IT makes you smart
An amusing look at doctors’ obituaries in the last taster of Medicine’s Strangest Tales P30
Keep taxman sweet Accountant Susan Hutter gives useful pointers on staying the right side of the taxman P39
I’m under investigation
What are you to do if a private hospital wants to investigate your practice or suspend practising privileges? P42
By Robin Stride
Independent practitioners are being cautious about chasing more overseas business following a fall in the number of acute patients coming to central London from abroad.
New figures for the area show the self-pay market dipped 15% between 2014-15 – a drop in value from £261m to £222m.
According to a detailed state-ofthe-market report by analysts Laing-Buisson, the fall in international self-pay dragged down a general growing trend in UK self-pay.
Embassy patients held up overall, rising 1% from £320m to £323m and were helped by an improved NHS PPU performance, although many independents suffered declines.
The UK private medical insurance contribution rose 11% from £782m to £870m, representing 61% of the funding.
Report author Ted Townsend told Independent Practitioner Today: ‘While it is hard to tell if the downturn in overseas patients is a hiccup or a new longer-term trend, it would appear that many practitioners are becoming wary of overcommitting time and energy to this historically lucrative market.’
He said a drop in the oil price hit the amount of money available to overseas patients, while new competition plus a desire to keep
patients at home had affected overseas revenues in London ‘and apparently continues to do so’.
The issue for many private practice businesses was how much time and effort they should now invest in overseas patients if the trend was going away from them.
His report for LaingBuisson says NHS PPUs overall have a higher dependence on embassy earnings than the independent sector, suggesting there is still demand out there. They are thought to have suffered less of a down-turn in 2015 than private hospitals.
But against this, various Gulf countries appear to be cutting the number of patients sent abroad, said Mr Townsend. London faces growing competition from other centres, particularly in Germany and the US for the more complex patients and India, South Korea and Thailand for the less complex.
His report states: ‘In general, 2015 seems to have marked a point where both sides re-assessed the existing patient flows, and possibly some hospitals have started to become a little bit more cautious in over-investing in overseas/embassy patients as a source of revenue growth.’
The private acute medical care market in central London grew to an estimated value of £1.43bn during 2015, the report says.
This is equivalent to around 35% of the national market for
private patient revenues in independent hospitals and PPUs in the UK.
But while this represents overall growth of over 4% compared to 2014 and an improvement on the 2.6% growth seen in 2014, this is still down on the ten-year average growth of 7.8%.
The report says private hospitals appear to be getting better at marketing to prospective self-pay patients, introducing packaged prices and targeting individual patients effectively as consumers, rather than relying on private consultants to bring them the work.
But it adds: ‘However, not all hospitals, nor consultants, feel able to take the risk that a patient may need to come back for unanticipated further treatment, particularly for the complex patients that central London hospitals tend to cater for. This has affected the types of treatments available, broadly limiting them to the less complex end of the spectrum.’
On consultants’ groups, the report says forming a partnership or company with more than four to six clinicians seems to be difficult in central London, particularly if their private practice is still only part-time.
Simply sharing the proportion of their fees spent on admin/staff/ offices with other clinicians is not enough to build up any capital in a business to be used for invest-
ment and few specialties appear to have key diagnostic or treatment procedures that can be done outside hospital.
Hospitals’ existing investment in equipment means that it can be difficult for groups of clinicians to establish a critical mass sufficient to be able to offer its own end-toend patient services.
LaingBuisson’s Private Acute Medical Care in Central London . Available at www.laingbuisson.com
Pipework makes an artistic impression in a new cancer centre funded by HCA Healthcare. See full story on page 8
the sum is greater than the parts tips on improving teamwork, upon which the success of private practice is based P10
what you can tell relatives a look at what the Gmc’s confidentialty guidance says on disclosures to family P18
don’t work harder for less money
Knowing profit from your profitability is vital when measuring performance P21
a lexicon of a well-run PPU
philip Housden begins a summary of his series’ advice on private patient units P26
online prescribing is no panacea a legal briefing on the pitfalls and perils of prescribing medication online P36
emotion sickness
How to avoid succumbing to the vagaries of human emotion when investing P40
The snap general election has brought a dose of joy and pain to independent practitioners.
Some important business issues we’ve covered in recent months have been affected. On the plus side, the headache of quarterly returns under HMRC’s Making Tax Digital programme is off the agenda – for now.
Another threat to doctors’ businesses, under plans to cut the new dividend tax allowance, was also left out of the Finance Bill.
But the election has done nothing to speed up progress on revising the discount rate formula that threatens hefty
rises in defence fees (see page 3).
Another victim is the Association of Medical Insurers and Intermediaries’ (AMII) petition to fight further unfair increases in insurance premium tax on private medical insurance – our lead story last month.
The AMII is after 100,000 signatories so the issue can be debated in Parliament. But with Parliament dissolved on 3 May all business, including petitions, had to stop until after the poll.
Annoyingly, signatures cannot be transferred, so after the election, please sign up again –or for the first time – at amii. org.uk/iptpetition
tell US yoUr newS Editorial director Robin Stride at robin@ip-today.co.uk Phone: 07909 997340 @robinstride
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Next month’s snap general election has proved beneficial for doctors facing increased digital tax reporting and lower dividend payments from their limited companies.
Several controversial revenueraising plans announced by the Government recently were cut from the Finance Bill to get it approved in time.
The proposed cut of the new dividend tax allowance, forcing doctors running their business as a limited company to pay more tax, is delayed.
From 2018, it was to drop from £5,000 to £2,000. And this would have also impacted doctors with shares outside of ISAs or pensions.
Plans to introduce controversial quarterly digital tax reporting also
missed going into the Finance Bill. Simon Bruce, chief executive of specialist financial planners Cavendish Medical, said several recent political Uturns, including dropping higher National Insurance Contrib utions for the selfemployed, had brought welcome relief to doctors facing constant financial pressures.
But the plans were only delayed – not necessarily removed altogether. He added: ‘It is wise to ensure your own finances are in the best possible position to be able to face whatever announcement comes next.’
He advised specialists to have a coherent plan and proactively manage it – ignoring shortterm forecasts and ‘electioneering hype’.
Doctors providing services to the NHS via their own company have voiced concerns about new offpayroll working legislation.
Government plans were announced last year to reform the way those working for public sector bodies via their own companies will be taxed.
Now new Finance Bill legislation could have implications for doctors providing any service to the NHS, whether clinical, research or clerical, via their own company.
An HM Revenue and Customs’ note in March last year stated: ‘The Government announced at Budget 2016 that it will reform the intermediaries’ legislation for public sector engagements. Liability to pay the correct employment taxes will move from the worker’s own company to the publicsector body or agency/third party paying the company.’
But specialist financial planners Cavendish Medical said several doctors it spoke to took this to mean that private practice income would now be subject to tax and National Insurance at source as
opposed to the current system of individuals or groups raising invoices, dealing with their own expenses and tax position.
Technical director Patrick Convey said: ‘It appears this amendment is directed at high profile public servants whose main employment was, for example, predominantly with the BBC but who were paid via a service company. This meant the BBC did not deduct any tax or National Insurance at source, nor did it pay employers’ National Insurance contributions nor make a pension contribution.
‘We do not believe this has an impact on normal private practice models, but where medics conduct NHS Choose and Book or waiting time initiatives privately and invoice via a limited company, this practice will be impacted.’
Accountant Andrew Lang, of Sandison Lang, said: ‘The only incidence I can think of that may be applicable is where a doctor in private practice has a contract with a publicsector body to provide healthcare to, say, a Government department, then it may be the new rules apply.’
Incorporated Health Ltd has announced the appointment of specialist medical accountant Dr Ray Stanbridge as a nonexecutive director.
The company, set up by Guildford and Londonbased consultant radiologist Dr Tony Lopez, is engaged in providing new and innovative partnership solutions for diagnostics, endoscopy and minimally invasive surgery in close partnership with consultants, insurers, hospitals and clinics ‘for the benefit of all’.
Dr Stanbridge said: ‘I am delighted to join this company, which, in a very fast changing market, is demonstrating the need for new cost solutions, full consultant involvement and cooperation, rather than conflict with hospitals and insurers.’
ray Stanbridge (right) and radiologist dr tony lopez (top)
Share your experience of what has and has not worked in your private practice. even if it’s bad news, let us know and we can spread the word to prevent other independent practitioners falling into the same pitfalls. contact editorial director robin Stride at robin@ip-today.co.uk or phone him on 07909 997340 tell US yoUr Story
by robin Stride
Nearly six in ten consultants responding to a BMA survey revealed they had been challenged by private medical insurers about their fees.
The association’s annual private practice conference heard 57% had been quizzed over their charges and 30% had experienced a refusal to pay.
According to the BMA’s Private Practice Committee study sent to 10,000 consultant members across the UK (1,149 replies with just 379 independent practitioners):
43.9% said they had problems with patients receiving treatment authorisation;
31.8% had been threatened with derecognition by insurers;
26.7% had experienced patients being redirected to a different consultant.
Just over a quarter of consultants reported cases where patients were given ‘derogatory/misleading’ information from their insurers.
Asked if the threatened derecognition had gone ahead, four said it had ‘on all occasions’, 18 said it had on ‘some occasions’, 74 said ‘No, never’ and – strangely – nine specialists said they did not know.
Over a third of consultants (35.6%) said they did not reduce their fees after a challenge, 22% did on all occasions, and 40.8% did sometimes.
Private Practice Committee chairman Mr Derek Machin admitted the survey responses were lower than he would have
liked and said doctors should be circumspect about how much reliance was put on them.
But he claimed many of the figures were ‘a dreadful indictment of the insurance industry’.
A small minority of doctors admitted to cutting their fees below insurers’ limits since January 2016 ‘to improve competitiveness’, but 88.3% did not. Dropping fees, however, only resulted in more patients for around a fifth of those who did it.
Of a sample of 293 doctors, 40% spent up to 20% of their earnings on expenses, a third spent between 2140%, 18% spent 40%60% and 9% spent 60%.
Looking at changes in the proportion of earnings from the three main sources, comparing 201516 with 201415, around 80% of consultants reported selfpay, private medical insurance and NHS patients seen in the private sector had stayed the same.
But earnings from self pay patients had risen for 39% (sample 304) and 38% for patients with insurer contributions (sample 323), and 17% for those seeing NHS patients in the private sector (sample 309).
Consultants were asked what impact various factors had on their private practice earnings in the last year. Restriction of availability of procedures in the NHS had led to increased earnings for nearly one in five, while longer NHS waiting times brought higher income to 30%.
Turn to conference reports on page 6 and 7
The snap general election has hit hopes of a quick resolution to the private doctors’ defence fees controversy.
Medical and Dental Defence Union of Scotland (MDDUS) chief executive Chris Kenny said: ‘It is vital that resolving this discount rate issue is top of the intray for the incoming Lord Chancellor, Chancellor of the Exchequer and Health Secretary.
‘In the absence of action, private doctors face higher charges for their own indemnity – and, to rub salt in the wound, higher employers’ liability insurance charges for their staff as well.
‘We told the Lord Chancellor before the election was called that we’d hold her to account for meeting the timetable of producing a fairer system by the summer and we’re sticking to that.’
Defence fees are set to rocket due to a lowering of the discount rate formula for deciding compensation payments, from 2.5% to 0.75%.
The Medical Protection Society said the rate should be set following thorough consideration of the potential impact on the NHS, the public purse and the affordability of professional protection for healthcare professionals.
It said the case for a whole package of legal reforms to tackle spiralling clinical negligence costs were becoming ever more pressing.
HCA’s The CyberKnife Centre in Harley Street has been rated ‘outstanding overall’ by the Care Quality Commission (CQC). It was given outstanding for being wellled and effective, and good for being safe, caring and responsive. Inspectors found ‘many examples’ of innovative practice, excellent multidisciplinary team working, and people said care exceeded their expectations.
By Leslie Berry
A new health tech start-up has launched the first virtual multidisciplinary team (MDT) system for independent practitioners.
Hailadoc, set up by consultant paediatrician Dr Ezam Mat-Ali, is a clinical communication system allowing them to run more efficient virtual multidisciplinary team reviews of patient cases. Information is cloud-based and hosted securely in the EU.
The first groups of independent doctors are using it to improve care for private patients with skin and breast cancer and complex scar management.
