax advisory service specialising in the medical profession. Martin Murray is a partner at Sandison Easson & Co, specialist medical accountants

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd. Additional information: Sandison Easson and Co

whAt’S coMing in JUne’S edition

Our June issue, out on 26 June, is packed with advice and tips from a range of experts to help you run your private medical practice. and there will be a free copy of our 2014 Wealth Management guide to help you and your practice. Coming up next month:

 So how much money are you prepared to lose if it all goes wrong? In an in-depth report for Independent Practitioner Today, an entrepreneur shares the ups and downs of starting a medical business

 Selling practice goodwill – we report from the latest seminar run for doctors and their accountants

 a warning about recent tax investigation trouble for doctors – and what to do about it

 MDU chief executive Dr Christine Tomkins spells out what can be done to curb the alarming rise in the cost of clinical negligence compensation claims

 Consultants are still getting into trouble for flouting the rules when conducting private work in the NHS. We asked Medical Protection Society medico-legal adviser Dr angelique Mastihi for tips and advice

Published by The Independent Practitioner Ltd. Independent Practitioner

Today is editorially independent and thanks Bupa for its assistance with distribution.

Printed by Williams Press

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 2014

Registered office: 7 Lindum Terrace, Lincoln LN2 5RP

Write to Independent Practitioner Today PO Box 198, Cranleigh GU6 9BB

 Why the case for computerising your practice administration and finances is now overwhelming

 Practice management: the key to commercial success

 Profits Focus examines the latest accounts of anaesthetists

 The rise of the ISa millionaire. Why regular saving is a good habit to adopt

 Business Dilemmas – more of your ethical questions answered

 Will our ‘Doctor on the Road’ columnist enjoy summer in the Jaguar F-type convertible?

 ‘Private Practice expert’ Dev Lall looks at publishing for patients and profit

 The efficient management of clinical waste for private gPs and consultants

 Plus all the latest monthly features and news

aDveRTISeRS: The deadline for booking advertising for our June issue is 30 May

eDITORIaL INqUIRIeS

Robin Stride, editorial director

Email: robin@ip-today.co.uk

Tel: 07909 997340

aDveRTISINg INqUIRIeS

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Publisher Gillian Nineham Tel: 07767 353897.

Email: gill@ip-today.co.uk

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