Doctors and their administrators control who is invited onto the system to input into a patient’s care. Users can upload diagnostic images and pathology reports, and add their comments on the patient’s diagnosis and treatment.
The system can be accessed from anywhere at anytime, which makes MDT input easier in independent practice. This is a key problem to
Private doctors are treating increasing numbers of younger generations for conditions usually associated with old age.
A Bupa analysis of over 60,000 procedures and 4.7m hits to its online health information pages in 2015 found this ‘the most striking trend’.
Haemorrhoid removal and varicose veins were two of the most common procedures for 26-35 and 36 to 45-year-olds within the surgical heart and circulatory diseases category.
This age group is now the most
solve because private doctors are often based at different sites and available at different times.
Chief medical officer and cofounder Dr Mat-Ali said: ‘Our goals are to make healthcare more efficient and improve quality. Our system gives independent practitioners a better way to discuss patient care securely.
‘Practitioners can run virtual MDT meetings, which helps them to run their practices more efficiently. They can also improve the quality of care by reducing avoidable delays to diagnosis and treatment.’
152 Harley Street, a private specialist skin clinic, is using the system to make its scar management services more efficient.
Clinic administrator Natalia Pastuszak said: ‘It’s helped us to streamline our workflow and get faster inputs from multiple clinicians, as they can use the system wherever they’re working that day. This helps lower practice costs by reducing unnecessary travel and meetings.’
Consultant dermatologist at 152
likely to undergo knee and back procedures. Multiple arthroscopic knee operations and epidurals for back problems were in the top five most common procedures for this age range.
Stressful lifestyles coupled with the increasingly sedentary nature of modern living are factors behind this, the insurer believes.
Bupa reported a sharp rise in patient searches on its site for conditions associated with stress. Searches for piles, IBS and peptic ulcers rose 2,454%, 1,818%, and 347% compared to 2014. Searches for stress rose 388%.
Bupa medical director Dr Steve Iley said significant numbers of customers were prematurely experiencing conditions normally associated with much older people.
Harley Street, Dr Emma Craythorne said: ‘We’re running a virtual MDT process for scar management, which is helping us create each patient management plan faster, reducing treatment delays and improving care. It allows multiple specialists to review images and comment in a secure, recorded way.’
Dr Richard Barlow, consultant dermatologist with a private practice in Chelsea and founding president of the British Cosmetic and Dermatological Surgery Group, said: ‘It’s very useful for data-protected management of patient queries and helps to reduce unnecessary emails and text messages. It has great potential to streamline the skin cancer MDT which I’m part of in private practice.’
Dr Mat-Ali said: ‘Independent practitioners have told us they want a better way of sharing patient information with colleagues. We’re developing an easyto-use and secure system and adding features in response to doctor feedback.
‘We’ve had interest from a wide range of physicians and surgeons who want to use virtual MDTs for complex patient cases. We’re looking forward to adding independent practitioners from more specialities who can also benefit.
‘We are also looking at how the system can improve communication with patients, such as virtual consultations. As part of this, Hailadoc is being piloted in Guy’s and St Thomas’ NHS Trust by clinical dermatology nurses’.
tRy It foR fRee
hailadoc is offering Independent Practitioner today readers a free trial of the platform for their independent practice from May to July. apply by emailing chief executive dr ezam Mat-ali at dre.mat-ali@hailadoc.com
The Care Quality Commission (CQC) has taken further action to protect people using websites to buy prescription medicines.
Reports published on four more providers give examples of people being put at risk of harm due to poor identity checks, inadequate medical history recording and clarification of their symptoms, inappropriate medicines being prescribed and lack of communication with the patient’s GP.
The regulator suspended the registration of one, imposed conditions on two of them and
instructed the fourth to improve its practice.
Prof Steve Field, CQC Chief Inspector of General Practice, said: ‘Online companies, and the people working for them, have a duty to protect the people seeking their support. They must follow relevant guidance and best practice to make sure that they know whom they are communicating with, how medicines fit in with their medical history, and that their GP is made aware of any prescribing decisions.’
See feature on prescribing, p36
By a staff reporter
A consultant’s unique centre of excellence for all skin and related conditions has opened in Belfast with the help of a loan from an unusual source.
Belfast Skin Clinic turned to the Growth Loan Fund, which helps small to medium enterprises in Northern Ireland, and was lent £50,000 to cover the cost of a full body mole scanner.
Dermatologist Dr Pamela McHenry, who has led the development, said the fund was approached for assistance with the fit-out, equipment costs and working capital requirements for the business.
She said: ‘The facility will allow Belfast Skin Clinic to grow and deliver world-class care in dermatology and associated specialties across Ireland.’
The clinic offers a comprehen-
sive range of diagnostic and treatment services, bringing together consultants in dermatology, plastic surgery, allergies, immunology, rheumatology, paediatrics and cosmetic dermatology. Purposebuilt, it has ten consulting/treatment rooms and an operating theatre.
Andrew Gowdy, of fund admin-
Ten consultant oncologists have formed a joint venture partnership with GenesisCare to deliver radiotherapy services at the company’s 11th UK centre.
The deal gives the doctors the chance for greater influence in the design and delivery of the service and the opportunity to invest in the future of radiotherapy services. This is common practice for the company back in Australia but unique for it here – although similar deals are expected to be announced for more consultants in future.
The Berkshire Oncology Partnership’s Dr James Gildersleve said: ‘Getting to this point in our collaboration has been rewarding and refreshing.
‘It is a genuine partnership and we have had input every step of the way, from deciding on the location and property design, through to agreeing our diagnos-
tic partners and the services to be provided.
‘We are looking forward to the next phase as we develop the services together. We believe this partnership with GenesisCare allows us to be sure our patients will receive the highest quality private service.’
Building work has begun at the property in Alma Road, Windsor, and it will be the largest yet, measuring 19,900 square feet set over three floors.
The Windsor Diagnostic and Cancer Centre will offer services to patients across Berkshire, west London and further afield.
John Allen, executive manager for international operations at GenesisCare said: ‘We are excited to have entered into this partnership. We work closely with our consultants throughout the world and value their clinical expertise.
‘Through this new joint ven -
istrators WhiteRock Capital Partners, said: ‘A property which has been left empty for several years has been transformed with jobs being created in the local area. We were delighted to be part of a funding package that enabled the project to grow from an idea to getting patients through the front door.’
Companies seeking funding from the Growth Loan fund must be based in northern Ireland, demonstrate growth and are generally in the manufacturing, engineering or tradable services sectors.
Loans are typically unsecured and personal guarantees not sought.
they are expected to be complementary to existing sources of finance, including banks, trade finance sources and equity investors.
Loans are provided on a fully commercial basis, with monthly loan repayments required over typically a five-year term.
More details available by emailing info@whiterockcp.co.uk
ture, our close alignment ensures that patients will receive the very best clinical care in a first-class environment.
‘We will be looking to implement this model at all our new centres going forward and potentially to offer the same opportunity at some of our existing centres, where we seek to have a close interaction with our consulting physicians.’
A Versa HD Linac radiotherapy
system from Elekta will be installed initially and patients will benefit from access to a large diagnostic suite which will include a fourdimensional CT and MRI scanners. The centre will house a number of consulting rooms centred around the diagnosis and treatment of cancer, deliver holistic therapies for patients and offer access on site to a supervised gymnasium. It is planned to open to patients in October this year.
By Robin Stride
Nearly three-quarters of consultants have no idea if the data their private hospital submits to the Private Healthcare Information Network (PHIN) is correct.
Asked in the BMA’s survey (see page 3) whether they believed the feedback was accurate, 73.8% admitted they did not know, 12% said ‘no’, and only 14.2% said ‘yes’.
More than half the private doctors surveyed admitted ignorance about the Private Healthcare Information Network’s (PHIN) Article 21.1 (publication of consultant per formance measures) and 11 performance measure categories.✱
52.3% said they had never heard of them while 42.7% had but did
not know the details. Just 5% claimed a good understanding of the detail.
BMA Private Practice Committee chairman Mr Derek Machin called the findings ‘very worrying’.
He observed that, in his experience, NHS data was ‘mostly wrong’ and while not worried about the private sector data, he was concerned about NHS data and the ability to get it changed if it was wrong.
‘I have a lot of concern about the accuracy of data and people getting into trouble because the data is not accurate,’ he told the meeting.
He feared data needed by PHIN might get doctors into trouble through no fault of their own, such as if a fictitious mischievous
top five wayS conSultantS Set theiR feeS
1. Set independently using an insurance schedule as a guide (22.8%)
2. variable according to re-imbursement available from the private insurer (22.5%)
3. Dictated by insurers – (18.9%)
4. other – (17.5%)
5. assured scheme with insurer/s (12.1%)
insurance schedules used as a guide for fee setting: Bupa 61%, aXa ppp 37.8%, aviva 29.6%, pruhealth 17.7%
futuRe planS foR pRivate pRactice woRk
will work in private practice until retirement (85.3%)
considering stopping private practice work in next 12-24 months (12.4%)
plan to stop private practice in the next 12 months (2.3%)
colleague erroneously reported a surgeon had only done 75 of the 100 operations he was down for.
In fact, the surgeon’s name was on the list, but this had not been updated by the nurse when he was away.
✱ 11 performance measures:
Activity, volume (number of admissions);
Length of stay;
Infections rates (SSI and HCAI);
Re-admission rates (28 days);
Revision rates;
Mortality rates;
Unplanned transfers;
Patient feedback and/or satisfaction;
Clinical registries and audits;
Improvement in health (PROMs);
Adverse events.
why people plan to give up pRivate pRactice
1. controls put on fees by private medical insurers are too restrictive to make it profitable
2. not financially viable
3. no longer attractive
4. not conducive to maintaining a good work-life balance
5. indemnity costs too high to make it feasible
Source: BMA Private Practice Committee survey published April 2017. The survey was sent to 10,000 BMA consultant members across the UK. Of 1,149 responses, 379 came from independent practitioners
A defence body medico-legal adviser warned the conference that the new discount rate formula for assessing payouts in personal injury claims would have a ‘seismic impact’.
Dr Helen Hartley, of the Medical Protection Society, said claims that had been settled for £5m could rise to £12.8m in future.
Defence bodies have warned that subscriptions will rise dramatically due to the Lord Chancellor lowering the discount rate from 2.5% to -0.75% (Independent Practitioner Today, March 2017).
She said the defence bodies were trying to help doctors to afford subscriptions by lobbying Government over the impact of the cut and for clinical negligence legal reforms.
The biggest challenge was to try and get the discount rate remitted.
why people Don’t Do pRivate pRactice
1. preference to use available time in other ways, for a good work-life balance
2. nhS income is sufficient to cover desired standards of living
3. ethical objection to private practice
4. no perceived demand or opportunity in geographical area
5. other
indemnity costs in their specialty too high to make it feasible (5)
prefer to use available time in other ways for a good work life balance (5)
lack of perceived demand or opportunity in geographical area (4)
increase in difficulty in dealing with private medical insurers (3)
nhS income was enough to cover desired standards of living (2)
the controls put on fees by insurers were too restrictive to make it profitable (2)
cost of premises were too high (2)
Retirement (2)
bma private practice conference 2017
By Robin Stride
Consultants were assured their performance measures would not be published by the Private Healthcare Information Network (PHIN) before they had been allowed to check accuracy using an online portal for doctors and hospitals.
PHIN chairman Dr Andrew Vallance-Owen said performance measures would be adjusted for complexity and benchmarked across specialties.
PHIN, set up in the wake of the Competition and Markets Authority (CMA) inquiry into private
GPs could get their own private practice conference in future.
The BMA Private Practice Committee is giving ‘serious thought’ to the idea, as leaving the NHS, or starting a private practice venture in tandem, is increasingly popular among GPs.
A third of the 180 doctors present were from NHS and private general practice.
Seven per cent of NHS surgery is now done in independent hospitals – but it could be a lot more, according to the founder of market analysts LaingBuisson.
Mr William Laing predicted it would go up to 10% ‘in the not too distant future’.
The audience were asked if revalidation had improved their practise.
No hands went up.
healthcare, was promising not to publish consultants’ or even hospital information until it was checked for accuracy by them.
It would work with hospitals to gradually roll out consultants’ access to the portal, he said.
And PHIN’s patient website would be clear and simple to understand with contextual information to help people interpret data.
Dr Vallance-Owen encouraged consultants to get engaged with the process, as this would enhance the value of information published.
At April 2017, PHIN had received data from hospitals providing 85%-
90% of privately funded care in the UK. By the end of last month, it expected to host basic performance measures for over 222 hospital sites: activity volumes, length of stay and patient feedback.
But he said some hospitals had not submitted data and activity was missing for many consultants, leading to publication for consultants being delayed until 2018 ( Independent Practitioner Today , February 2017).
Dr Vallance-Owen said data was robust for submitting hospitals but not at consultant level. But there was now time to work with
Doctors were warned that going into private practice was no longer the ‘haven’ of 20 years ago.
Regulation was very much more intensive and doctors faced rising expenses and increased litigation, BMA Private Practice Committee chairman Mr Derek Machin said.
It had moved from being a cottage industry and was generally more difficult to succeed and doctors needed to be more professional.
He warned the set-up costs could be considerable and geography and specialty were important areas to consider.
Doctors should research the market in their area and income potential.
A leading accountant advised existing and would-be private doctors to use Independent Practitioner Today as a resource to help them in their practice.
Specialist medical accountant Martin Murray, of Sandison Easson, told the conference the journal was a ‘fantastic publication.’
Occasionally, patients were not profitable. Some people were earning only £30-£40 an hour after tax and found it much more profitable to do waiting list initiatives or NHS work because their overheads went right down.
them and the specialty associations to ensure PHIN got consultant performance measures right.
Publication of consultant performance measures (Article 21) is due in April 2018 and consultant fees (Article 22) in April 2019.
PHIN hoped the private sector would take a lead in developing more patient-reported outcome measures (PROMs) than the NHS did, said Dr Vallance-Owen.
And the network agreed with the BMA’s Mr Derek Machin that the data from private hospitals was better than the NHS.
See page 9
A self-pay boom is on the way for the private sector, according to an independent hospitals group medical director.
Dr Jean-Jacques de Gorter, of Spire Healthcare, predicted that the number of self-pay patients would double in the next decade and equal the numbers of people being treated under private medical insurance.
He told doctors the opportunity to innovate in the self-pay market were also greater.
Talking of costs, he said the information on a lot of hospital websites made it look like they were trying to make it as difficult as possible for customers. But he believed that would change in the next few months.
The BMA’s Mr Derek Machin said he shared Dr de Gorter’s pessimism about private medical insurance.
By Charles King
HCA Healthcare UK has unveiled a £50m investment in cutting-edge cancer care with two centres equiped with the latest technology.
They are the £38.2m London Bridge Hospital, Private Care at Guy’s and the newly-built £12m HCA at Sydney Street, an outpatients and diagnostics centre in Chelsea.
The 53-bed Guy’s facility opened last month on the top four floors of the famous teaching hospital’s new Cancer Centre in Great Maze Pond.
It hosts the UK’s first integrated robotics theatre, including the Da Vinci robotic system, enabling surgeons to perform complex keyhole surgery for urological procedures with faster recovery times for patients.
The opening marks a further expansion of the London Bridge Hospital campus which last year opened a £30m outpatients and diagnostics centre at The Shard.
Sydney Street in Chelsea, opened at the beginning of May, will provide a range of outpatient cancer services, including cancer treatments provided by Leaders in Oncology Care (LOC).
The unit also houses a blood laboratory and aseptic pharmacy manufacturing suite and a digital PET CT scanner – one of the first in a private setting in London – to help diagnose and stage cancer earlier.
HCA at Sydney Street is supported by HCA UK’s The Lister Hospital, which will provide
patients access to a nearby oncology inpatient ward and intensive care facilities.
The hospital group said its investment was a response to growing demand for cancer services in the capital. It is recording 150,000 patient visits per year and has seen year on year growth in demand.
Both new centres are designed to deliver cancer care in a convenient and comfortable setting for patients.
All London Bridge Hospital cancer services have been transferred to London Bridge Hospital, Private Care at Guy’s, a short walk from London Bridge Station.
Guy Reynolds, vice-president of cancer services at HCA Healthcare UK, said: ‘HCA Healthcare UK is committed to providing patients with the very best in cancer care, whether that’s cutting-edge surgery, providing access to clinical trials through the Sarah Cannon Research Institute UK or delivering the most advanced treatment plans and innovative drugs.
Mr Reynolds, who is also chief executive of Leaders in Oncology Care, added: ‘Throughout the HCA Healthcare UK group, we provide an integrated approach to cancer services, meaning that our patients have access to excellent care and support during their whole journey and beyond with our survivorship programme, Living Well.’
HCA has invested £100m in cancer services since 2008 in London, Essex and Manchester.
London Bridge Hospital, Private Care at Guy’s is a £38.2m, 63,000ft private hospital in the top four floors of the new Cancer Centre at Guy’s. it has 40 inpatient beds, nine day surgery beds, a fourbed intensive care unit, four integrated operating theatres, Da Vinci robot, 18 chemotherapy bays, X-ray, fluoroscopy, ultrasound and radiotherapy. the centre specialises in a number of areas including urology, gynaecology and breast surgery.
Janene Madden, chief executive of London Bridge hospital, said: ‘we are always working to provide the highest-quality care across the London Bridge hospital campus and the hCa uK group as a whole, so i am proud that this new facility will offer our patients state-of-the-art care and the latest technology in a location that is convenient for them.’
HCA at Sydney Street Outpatients and Diagnostics Centre is a £12m investment in Chelsea covering 30,000 square feet over five floors. it has been purpose built to offer rapid and convenient access to outpatient oncology and haematology services in south-west London, with chemotherapy provided by Leaders in oncology Care. it houses one of the first digital Pet Ct scanners in the capital.
the Lister hospital chief executive suzy Jones said: ‘the sydney street facility allows us to provide cutting-edge cancer services to our patients close to home, with support from the Lister hospital and the wider hCa uK network when needed. we always strive to provide exceptional services to our patients and i am proud to say that this facility will help us provide the very best cancer treatment and care available.’
The first of a series of long-awaited performance measures intended to improve the availability of information to patients considering private healthcare services was published by The Private Healthcare Information Network (PHIN) earlier this month. The aim is to start to bring standards of data quality and transparency in line with the NHS
PATIEnTS CAn now, for the first time, find ‘independent and credible’ information on hospitals when considering their private care options.
According to the Private Healthcare Information network (PHIn), this will be particularly useful when discussing options with their GP or specialist.
The three performance measures, published earlier this month, cover 149 common procedures at over 200 hospitals and show the number of patient admissions, average lengths of stay for each procedure and the same patient satisfaction measure for hospitals as used by the nHS –the ‘Friends and Family Test’.
These new measures will be added to existing information including up-to-date inspection ratings from national regulator the Care Quality Commission.
PHI n ’s chief executive Matt James said: ‘The information we are publishing represents a significant step towards greater transparency in private healthcare.
‘This is the first comprehensive attempt to measure the activity and performance of private healthcare across the UK to nHS standards.
‘The availability of better information will help patients directly and will also encourage care providers to better understand the quality of their care and strive for improvement.’
PHI n chairman Dr Andrew Vallance-Owen said: ‘This is a really important day for patients that use private healthcare. Patients considering a private hospital are seeking choice and
control, and that demands simple, clear information to help them make decisions.
‘Healthcare is a complex environment, but the team has done a great job, working closely with clinicians and hospitals, of bringing clarity and credibility together in this website.’
Private hospitals, including nHS hospitals that provide some private care, are required to supply
‘the team has done a great job, working closely with clinicians and hospitals, of bringing clarity and credibility together in this website’
comprehensive data to PHI n , allowing activity and quality to be tracked and reported for the first time. PHIn estimates that the first tranche of information covers more than 80% of privatelyfunded healthcare in the UK.
The performance measures are the first three, of 11, specified by the UK’s competition regulator, the Competition and Markets Authority (CMA), whose 2014
‘this is the first comprehensive attempt to measure the activity and performance of private healthcare across the uK to nhs standards’ Matt JaMes
investigation found a problematic lack of transparency for consumers in private healthcare.
Further measures will be released over the next 12 months, including infection rates, rates of adverse incidents and measures of the relative health improvement offered by key treatments. Meas ures for consultants will follow in 2018 and fee information from 2019.
Mr Geoffrey Glazer, consultant surgeon and chairman of the Federation of Independent Practitioner Organisations (FIPO), said: ‘Publication of these first measures for hospitals is an important step.
‘We will continue working along side PHI n as they move towards publication at consultant level, ensuring there is a strong clinical voice and that the information produced is fair, statistically reliable and will assist patients.’
The newly published performance measures can be found at www.phin.org.uk.
Mr Geoffrey GLazer
‘Publication of these first measures for hospitals is an important step’
The well-known saying ‘no man is an island’ is particularly true for anyone working in private practice, as it is impossible to succeed without a supportive team and the benefits of teamwork. Jane Braithwaite suggests how to get the best from your team and gives a dozen tips to bring success
A consultAnt setting up in private practice may initially believe that he or she will work in isolation. But they will soon recognise the necessity of a support team to manage private clinics and another team entirely to run regular theatre lists.
e ach team will have different members, different objectives and very different dynamics.
What is the definition of team?
A team is a group or people who have come together to achieve a common goal. ideally, the performance of the team is greater than the sum of the performance of the individual team members. given that you will be part of one or more teams, and you are likely to be the team leader, it is important to understand how to
maximise the potential of these teams.
Does a team need a leader?
Any group or team needs a leader to be effective and to maximise potential performance. Research also suggests this to be true.
A team without a leader and clear direction can become just a talking shop. it may be a very jolly one, but progress, if any, will undoubtedly be slow. the leader is the one who commands a group and influences that group towards a specific result. A leader is not dependent on title or formal authority. in practice, a team normally has a formal leader by title, but it is interesting to observe how a leader can emerge from within a team if no one else takes ownership of the role.
Success is dependent on the leader engaging with team members to encourage them to contribute their ideas and opinions
Daniel goleman is responsible for popularising the concept of ‘emotional intelligence’, but he also wrote a great book called Primal Leadership which articulates different leadership styles and the pros and cons of each. it is worth exploring the different styles that might be useful to you.
➲ Commanding
the commanding, or autocratic, leadership style is the most popular style of leadership. the leader holds all the authority and responsibility for decisions made. t here is no consultation with team members. Decisions are announced and the leader expects them to be implemented. the most appropriate use of this style is in a crisis where a decision needs to be made and acted upon quickly.
so, this style is vital, but should only be used in the right scenario, which is one where decisive action is required. the potential downside of commanding leadership is that team members start to feel demoralised and like robots with no intellectual stimulation, which, in turn, leads them to feeling alienated.
this style has historically been used widely by the armed forces, but they have recognised that it is only of use in certain situations and are embracing other styles. An obvious use of this style for the medical practitioner is in an emergency, perhaps in theatre. i would advise any team to discuss this way of working and recognise when it is appropriate. if all team members understand this commanding style is only used occasionally, but when necessary, they will respect it and there is less risk of people feeling alienated.
➲ Democratic t he democratic or participative style is where the leader taps into the collective wisdom of the team and the team’s subordinates are involved in the decision-making process.
this style is highly regarded by most, who feel engaged and valued when working in this way. success is dependent on the leader engaging with team members to encourage them to contribute their ideas and opinions. there are no major downsides of the democratic approach, but it is
important to recognise that is not ideal in a crisis, as it does not allow a fast response.
By the time everyone reaches a consensus, it’s too late. in an emergency, the leader needs to recognise the need to switch from democratic behaviour to the commanding style to ensure fast action.
➲ Coaching
the coaching style is most valuable when your focus is on developing the people within your team. it works well with a team of people who show initiative and want support with their professional development.
t his style is obviously highly appropriate when engaging with junior medical staff, but also with anyone who has a desire to learn and develop.
➲ Affiliative
t he affiliative style requires no leader and relies on teamwork.
this style is great at creating harmony, but a culture of group praise can lead to accepted poor performance.
this is the model that i suggest can become a lovely, jolly talking shop with slow or no progress.
A good leader needs to be able to adopt several different styles
depending on the team and the situation. leadership is not about ‘the leader’, it is about the needs of the people you are leading and you will need to move between styles in different scenarios.
A leader is the one who knows the way, goes the way and shows the way.
Remember, in the sporting world, if a team has a great season, the manager is worshipped by the team, the press and all the fans. But if a team fails to perform well, the person who gets sacked is the manager.
As i sign off this month, i would like to leave you with this thought, to help you, as you ponder your role as leader and team player.
‘ n o one can whistle a symphony. it takes a whole orchestra to play it.’ H. E. Luccock
Jane Braithwaite (left) is managing director of Designated Medical
1. Be clear of the teams you belong to and your place within them. Which teams do you lead? What do they need from you as their leader?
2. Define the team objectives and agree them with your team. This should be a collaborative process where you engage with your team to agree the goals and plan how to achieve them.
3. Ensure you build effective teams with the skills and expertise needed to achieve the requirements of the team and to enable the team to meet the objectives. Identify any skills gaps and plan how to fill them.
4. Aim for a diverse team. You do not want a team of people with identical personalities. A greater mix will lead to a greater perspective.
5. Communicate the team purpose and objectives clearly to your team. Repeat this regularly to ensure the team maintains a focus on the same direction.
6. Manage your team members. This is about communication with everyone on your team. It is best to schedule regular one-to-one review sessions. These do not need to be long meetings, but frequency is most important.
Schedule a 30-minute catch-up with each team member every month or quarter and stick to it. Be certain to also use these meetings to listen carefully and learn from what you hear.
7. Hold team meetings and discussions. Any team needs regular opportunities to review its objectives and discuss how things are going. The best way to do this is via regular team meetings. These do not need to be held in glamorous surroundings and take up the whole day. A focused hour with no interruptions held every month will make a significant difference. 8. Encourage feedback. Your team has useful insights into your practice, your patients and your ways of working. Ask members for feedback on what is working well and what could be improved.
9. Involve all team members. Who is not talking to you and sharing their thoughts? Try to engage them more fully. The team performance is dependent on everyone contributing and some need more encouragement to participate than others. Often the quietest team members have the most valuable contributions.
10. Reward success. It is amazing how much difference a simple ‘thank you’ makes. So, when you experience someone on your team exhibiting the behaviours you want to encourage, comment loudly. Say ‘well done’ and ‘thank you’. You do not need to buy gifts and champagne – although that would be appreciated too, of course – but ensure you are making sure everyone knows how much you appreciate their efforts.
11. Review failure openly. To create a culture where people can perform to their best ability, they need to feel safe. Remember, scared employees do not perform well. So, when something goes wrong – and it always will –handle it carefully. Focus on understanding the problem and don’t look to place blame. Once the issue is fully understood, engage your team in how to change things so it is not repeated.
12. Be autocratic and decisive in the correct situations. Explain to your team why this is appropriate so they understand and respect this change of style. Be mindful to revert to a more appropriate style once the crisis is over.
Every doctor resents spending their valuable time churning through paperwork, but finding the right balance between your clinical and management responsibilities can be a challenge.
The answer lies in working smarter rather than harder, as Healthcode’s Peter Connor (right) explains in the first of our series on using technology to support your independent practice
Setting up your own independent practice should mean greater clinical freedom, the chance to spend more time with patients and the chance to generate additional income.
And yet some practitioners find that day-to-day administration and management takes up more time and energy than they expect as their practice grows.
A recent study by the Centre for the Modern Family 1 found that people who chose to leave traditional employment in search of greater control of their working life, did not necessarily find it when they became their own boss. it revealed that 18% of respondents who lived in a self-employed household said their family member was always on call at work and 19% said their relative had more financial worries since becoming their own boss.
this national survey wasn’t specifically focused on doctors, but many independent practitioners will have had a similar experience.
Barriers to success
every new business owner feels overstretched at times, but if any of these situations listed below are familiar, you should address them before they hamper the development of your practice or become a distraction from your clinical work:
i nvoices aren’t raised until weeks after treatment and sometimes go astray;
the practice is regularly obliged to write off unpaid debts;
You don’t know how much money is owed to the practice at any one time;
You have a full appointment book but the practice often experiences cash flow problems;
You always seem to be rushing between appointments and clinics. the good news is that all is not lost. By tapping into the latest practice management technology, your practice can operate more effectively and you can access the performance data you
need to make informed business decisions.
A practice management system which is developed specifically for independent practice should allow you to manage your workflow from one place, from capturing patient details and appointment scheduling to electronic medical billing and generating management reports that help you keep track of the money you are owed.
Although it is possible to get by with separate spreadsheets, word processing and generic accounting software, you will probably have to spend extra time re-entering data and completing administrative tasks. A purpose-built system should save you time and quickly repay your investment.
Selecting a practice management system can and should be straightforward. You should not need to
plough through piles of impenetrable technical specifications and unintelligible jargon. Healthcode’s step-by-step guide below will make it easier to manage the procurement process.
Step 1: create a wish list
Ask yourself what routine practice tasks could be managed more efficiently and what business intelligence would better support your decision-making. For example:
Can you record and retrieve patient details as quickly as you would like?
How easy is it to schedule appointments across different locations and ensure staff can keep track of your whereabouts?
Can you communicate effectively and securely with patients, surgeons and private medical insurers?
How do you create invoices and keep track of who has paid?
Can you keep track of the practice’s financial performance?
A wish list will help you decide what is most important and focus on this from the outset.
Step 2: Set your budget
Only you and your financial adviser can determine how much you can afford to invest. the most important consideration is whether you want to host the practice management software on your own server or subscribe to an online practice management solution.
the former tends to have higher upfront costs, whereas an internet-based solution will charge a monthly or annual fee.
You also need to consider:
Ø How much you expect to save in time and increase your revenue;
Ø Ongoing technical support, including back-up and disaster recovery. Some providers may charge extra for technical support;
Ø t he tax implications of your investment; Ø Future upgrade costs (serverbased systems).
Step 3: Decide the implementation time-scale
Set a target for project completion and beware of drift. Break the project down into a series of tasks, and set a deadline for each.
Step 4: Research system functionality
Review the practice management solutions on the market to see which meet your criteria. i t’s helpful to create a comparison table so you can record which systems offer the functionality and features you need – as in the table on the opposite page.
Step 5: make a short list
Select two or three providers who can potentially offer the functionality, security and support you
it’s essential to check that the provider has strict information security safeguards in place which meet the latest data protection standards and will help you meet your future legal obligations
Step 7: Feel secure Failure to take reasonable steps to protect your patient data could leave you vulnerable to cyber criminals, cause serious reputational damage and incur a hefty financial penalty from the i nformation Commissioner’s Office (iCO).
need. it pays to whittle the number of potential providers down as much as possible at this stage. So if you can, seek recommendations from colleagues in your specialty.
Step 6: make contact
On the basis of your initial interaction with each provider, you should feel confident that they tick the following boxes:
❏ Efficient and responsive customer service.
❏ Understand the evolving requirements of the sector? Specialist know ledge of private healthcare is an asset, as it means the system should keep pace with new developments.
❏ Talk your language. i t is difficult to imagine a productive business relationship with a jargon-spouting representative.
❏ Financially stable. t he last thing you want is for a vendor to go out of business a year after you have invested in its software. the business failure rate is generally higher for smaller companies in their first five years of business, but it always pays to do your research. As well as asking for references, consider checking with Companies House or buying a report from a reputable ratings agency.
❏ Large enough to handle your requirements. You don’t want to be dependent on one person to resolve every problem.
❏ Provides testimonials – speak to users in similar practices. Ask about system functionality, reliability and customer service.
❏ Ready to demonstrate the system so you can assess it for yourself. i t’s worth asking whether you can test out the system for a limited trial period.
trust your instincts – if you feel uncomfortable about a provider, it will be difficult to work with them in the long-term.
it’s a subject we’ll cover in more detail in the next two articles, as there are significant changes looming in the field of data protection, including a new law – the general Data p rotection Regul ation –which comes into effect next year.
i t’s essential to check that the provider has strict information security safeguards in place which meet the latest data protection standards2 and will help you meet your future legal obligations. p assword protection and data encryption should be a minimum requirement for any secure practice management solution and you should also ask about the arrangements for storing data –will it be held in the cloud or a private dedicated infrastructure and, if so, will this be located in the uK or overseas?
t he i CO website has a collection of guidance on data protection considerations for healthcare organisations,3 as well as specific advice for businesses on secure back-ups and cloud computing.4
Step 8: Ensure you have enough support the provider must be able to offer the right level of support through installation and beyond. Ask them:
Ø Will they offer initial training?
Ø Do they provide ongoing technical support, including site visits if required?
Ø i f the system crashes, how quickly can they guarantee a response?
Ø i s data back-up and recovery included and, if so, what assurance is there that data will be stored securely?
Ø How will system updates be managed and will technical support be provided as part of the package?
Step 9: monitor
Signing up with a provider is not the end of the story. You and your team should monitor progress, particularly during system instal-
and alerts
membership status with insurer
Diary management
Make and change appointments
Manage schedules across different locations
Set up recurring sessions
Billing and payments
Create and securely submit e-bills to
Reconcile payments including
Re-allocate shortfalls
Document management
Reports
protection and access
mobile devices
“ Kay looks after calls when our team is busy. The result? More appointments, outstanding service levels.”
Moneypenny client since
Moneypenny will support your existing team by looking after overflow calls whenever you need – sending detailed messages back to your practice.
lation or set-up if you decide on an online solution, to ensure your expectations are met.
i t’s also a good exercise to review the system when it has been live for six months and at regular intervals thereafter to ensure it continues to meet the needs of your practice.
u ltimately, a good practice management system should be capable of supporting your practice from the moment it is installed and as it grows.
next month: Using technology to communicate securely
References
1. Self-employment and the family –Centre for the Modern Family (Scottish Widows), February 2017.
2. ISO 27001 Compliance, British Standards Institution.
3. https://ico.org.uk/for-organisations/ health/
4. https://ico.org.uk/for-organisations/ guide-to-data-protection/encryption/ scenarios/backups/
In her second article about the GMC’s new confidentiality guidance,1 the MDU’s Dr Catherine Wills (right) focuses on disclosures to a patient’s family and carers
T HOS e C l OS e to a patient may play a significant role in providing support and care and naturally may want to discuss their loved one’s health with you.
Although you need to be sensitive and supportive towards them, you must consider and respect your patient’s confidentiality.
If your patient has capacity, the GMC says you should note carefully ‘what information they want you to share, with whom, and in what circumstances.
‘This will be particularly important if the patient has fluctuating or diminished capacity or is likely to lose capacity, even temporarily’ (paragraph 36).
The GMC says you should ask patients early to avoid misunderstandings and causing distress to anyone that the patient wants to be informed.
Occasionally, someone close to the patient might want a discussion without involving the patient. The GMC says ‘you should not refuse to listen to their views or concerns on the grounds of confidentiality’, because the information might be helpful to you (paragraph 39).
However, you should consider whether your patient would see such a conversation as a breach of trust. And you should make clear that ‘you might need to tell the patient about information you have received from others – for
example, if it has influenced your assessment and treatment’ (paragraph 40).
You should also be careful not to inadvertently disclose personal information during the conversation by confirming or denying a statement about the patient’s health.
There may be circumstances when you believe it would be beneficial for the patient for you to share information with someone who might support them.
If your patient refuses consent for you to share information, it may be appropriate to encourage them.
But you must abide by the patient’s wishes unless you believe disclosure is justifiable in the pub-
Your duty of confidentiality continues after your patient has died. if you are approached for information by bereaved relatives or friends, ask yourself:
Has the patient left instructions? if so, these should usually be respected
Would releasing information benefit or cause distress to the patient’s family/partner?
Would disclosure breach the confidentiality of others?
is the information public knowledge?
What is the purpose of the disclosure?
lic interest. In this unusual situation, seek advice from your medical defence organisation.
Patients without capacity
When a patient does not have capacity to make a decision about disclosure of information, the GMC says it is ‘reasonable to assume the patient would want those closest to them to be kept informed of their general condition and prognosis, unless they indicate – or have previously indicated – otherwise’ (paragraph 38). But remember that doctors must not assume incapacity on the basis of medical condition, age, apparent inability to communicate or anything else. You must assess capacity.2
If someone close to your patient who lacks capacity asks you for information, you need to decide whether this is of overall benefit to the patient.
The GMC says you must prioritise the patient’s care, respect dignity and privacy, and support their involvement in decisionmaking as far as you can.
You also need to take into account evidence of the patient’s previously expressed wishes and whether the disclosure decision could reasonably wait – if incapacity is temporary.
Also consider the views of anyone close to the patient or anyone the patient has asked you to consult or who has legal authority as well as what you know of the patient’s wishes, feelings, beliefs and values.
While there may be circumstances when you need to share information with the relatives, carers or friends to assess the overall benefit to the patient, the GMC states ‘that does not mean they have a general right of access to the patient’s records or to be given irrelevant information about, for example, the patient’s past healthcare’ (paragraph 46).
If the patient without capacity has asked you not to disclose information but you believe disclosure is of overall benefit to them, you should try and explain to the patient why you believe it is appropriate.
If they continue to object, you can still disclose relevant information, but you should inform the patient before doing so and consider the views of an advocate or carer.
It’s also a good idea to seek medico-legal advice. The GMC expects you to document your discussions and reasons for deciding to disclose information.
Finally, you must share relevant information with a relative/carer if they have legal authority to make health and welfare decisions on the patient’s behalf, such as if they have lasting power of attorney (paragraph 47).
If something goes wrong and your patient is unconscious or has died, it may be necessary to speak to those close to the patient, to fulfil your professional duty of candour or to meet your organisation’s statutory obligations.
The GMC expects you to respect the patient’s previously expressed wishes about information-sharing, but says: ‘You must still do your best to be considerate, sensitive and responsive to those close to the patient, giving them as much information as you can’ (paragraph 101).
You should usually disclose relevant information about a deceased patient when someone close to them asks about the circumstance of the death and you have no reason to believe the patient would have objected.
Sometimes those close to the patient have a right of access to records under the Access to Health Records Act 1990 or the Access to Health Records (Northern Ireland) Order 1993, unless an exception applies. If you have any doubt, seek advice from your medical defence organisation.
References:
1. Confidentiality: good practice in handling patient information, GMC, 2017. www.gmc-uk.org/Confidentiality2017. pdf_69037815.pdf
2. Consent: patients and doctors making decisions together, GMC, 2008. www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp
Mental Capacity Act Code of Practice, 2005 and Adults with incapacity (Scotland) Act Code of Practice, 2000
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Knowing your profit from your profitability is essential when measuring private practice financial performance. Ebert Hyman explains
For smaller businesses, the primary objective is often one of survival through maximising profits – ‘the bottom line’ – and minimising risks.
Increased profits do not necessarily result in increased profitability, and it’s important to read the signs to avoid working harder for less.
Consider the following simplified accounts for Practice a over two years:
Year 2 Year 1
Revenue £13,000
£10,000
Costs (£6,000) (£4,000)
Profit £7,000 £6,000
Profit 54% 60%
margin
profit
In simple terms, your business is profitable when revenue exceeds costs, and loss-making if your costs exceed your revenue. Profit is calculated at the end of an accounting period and is therefore historic – based on activity that has already taken place. Using the example above, Practice a’s profit has increased by £1k (or 17%) compared to the previous year. If a’s main objective is to increase profit, then this would be the end of the conversation and everyone would be happy. But focusing on profit alone may not be the best strategic objective for your business.
a mong other things, it can encourage short-termism where decisions are made to increase short-term profit at the expense of longer-term goals. an example is suspending IT investment to reduce overall costs to increase profit in a particular year. Profit is certainly a good indicator that the practice has performed well, but by no means the only indicator.
This is where I’d suggest you start playing the ‘percentages game’.
Practice a increased its revenue by 30% in Year 2, which is great
news. But, at the same time, costs increased by 50%, which should signal the need for further investigation.
In order to understand the relationship between revenue and costs, it’s important to know what each figure represents. Your accountant – and indeed the manager in charge – should know or be able to draw this information from your accounting software.
Now that you know the basics, it’s worth asking: ‘Why did revenue increase?’
The answer might be as simple as increased capacity to see patients. It’s probably a combina-
tion of factors; for example, where the practice increased its fees at the beginning of the year, a new doctor joined the practice resulting in more capacity to see patients and the mixture of services generating a higher return. It’s true that over-analysis can lead to operational paralysis. But, where possible, one should also ask the question: ‘Did revenue increase in line with our expectations?’
The practice will have specific knowledge on any factors which might affect their revenue figures in a particular period.
For simplicity’s sake, let’s ➱ p22
assume in our example that revenue is made up of consultation fees only. If the number of patient appointments increased on average by 50%, but the practice knows that re-imbursement levels for a group of patients reduced by 20% compared to the previous year, the practice would expect its total revenue to increase but by less than 50%.
Now ask: ‘Why did costs increase?’ The increase in spending may be perfectly obvious; for example, employing additional staff in Year 2 to cope with the increased administrative workload or a ‘one-off’ marketing expense to introduce the practice to the general public. once again, it’s likely that a combination of factors will play a part.
The profit margin is a ratio which measures the profitability of your business, and is shown as a per-
centage using the formula ‘Profit/ revenue’.
Profitability measures the efficiency of the business in turning revenue into profit. The higher the percentage the better.
In our example, the profit margin for Year 2 was 54%. This is 6% less than the previous year.
From the investigations above, we know that although revenue increased by 30% compared to last year, costs increased by 50%. l ogic therefore dictates that although we made more profit, we were less profitable due to comparatively higher costs.
Practice a might be in a unique position where the 60% profitability in Year 1 was unusually high and unsustainable.
The practice may have been experiencing a year where major expenses were put on hold –remember short-termism? – or it was operating at maximum capacity, given its resources, which led to added expenses alongside the growth in Year 2.
From our example, we know that profitability went down by 6%. This may be acceptable given all the factors that influence the figures, but this may warrant an objective for the management of Practice a to try increase effi -
ciency and ultimately profitability in the coming year.
The simplified accounts for Practice a has three variables, namely revenue, costs and profit. If we increase revenue and control costs, we should be able to increase profit – and profitability. a ssuming there is sufficient demand, the practice could decide to grow the business by increasing the capacity to see patients.
It might decide to extend clinic opening hours or invite another clinician to join their team. Both actions should result in added capacity.
a nother example would be where the practice identifies and then offers new services to patients according to their needs and wants.
one could argue this diversification might complement current
new processes are often added to existing ones instead of replacing them, resulting in an increased administrative workload
services and enhance the patient experience.
There is much to say about controlling costs and operating efficiently, but we’ll focus on three areas which may seem obvious but are often neglected.
1
The first (and most obvious) is knowing what your expenses are, the movement over time and when to act.
a good set of management accounts will offer variance analysis for each expense line, showing you the movement over time – be this monthly, yearly or both. It should then be relatively easy to spot irregular movements and investigate further.
2
The second area is supplier contracts, which should be reviewed annually.
Unless your business is particularly loyal to, or there is no alternative supplier, do ask for a price review.
I have seen suppliers reduce prices in response to a simple request to review your price list. You may have been rolling on with inflationary increases year on year, which seem negligible at the time but can compound to overspending in the longer term.
3
The third is internal processes. This idea links in with improving efficiency and removing non-essential – or nonvalue-adding – activities.
It’s probably unfair to assume people in general don’t like change, but certainly a lot of people fall into this category in the workplace.
New processes are often added to existing ones instead of replacing them, resulting in an increased administrative workload. This often leads to capacity problems with pressure to recruit more staff.
While increased profit is certainly a good thing and should make you smile, you want to keep an eye on profitability to make sure that you are running an efficient business which is able to compete and grow.
Ebert Hyman (right) is a chartered global management accountant and general manager at London Urology Group and 101 Diagnostics
A tax rule means doctors who go abroad and let out and sell their UK house are in for a nasty surprise. Melanie Thomas (below) explains
Doctors who are living overseas and who sell a home in the UK should beware of being caught out by changes to the capital gains tax rules.
the changes, which came into force on 6 April 2015, mean that non-UK residents must pay tax on any increase in the property’s value from that date until the date of the sale, and to submit a capital gains tax return within 30 days of completion.
Many doctors who go to live or work overseas are unaware of the changes and we are aware of a number of cases where people have unwittingly fallen foul of the rules. typically, the people who
will be affected are younger doctors who take up an initial contract overseas and let out their home in the UK while they see how things go.
If they decide to stay on at the end of it, they may then consider selling their UK property. But they are likely to be unaware of the rules and it often doesn’t occur to them to tell their accountant until it’s time to do their annual tax return, when it may be too late.
In one case, a client and his partner who sold their home in the UK were fined £1,300 each for failing to submit a return within the 30-day period – even though there was no capital gains tax payable.
We are aware of a number of cases where people have unwittingly fallen foul of the rules
he didn’t inform us of the sale at the time and the solicitors who carried out the conveyancing failed to advise him of the rules.
t he rules apply to non-UK residents selling UK residential property, whether it is their home or a rental property. so this represents a potential new tax charge, as, previously, non-residents would have paid no capital gains tax on their UK residential property.
t hey must also submit an online capital gains tax return within 30 days of the sale –whether there is any tax to pay or not – and even if they have made a loss on the property.
If, as in the case above, the property is held jointly, then each non-
resident person must file a return and pay their share of any charge. to calculate any capital gains due, they will have to have a valuation of property as at 6 April 2015.
Any tax due must also be paid within 30 days of the sale, although those who are registered for UK tax can choose to pay it at the same time as tax due for their normal self-assessment – in other words, by 31 January 2018 for gains realised in the 2016-17 year. there are daily penalties for the failure to file a return or pay the tax on time.
t he rules are complex, so the best solution for anyone in this position and considering a sale is to consult your accountant in advance for advice on your individual circumstances.
Let’s look at the case of a doctor who is single and non-resident and is selling a buy-to-let property he holds in the UK.
t he figures from his case are shown in the box above. he is a higher-rate taxpayer who is eligi-
ble for an annual capital gains tax exemption. we will assume the sale completes early next year. however, the rules are lengthy and complex. this example uses the standard method of calculating the cost, but you can choose other methods – ask for individual advice from your accountant.
there is a fixed penalty of £100 for late filing, where the return is delivered within three months of the filing date. For those received
more than three months late, a penalty of £10 a day will be charged for up to 90 days.
For returns received more than six months late, a penalty of £300 will also be due. For those received more than 12 months, another fixed penalty of £300.
A client and his wife who filed after six months but before one year each received a penalty of £1,300.
Melanie Thomas is an accountant at Hall Liddy, Manchester
In Independent Practitioner
Today’s series over the last year, Philip Housden (right) has considered the challenges faced by NHS private patient units (PPUs).
He has offered insights through the annual cycle to help PPUs make the most of the many opportunities the market presents –and deliver increasingly improved services for private patients and better financial returns for NHS trusts.
Now he summarises the series through an A-Z guide, aimed as an aid to local consultants and managers as they work together to drive forward private patient activity
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Consultants want to work with a PPU that is ‘hassle-free’.
Supplying a hassle-free experience requires an admin team, ideally located on or adjacent to the private patient ward, that makes things happen and works with a standard ‘yes’ response to a booking request.
There are standard financial and management systems that deliver what PPUs need, easing the relationship with insurers, and providing the activity, quality and financial information that managers are hungry for and regula-
tors such as the Private Healthcare Information Network (PHIN) increasingly demand.
Oh, and the private patient office should also be run separately from overseas visitors admin too.
Amenity beds have been around for many years, most noticeably giving mums the opportunity to book a single room when giving birth, and also for some side rooms on general NHS wards, when those rooms are not required for clinical priorities.
Patients taking an amenity bed will remain NHS patients while releasing a NHS bed when they move to the PPU.
Prices vary, but typically £250£300 a night will be the cost for an ensuite room with the hotel and privacy comforts it brings.
It is perfectly possible for NHS trusts to aim to build the amenity bed revenues from scratch to well into six figures quite quickly.
The evidence is that amenity patients are satisfied with their experience and can then become advocates for the services of the PPU to their friends and family.
some colour and a top-floor view and the PPU can definitely meet the expectations of consultants and their patients. But the PPU has the added ‘X factor’: 365-day services and critical care back-up. This is the ‘best of both promise’ – and patients and consultants understand and like it.
The key customers are consultants first, then their patients.
PPUs have to demonstrate to consultants that the NHS trust can deliver reliable admin, and also access to theatres and beds. This is the absolute baseline to building a PPU.
But to be really successful, PPUs have to deliver the ‘best of both promise’ to convince consultants that their patients’ experience will match expectations of privately funded care and have that peace of mind that comes from having the whole NHS there to back you up.
Where does the patient demand for NHS PPUs come from? Private patient services in most trusts fill in service gaps rather than compete head-on for market share against local competitors.
Consultants should not worry; a PPU will stimulate demand and grow the size of the private patient market – it will not cannibalise it.
PPUs support the most complex insured cases: those procedures that need specialist equipment and those patients best supported by 24/7 infrastructure; and pri -
The local PPU brand should be clearly associated with the trust and the NHS, but also recognisably representing private patient services across the trust’s campus.
A signature colour helps. In recent years, private hospitals have replaced carpets and curtains with a much more clinical feel, and, in the same period, many NHS trust new buildings have included a range of single rooms.
This has brought the patient experience in private hospitals and NHS PPUs much closer together. Throw in the TV and
vate patients needing acute nonelective care too.
Without a PPU, these patients most likely default to the NHS.
The single most important ingredient that drives a PPU forward is the ‘will’ of the NHS trust to make it so.
Executive director support, and that of the wider board too, is fundamental to setting the tone for private patient activities to commence and flourish in a trust.
The absence of visible backing for mixed provision will be understood by consultants, and rightly so. Once the trust chairman and chief executive have set the tone that ‘private patients is something the trust does’ and been seen to say so, business will start to build.
The PPU must run as a separate trading account and profit centre.
This should include paying for internal services received from theatres, imaging, critical care and so on, as well as the cost of estate facilities and other corporate overheads.
Why? So that the full costs of service are understood and a gross and net margin and return on investment are identified.
Staff working in a ‘trading’ situation with fluctuating activity and non-guaranteed revenue streams find that this focuses the mind, and in a good way.
The vast majority of staff, clinical and non-clinical, then appreciate there is a closer link between what they do, how they do it, the
quality and reputation of that work, and the resulting success of their team. So, as in a private hospital, ‘busy’ becomes ‘good’.
A PPU is in the privileged position of being able to ‘keep score’ and share how the team is doing regarding income, costs and surpluses. That’s why they can and should be fun places to work within a trust.
The most crucial of relationships in a PPU are those between the trust – specifically trust managers – on the one hand and the consultant as practitioner on the other.
The umbrella for getting this right is governance. And the key principle for PPU governance is based on respecting the different relationship with consultants who are working within the PPU not as employees, but as independent practitioners.
Governance must be balanced by also protecting the interests of the trust – directed to ensure patient safety and best clinical outcomes and overseen by the medical director.
This is achieved through a clear policy document setting out the rights and responsibilities of all admitting practitioners in the PPU and how things are different from the NHS – although remaining part of it.
Although patients can’t easily judge the surgeon or physican’s competence, they can the food.
Smaller trust PPUs struggle with the delivery of separate menus due to the low daily patient volumes and the difficulty of running a different process within the larger organisation. But this is not a deal-breaker.
Working with the trust caterer
and particularly with the way that food is served will achieve a lot.
Experience has shown that investing in crockery, cutlery and presentation, together with delivering food with a smile can achieve the same patient satisfaction ratings as an expensive new menu.
Not all private medical insurers include NHS PPUs in their networks; it varies from place to place.
With the insured market worth 75% of PPU incomes and over 90% of all insurance in the hands of just four providers, it is important that PPUs work to improve the relationship with Bupa, AXAPPP, Aviva and Vitality.
To get into networks and to gain quality accreditation requires effort and these discussions will mix finance and quality – without guaranteeing volumes – so PPUs
have to work with the consultants to achieve that.
The trend is, though, that insurers are increasingly working to direct some activity towards providers that can meet quality specification requirements.
For trusts where PPUs form less than 1% of activity and turnover, it is difficult to disentangle quality and access issues away from the NHS service in such a way that that the insurers want to see it.
These are all good reasons to articulate to insurers that the PPU is delivering what the independent hospital cannot: that’s good for defending tariffs and for gaining insurer authorisation for patient care.
More next month, starting with J – Junior doctors
Philip Housden is a director of Housden Group, a management consultancy specialising in commercial support in the healthcare sector
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How much you expect to receive for a specific piece of work or service depends on negotiation between you and those who are paying. Ensuring you get the cheque is another matter, says Michael R. Young
YOUr TErmS of business should always make it clear to solicitors when you expect to be paid.
The majority of firms are very good at paying their experts on time, but some do need a gentle reminder by way of a phone call along the lines of: ‘I am expecting a cheque but it hasn’t arrived yet. I was wondering if it might have got lost in the post.’
It’s amazing how many of these cheques arrive the following day.
Some firms need a written reminder, but very few, if any, never pay.
Don’t expect to be paid in advance for a report. But it is not unreasonable to expect to be paid promptly once you have submitted your invoice/fee note.
Your invoice/fee note should show the following:
The name and address of the law firm;
The solicitor’s reference for his or her client;
Your reference;
The client’s name;
An exact description of the
work carried out, for example:
‘The preparation and submission of a liability and causation report according to your instructions as set out in your letter dated DD/ mm/YYYY’;
The full amount due in figures;
The date by which payment is due;
To whom the cheque should be made payable or bank details for payment by BACS.
Once payment has been received, send the solicitor a receipted copy of the invoice for his or her records. Don’t forget to keep a copy for your case file.
Do not forget that all your earnings must be declared to Hm revenue and Customs. But remember to claim all expenses, such as stationery, postage, books, research material, training courses, travel, and accommodation.
This ongoing series in Independent Practitioner Today is adapted from The Effective and Efficient Clinical Negligence Expert Witness, by m ichael r . Young, price £60 from Otmoor Publishing.
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When a case has been closed – settled – you will be left with a pile of paper records, your written notes and records that you have stored electronically.
How long should you retain the records for? Bearing in mind the fifth principle of the Data Protection Act 1998, you should not keep any records once the solicitor has confirmed to you in writing that the case is closed.
Either return all of the records by recorded delivery to the solicitor or tell the solicitor that you will shred them.
Delete all computer-based records – including those held on portable storage devices such as memory sticks.
If later you are asked to work on the case – for example, if having won the civil case, the claimant then lodges a complaint with the defendant’s professional regulatory body, and you are asked to prepare another report – you can always ask the solicitor for another copy of the file, which should include a copy of your original report.
Sometimes cases go ‘cold’, so, once a year, it is worthwhile writing to the instructing solicitors, asking them if any files you have not worked on in the last year or so can be destroyed.
Replying to this letter won’t always be top of their list of priorities, so include a sentence that states that if they don’t reply, say, within 30 days, then you will go ahead and destroy or delete the files.
Unless you have a limitless amount of storage space, keeping huge numbers of case files is unrealistic and probably illegal. Good housekeeping is essential to be compliant with the Data Protection Act 1998.
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TV doctor and full-time writer Dr Michael O’Donnell (right) brings the last taster from his new book, Medicine’s Strangest Cases. This month, he looks back at doctors’ obituaries
One charming medical tradition is the civility with which doctors deal with one another in public.
Offstage, they can be as bitchy as those who practise the other performing arts, but their traditional public relationship is one of deference and exaggerated politesse.
Things now may not be quite what they were, but, in the 1960s, doctors were still introduced at meetings in terms that would sound extravagant in their obituaries.
medical audiences which heard ‘Tonight we are privileged to be in the presence of someone who has made a significant contribution to contemporary thought and practice’ would recognise the routine introduction of a consultant from a local hospital.
a nd the obituaries themselves were products of a process that John r owan Wilson, surgeon, journalist and novelist, described as ‘doing old Freddie proud’.
Wilson was, at the time, in charge of the obituary pages of the British Medical Journal (BMJ), a useful post for writers in need of the sustenance of a regular cheque until they establish themselves as authors.
a previous incumbent, richard gordon, distinguished himself by publishing the obituary of a prominent doctor who was still alive.
When a doctor of music of the same name perished, gordon rang a few friends of the putative corpse and persuaded them to supply a few kindly words.
The subject of the obituary was not at all put out; indeed, he was amused. The people who were really cross were his friends, who had said flattering things about him that they would never have uttered if they’d known he were still alive.
When Wilson took the job, the BMJ’s editor, hugh clegg, assured him that though he might find the work a little boring, he was performing a vital function.
‘Obituaries are the very stuff of medical history,’ he would say whenever he felt Wilson was looking down in the mouth.
every doctor over 50, said clegg, turned to the obituary column in eager expectation. if he saw that one of his friends or rivals had finally hung up his stethoscope, he would rub his hands in
triumph and his step that morning would have an extra spring.
‘Did you read about old Freddie?’ he would ask his friends, wagging a copy of the journal.
‘They did him proud. his wife will be pleased about that.’
Doing Freddie proud, said Wilson, was largely a matter of length. The content was of less concern than the column inches.
Whenever he was rapped over the knuckles about an obituary, it was always for giving someone more or less space than he or she was considered to deserve.
Judgement on delicate matters of this kind, he claimed, was what separated the men from the boys in medical journalism.
in 1963, Wilson compiled a glossary of words and phrases plucked from obituaries submitted to the journal, adding a note of the truth that lay behind each cliché.
much of his glossary – see box below – has survived, augmented down the years with phrases diagnosed by others.
Thanks to the lingering tradition of medical politeness, some would say it is as useful a codebreaker today as it was when Wilson first created it.
a fter he left the BMJ , John r owan Wilson would occasionally amuse himself by rewriting a published obituary, substituting the truth for the clichés.
i t is still a rewarding game to play.
Medicine’s Strangest Cases, recommended price £7.99, ISBN 9781910232941.
Published by Portico, an imprint of Pavilion Books
A character: A tiresome old man
A perfectionist: An obsessional neurotic
Assertive: A bully
Plain-spoken: Offensive
Did not suffer fools gladly: Damnably offensive
Not easy to get to know: Morbidly suspicious
Mercurial: Paranoid
A man of strong opinions: A bigot
Charming: Dim but smiled a lot
Respected: Feared
One of the old school: Hopelessly out of date
Widely travelled: Left his juniors to do his work
Many interests outside medicine: His juniors did all his work
A popular after-dinner speaker: An eminent old bore
Fond of the good things in life: A drunk
Lived life to the full: A drunk
Popular patron of the student rugby club: A drunk
Had all the irresistible charm of the Celt: A talkative drunk
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The ten commandments for billing and collection Make sure the people you rely on in your practice are following these essential rules to keep your payments coming in. Gary Nials lays down the law
Thou shalt send invoices out promptly. the sooner you get the invoice sent, the sooner it will be paid. ideally, you should aim to get any invoice sent the same day of treatment or once aware an invoice is due.
Thou shalt keep a record of every invoice sent. it is imperative that you keep a record of invoices sent so you can track them. once payment has been received, it is also crucial that you mark them as paid, otherwise you will waste time chasing them. this will also look unprofessional on your part.
Thou shalt ensure patient contact details are taken on first appointment. the best time to get patient contact details are when they arrive for their first appointment. this is also the time they most expect to be asked. phone number and email are crucial – especially for following up with payments. A good policy is no details, no appointment.
Thou shalt ensure procedures are recorded by relevant ccSd code. insurers use codes for re-imbursement purposes, so it is crucial the correct ccSd (clinical coding and Schedule development group) code is attached to any procedure. Also be aware ccSd codes change monthly and insurers apportion different prices to different codes. (See page 34).
Thou shalt ensure you have correct letters of guarantee (logs) for embassy patients. embassies are very clear that they want a letter of guarantee (LoG) attached with any invoice.
if you have an embassy patient, make sure they have the LoG and check the details are correct in terms of consultant name, treatment and dates.
if not, receiving payment will be a big problem, so you really should re-arrange the appointment and insist they bring a LoG.
Thou shalt carry out bank reconciliation every Monday. Quite often, there are payments that hit your bank account with multiple payments included in it. While it is time-consuming, you must stay on top of this process of checking what invoices the payment is for – otherwise you will waste time chasing invoices that have already been paid. i suggest your relevant staff set aside time each Monday to look at the previous week’s payments.
Thou shalt be certain to invoice excesses and shortfalls for insured patients promptly. once you have carried out bank reconciliation and become aware of any shortfalls or excesses to be billed for insured patients, make sure these are sent to the patient promptly. the same principle applies as per the first commandment.
Thou shalt ensure your terms and conditions are clear to patients. clearly state on your patient registration form – as well as your website – what your terms of business are. this is another reason you should make sure you keep a record of when the invoice has been sent. if unpaid invoices break your agreed terms and conditions deadline, make sure you keep chasing them – which should involve a phone call, not just an email or letter. See that those working on this in the practice inform the doctor(s).
Thou shalt chase outstanding invoices on a regular basis. it is not enough just to send invoices and expect them to be paid. You need to chase invoices regularly and systematically and ensure that payments are recorded. if invoices have not yet been paid, this should become obvious in your system with some flagging format such as colour coding of green when still outstanding, black when paid and red when overdue.
Thou shall ensure staff inform the doctor(s) of late payers and problem invoices. remember, you have to pay tax on invoices raised, not payment received. this increases the importance of systematically sending and then properly chasing your invoices. even with this, there still might be non-payments for various reasons. if staff think the practice might need to consider writing an invoice off, they should let the doctor(s) know so it can be discussed. Better that way than leave it to chance. especially as you can get the tax back if you do decide to write it off.
if you cannot manage all of the above, then you need to decide what action to take and consider whether you should outsource this crucial element of your practice to a professional billing company.
Gary Nials (right) is managing director at Medical Billing and Collection
work in Private Practice is big business, so let Code Buster! keeP you in the know every month, the clinical coding and schedule development group (ccsd) reviews its 2,000-plus procedure codes, and more than 3,000-plus diagnostic codes, that form the basis of private medical insurance. it is crucial for independent practitioners and their practices to know these codes, so they bill correctly. if they don’t, then it could cost them money
Changes to note this month Specialties recently affected include: Spine, spinal cord and peripheral nerves (Code A, T & V), brain, cranium and other intracranial organs (Code B), urinary system and male reproductive organs (Code M & N), female reproductive organs (Code Q), investigations, simple procedures and consultation codes (Code S), abdomen –excluding urinary and reproductive organs (Code T), bones, joints and connective tissue/tendon muscle (Code W), interventional radiology (Code XR).
ThERE ARE ThREE nEw PROCEDURE CODEs
A5781 – Selective Dorsal Rhizotomy (SDR);
T3610 – Omental biopsy +/ an ascitic drain under image guidance;
W4244 – Tibial liner exchange in total knee replacement.
Four narrative changes
XR254, N2782, V3362, A7012 ; and two inactivations : S5210, S5240
ies (CTCA) with fractional flow reserve (FFR) calculation; K6310 – CT Coronary angiogram.
There is one narrative change IM017 – CT of the coronary arteries (CTCA) to CT of the coronary arteries (CTCA) as sole procedure.
Of special note this month, popular codes S5210 and S5240 are to become inactive from 27 April 2017.
The CCSD Working Group have advised that these codes are not required – an injection into subcutaneous tissue would be a local anaesthetic, in which case they have advised to use AC100
If it is a trigger point injection, use code T7290, or multiple trigger point injections, use code T7292
Please remember, however, that
CONTACT US TODAY
ThERE ARE 35 UnACCEPTAblE COmbinATiOns (AlsO knOwn As UnbUnDling)
V0390 added with V2200;
A5751 added with A5720, A5730, A5760, A5770, A7350, S5210; A5761 added with A5720, A5730, A5750, A5770, A7350, S5210; A5771 added with A5720, A5730, A5750, A5760, A7350, S5210; B0410 added with E1432; M6584 added with M6580, M6583, M7020, M7030, M6580, M6582, M6584, M7020, M7030; A3200 added with V0110; T6220 added with W8194, T7982; Q1281 added with Q1800, Q1802.
ThERE ARE AlsO TwO nEw DiAgnOsTiC TEsTs CODEs IM364 – CT of the coronary arter
codes are not mandatory for the insurers.
In other words, the inclusion of procedure codes within the Clinical Coding and Schedule Development Group list does not indicate the automatic agreement of individual insurers to provide benefit for this procedure. You need to contact each insurer directly to find out whether benefit is provided.
c ode Buster data is provided B y Medical Billing and collection. For Full details, go to the c linical c oding schedule developMent we B site at www.ccsd. org.uk
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Prescribing medication online is a particularly complex area, so it’s as well to know the pitfalls and perils. Christina Helden and Nabil Asaad outline the dangers
Interfaces such as a mazon, eBay and u ber that utilise the internet, sMs and apps to deliver goods and services are popular because they save time – and savvy healthcare businesses realise that patients are no different. they view time taken to make doctors’ appointments and queuing at the surgery as wasted time. s uch businesses are capitalising on this perception by creating interfaces which allow patients to obtain prescriptions remotely: online, by sMs or app.
however, while this may seem a natural and logical next step in health service provision – and it is potentially profitable – it is not without its legal hurdles, as prescribing medications is heavily regulated.
a ny healthcare business will need to consider the following key issues if they wish to develop a remote prescribing interface (rPI): the remote prescribing model;
Patient review and assessment; Who can prescribe; can an app do it all?
Remote prescribing model
rPIs typically offer a narrow range of prescription medications comprised of first-line medications for commonly diagnosed conditions. f or example, there are multiple online prescription services for cholesterol-lowering and diabetes’ medications.
the reason for this is that rPIs must comply with the same legislation and guidance governing traditional face-to-face prescribing. the most important of these is the requirement for a full clinical review and assessment.
While rPIs can theoretically be used to prescribe any medication – except controlled drugs – by narrowing the medications and conditions for which prescriptions will be provided, it is easier to ensure that a comprehensive
Remote prescribing interfaces must comply with the same legislation and guidance governing traditional face-to-face prescribing
Patient review and clinical assessment
the questionnaire containing the patient assessment must comply with GMc guidance outlined in Good Medical Practice in Prescribing and Managing Medicines 2013, the h uman Medicines a ct r egulations 2012 and the British National Formulary
patient assessment has taken place.
simply put, the patient assessment can be tailor-made to a particular condition and to the specific contra-indications associated with the particular medication being requested.
It is quite possible for such assessments to be administered remotely via a questionnaire containing closed questions designed to highlight contra-indications before being reviewed by an appropriate clinician.
In particular, it must elicit enough information about a patient’s medical history to allow the clinician reviewing the questionnaire to determine whether or not the medicine being requested is appropriate for a particular patient and whether the patient requires further examination or medical assessment via a face-to-face appointment before it is prescribed.
If the relevant clinician determines that the questionnaire provides enough information to prescribe the medication, the rPI
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must have a mechanism for conveying information about the drug, its possible side-effects and what the patient should do if he/ she experiences side-effects.
conversely, if the clinician does not feel that they can prescribe medication as a result of issues flagged up by the questionnaire, the rPI should have a procedure for notifying a patient of this and signposting them to an appropriate local clinic for a face-to-face consultation.
Importantly, even if the questionnaire and the clinical review are comprehensive, there is one risk that is difficult to mitigate: lying.
If a patient suffers an adverse effect from the relevant medication, a claim could be brought against both the rPI operator and the prescribing doctor. h owever, such a claim would likely be defensible if it can be demonstrated the patient had lied on the questionnaire and that the lie relates to something that would not have been picked up in a face-to-face appointment.
new legislation has recently come into effect that allows nurses, physiotherapists and pharmacists to prescribe medication if they have received the appropriate training.
The
But, as only the GMc currently provides guidance that allows for remote prescribing in the context outlined in this article, any business that is considering using an rPI will need to hire a doctor to conduct a clinical review of patient assessments. that doctor, in turn, will need to ensure that their assessment complies with the GM c ’s guidance: Good Practice in Prescribing and Managing Medicines and Devices 2013
can an app do it all?
the applicability and use of specifically-tailored questionnaires, set against a background of increasing interest in medical devices that comprise standalone software, raises the question of the point at which an app could complete the prescribing process without the need for a medical practitioner to intervene at all.
In some cases, technological and medical considerations may not, in theory, be a barrier to an app completing the process. the reality is that the regulatory regime requires that a regulated medical practitioner is responsible and accountable for the issuing of a prescription. On this basis, that practitioner would be ill-advised to attempt to delegate his decision-making to an app.
as in every case, the practitioners involved in these developments will require professional indemnity cover, in addition to insuring the business itself.
however, as this is a relatively new area to the market, there is no clearly established regime for this and it will be necessary to discuss the cover – and cost – on a case-by-case basis.
the need to overcome the issues described above may delay progress towards fully automated prescribing, but the ‘direction of travel’ towards meeting patient needs using more streamlined and convenient solutions will certainly continue.
rPIs can provide patients with a fast and safe way to access prescriptions for medications for common medical problems.
the remote prescribing model is dependent on a robust patient assessment in the form of a questionnaire and subsequent clinical review by a doctor. the content of each questionnaire depends on the particular condition and medication(s) that the questionnaire has been designed to address.
this inevitably means that any health business intending to utilise rPIs cannot use a ‘one size fits all’ patient assessment. r ather, the assessment is dependent on the medication being prescribed and on the legislation and regulations that govern that particular medication. On this basis, it is advisable for healthcare businesses wishing to undertake such an enterprise to seek legal advice to ensure that their patient assessment and clinical review is compliant.
Christina Helden (far left) and Nabil Asaad (left) are solicitors at Hempsons Solicitors. Christina Helden: Phone: 020 7484 7621. Email: c.helden@hempsons.co.uk Nabil Asaad: Phone: 01423 724102. Email: n.asaad@hempsons.co.uk
Qcan you advise the best ways to keep on the right side of the taxman?
accountant susan
gives some useful pointers:
➲ Don’t send your tax return in late
If you send in your tax return late, you not only will have to pay a penalty of £100 but will bring your case to the attention of hM r evenue and c ustoms ( h M rc ) for all the wrong reasons. It also means the tax inspector has longer to challenge the return.
Let’s say for the next tax return you make the deadline of 31 January 2018. Your return would be open to challenge until 31 January 2019. If you are late, h M rc can extend the period it challenges by at least four months. Why be on tenterhooks?
➲ Make sure you provide your accountant with all the necessary information for your tax return
Let’s say you have five different bank accounts, then remember that banks have a duty to report any interest above a certain amount to h M rc . If you fail to include one of them in your return, h M rc could challenge your tax return, which may lead to a much bigger investigation.
➲ Do fill in as much relevant detail on the ‘Any Other information’ section on the tax return
Do not underutilise this section; for example, if something unusual has happened in the tax year, such as transferring your business to a limited company.
One doctor I knew was a trustee for a relative’s will and opened a bank account in his name – the interest was considerable, but he didn’t put it on the tax return, as
he wasn’t the beneficiary. h e should have put details about the circumstances in this section.
➲ Keep source documentation for six years from the submission date of your tax return
It is rare that hMrc will investigate six years of tax returns, but just in case it does, make sure you do not shred important support documents. Information on, say, the valuation of a property and contracts with third parties that are still operational should be kept until they are obsolete – i.e even longer than six years.
➲ You must get the cut-off position right in your practice accounts remember, your accounts are not prepared on a cash basis, they are prepared on an accrual basis. so you will have to include all invoices raised to patients and insurers for work carried out in your financial year, even if the
invoices were not raised in the financial year-end or the funds were not received by the financial year-end.
similarly with expenses incurred by the practice, you must include them on an incurred basis rather than when you pay the money or receive the invoice.
➲ Keep back-up documents for all business expense claims
t hese include receipts, mileage logs and credit card statements. Your accountant does not need all of these to hand, but you will need to keep all your source documentation – as far back as six years – in case hMrc asks for this.
➲ Take out tax inquiry fee protection insurance there are no guarantees that you will avoid an on-the-spot investigation from the hMrc to ensure you don’t have to pay accountants’ fees to cover an investigation, you should ensure you have
protection insurance, which is, on average, £300 a year. remember, investigation costs can mount up depending on the complexity.
➲ Keep business transactions separate from personal transactions
Do make sure you have a separate personal bank account from your business bank account.
If you trade as a limited company, then it is mandatory. But even if you are a sole trader, separate accounts mean your accountant will not have to wade through all personal items and means less time and less accountancy fees.
➲ Make sure anyone who is employed by you is on payroll
Make sure any employee working for you is set up on a PaYe payroll. Beware allowing the practice secretary to be self-employed. even if the secretary does their own tax return, h M rc can still investigate you because you are not paying e mployer n ational Insurance contributions. If your secretary has no other work apart from your practice, then she will not be considered self-employed.
➲ Make sure spouse shareholders do a separate tax return
If you trade as a limited company and your spouse is a shareholder, then he or she will get a share of the dividend and this means they need to prepare their own tax return.
Susan Hutter is a partner with accountants Shelley Stock Hutter
We are all prone to making mistakes when investing, not because we are foolish, but because we are human. Dr Benjamin Holdsworth shows how to adopt a disciplined approach
‘If I have learned anything in my 52 years in this marvellous field, it is that, for a given individual or institution, the emotions of investing have destroyed far more potential investment returns than the economics of investing have ever dreamed of destroying.’ John C. Bogle, founder of the Vanguard Group and investment ‘legend’
Being an investor is not easy. We have to contend not only with the erratic and unpredictable nature of markets but also the erratic and irrational way in which we think and behave.
This manifests itself in different ways among the broad investing population:
Chopping and changing an
investment strategy based on recent market conditions;
Trading shares in an online brokerage account;
Thinking that we have some unique insight or talent for doing so;
Trying to pick when to be in or out of different markets or chasing ‘hot’ funds and managers.
The full list is long and undistinguished. Benjamin Graham, a great 20th century investment mind, famously stated (Graham and Dodd, 1996): ‘The investor’s chief problem – and even his worst enemy – is likely to be himself.’
Probably most investors act irrationally, rather than rationally as economic theory would demand.
The times when most investors become irrational are generally periods of market trauma or exuberance
sedates rationality like large doses of effortless money.’
While most investors can understand the simple concept of buy low, sell high, in practice their behaviour results in exactly the opposite. They are prone to being influenced by what is going on short-term in the markets. This makes them vulnerable to being whip-sawed as they move money from last year’s bad performers to this year’s hot performers.
This has spawned a new field of economics known as behavioural finance.
Understanding these demons can help us identify how we can try to control them. The times when most investors become irrational are generally periods of market trauma or exuberance.
a s Warren Buffett once said (2001), with reference to the technology stock hysteria of the late 1990s: ‘The line separating investment and speculation, which is never bright and clear, becomes blurred still further when most market participants have recently enjoyed triumphs. Nothing
for example, since the start of 2015, investors have faced a number of economically and emotionally worrying events: a UK general election and the 2015 Greek debt crisis, along with a slowdown in China’s growth rate and associated market jitters, the UK Brexit referendum and Donald Trump’s election as US President. It would have been emotionally tempting to become defensive and move at least a portion of one’s assets to cash. Those with fortitude, discipline and experience would have recognised this as just another period of uncertainty, where holding firm and sticking with the long-term plan made sense.
a basic 60% global growth/40% defensive balanced portfolio would have delivered well in excess of 20% over this period –not a bad return for inactivity. But ‘absolute return’ funds seeking to deliver positive returns over short time frames – and which have great flexibility to position their portfolios in the face of future market events – performed very poorly. They delivered a meagre 4% over this period, beaten by nearly every investment asset class.
Second-guessing the markets is a tricky business. Short-term, emotionally-driven decisions, mixed with overconfidence in the ability to see into the future, can be extremely costly.
Behavioural challenges and how to deal with them as investors, we have to contend not only with the erratic and unpredictable nature of markets but also the erratic and irrational way we think and behave. a lack of knowledge, combined with many illusions and biases can lead to costly errors in decision-making as itemised below:
Trap 1: Believing you are better than average h uman beings tend to be overconfident in their abilities. f or example, out of 600 professional fund managers asked in a study almost 75% said they were better than average.
Mitigation strategy: have some humility: plenty of very clever people get beaten up by the markets.
Trap 2: mistaking random noise for patterns a rational gambler playing roulette knows the chance of any number coming up is the same as any other number. Yet, a sequence of three red ‘9s’ in a row can create quite a stir at the table.
Mitigation strategy: If you detect a pattern in shorter-term data, it is probably meaningless.
Trap 3: problems with probability – and maths in general Many people will pay more for something that improves the probability from 95% to 99% rather than from 45% to 49%, despite the financial benefit being the same. virtually no one can compound in their heads.
Mitigation strategy: Do not ignore the maths. Sit down and spend a little time teasing out the numbers.
Trap 4: The monday morning quarterback – hindsight delusion
With hindsight, we often honestly think we could have predicted what has happened, such as a market fall. The evidence suggests we cannot.
Mitigation strategy: Do not believe you have predictive powers – it is unlikely you do.
Trap 5: i will throw my anchor out here, thanks
The human mind really likes to use mental ‘anchors’ when forming opinions, which in many cases leads to extraordinarily inaccurate outcome estimates.
The fTSe 100 level is a common investment anchor for clients, even if their investment portfolio is very different.
Mitigation strategy: Do not allow yourself to get hooked on meaningless anchors.
Trap 6: it is more familiar to me, and i get it
humans tend to make spontaneous generalisations, based on how they are influenced by recent events, press coverage, their own experiences, and the vividness with which a situation is portrayed.
Mitigation strategy: Stand back and seek a broader perspective.
Trap 7: i like a good story
We all love a good story and there are few better storytellers than fund managers.
The danger is that the narrative of a plausible sounding script, often full of contingent probabilities, tends to persuade us to assign a higher likelihood to the story coming true than is realistic.
Mitigation strategy: Be a sceptic – take everything you hear or read from the industry with a pinch of salt.
Trap 8: short-termism and obsessive portfolio monitoring
Many investors find it difficult to see the long-term wood for the short-term trees. Their focus tends to be on the effects of recent market conditions on their wealth. This affects their ability to make good long-term decisions.
Mitigation strategy: Given the ratio of pain to gain, the longer the period between peeks at a portfolio the better.
The solution: process, process, process
Investing using a well thoughtout, evidence-based and systematic investment process helps to take much of the emotion out of
investing. a good process won’t always deliver a good outcome, but, over time, it raises the chances of one.
While investing is simple, it is never easy, larely because of how we behave.
Perhaps reflect a while on these wise words written by Charles D. ellis in his excellent book Winning the Loser’s Game (ellis, 2002):
‘The hardest work in investing is not intellectual, it’s emotional. Being rational in an emotional environment is not easy.
‘The hardest work is not figuring out the optimal investment policy; it’s sustaining a long-term focus at market highs or market lows and staying committed to a sound investment policy.
‘ h olding on to sound investment policy at market highs and market lows is notoriously hard and important work, particularly when Mr Market always tries to trick you into making changes.’
Dr Benjamin Holdsworth (right) is a practising doctor and business development director of Cavendish Medical, specialist financial planners helping senior consultants in private practice and NHS
The content of this article is for information only and must not be considered as financial advice.
Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.
Levels, bases of and reliefs from taxation may be subject to change and their value depends on the individual circumstances of the investor.
The value of investments and the income from them can fluctuate and investors may get back less than the amount invested.
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So what are you to do if a private hospital wants to investigate your practice or suspend practising privileges? Dr Oliver Lord (right) gives some medico-legal advice
QI am a sports and exercise medicine consultant with practising privileges in a large, private hospital.
I have just discovered that the hospital is carrying out an investigation into my capability following complaints from colleagues and I am extremely anxious about what will happen. What should I do?
ABeing criticised is uncomfortable, especially as a clinical complaint or concerns raised by colleagues may lead to an investigation by the hospital.
Although these concerns may eventually be resolved, the collateral damage can be significant.
You should be sent a copy of the hospital policy that will be used. Read the policy and work out what is going to happen and when.
There is usually an initial phase of information gathering that may include statements or interviews, a decision by the management and then, if necessary, a hearing.
The policy should also state who will make the decisions and what rights of appeal you might have.
Contact your medical defence organisation immediately to request advice and support. It is helpful to write a factual statement detailing all of the relevant
events in chronological order, for the benefit of your defence adviser, while events are fresh in your mind.
Also, make sure you have all the relevant documents available, especially the clinical records.
Your adviser will assess your case, advise you on the best way to respond and arrange representation if the hospital allows it.
A doctor’s reflection on the events is the most important part of the investigation, so if you can demonstrate that you can openly reflect on the criticism and learn from the events, even if the actual complaint was unfounded, a positive outcome becomes much more likely.
It can also be helpful to get constructive comments from colleagues to help you establish what could have been done differently.
Do check within the hospital
If you can demonstrate that you can openly reflect on the criticism and learn from the events . . . a positive outcome becomes much more likely
policy whom you are able to speak to about the event. It may be preferable to have a discussion with a senior colleague who does not work in the same hospital, but remember to maintain the patient’s confidentiality.
Also, remember that hospital management should be putting patient safety ahead of all other concerns.
If there is enough concern for the hospital to begin an investigation, the process may not be cut short by a response from the doctor alone.
This is because the hospital may already have a good idea of the doctor’s view from the records but needs to corroborate this with other witnesses.
It is preferable to co-operate with the hospital and try to help it to complete the investigation as soon as possible.
Disclosing patient information to the police has been in the news in Independent Practitioner Today – see p10 of last month’s issue. Dr Nicola Lennard (right) looks at some ethical issues
QI have been emailed a copy of a court order by a police officer.
The order indicates that it is made under paragraph four, schedule one of the Police and Criminal Evidence Act 1984 (PACE) and that failure to comply is a contempt of court punishable by a fine or two years’ imprisonment, or both.
The order requires that I am to provide the police officer with a copy of the medical record of my patient or alternatively allow the police officer access to the record.
It makes it clear that only the section of the record that is related to the patient’s diagnosis and treatment of HIV is required, along with details of any referrals in connection with his HIV treatment.
There is no consent from the patient to disclose the information. Should I disclose this information?
AThe GMC’s new guidance on confidentiality explains the importance of the ethical and legal duty of confidentiality, but makes it clear that this is not an absolute right.
A doctor may disclose confidential information with the explicit consent of the patient, if it is justified in the public interest, if the disclosure would be of overall benefit to a patient who lacks consent or if the disclosure is required by law.
Paragraph 17 of the new guid-
ance indicates that you must disclose information if you are ordered to do so by a judge or presiding officer of the court.
Paragraphs 90 to 94 go on to explain that you should only disclose the information that is required by the court and that you should object if attempts are made to compel you to disclose information that appears to you to be irrelevant.
In addition, if you think that disclosure of the information might put someone at risk of harm, you should inform the judge. If you do not understand the basis for the order, you should ask the court or a legal adviser to explain it to you.
You also have a duty to tell the patient whose information is being requested what information you will disclose, unless this is either impracticable or would undermine the purpose of the disclosure.
Prior to disclosing the informa tion, you should check the valid ity of the court order. Each page of the order should be signed by the judge or presiding officer and should contain a stamp.
If you have concerns about the validity of the order, you can con tact the court directly or seek advice from your medical defence organisation.
You should only disclose that information required by the court and you should document in the notes the reason for the disclosure and keep a copy of the court order for the records. You should, if pos sible, inform the patient of the information that you have dis closed.
Dr Oliver Lord and Dr Nicola Lennard are medico-legal advisers at the MDU
If your practice is acquiring, refinancing, refurbishing or developing premises, Citron Singer can advise, source and arrange specialist property finance.
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Recording and claiming expenses is an essential part of ensuring you minimise your tax liability. But it can be an area of contention and often there can be misunderstandings –leading to expenses being claimed erroneously and then a tax inquiry.
Ian Tongue looks at the most common areas of contention and recaps on the costs that independent practitioners should be claiming against tax
Professional indemnity cover;
Certain examination and course fees;
Business mileage;
Certain medical equipment not provided by the employer;
Laundry of uniforms.
One area that remains somewhat hit and miss is the claiming of examination costs following the court case won by specialist registrar Dr Piu Banerjee in 2010. This court ruling should have created a smooth path for these costs to be allowable, but within HMRC there are still many tax inspectors who look to challenge such claims. Persevere with the claim if you have been knocked back or, better still, ask your accountant to make the claim, as they know how to word everything.
What about the cost of doing a fellowship? This was not considered within the Banerjee case and is highly unlikely to be taxdeductible for a number of reasons.
There is a subtle but important distinction between the costs that can be deducted as an employee and those that can be claimed if you are trading as self-employed –sole trader or partnership – or through a limited company.
The tax rules use the terminology that an expense has to be incurred ‘wholly and exclusively’ for the purposes of trade for a sole
trader, partnership or limited company business. This definition is quite wide and results in the majority of business-related costs being tax-deductible.
For an employee, however, for a cost to be deducted against employed earnings, the expenditure must be incurred ‘wholly, exclusively and necessarily’ in the performance of your duties.
This is a very narrow definition
of expenditure. In practice, there are a limited number of costs that HM Revenue and Customs (HMRC) will allow you to deduct against your salaried earnings.
The typical expenses that can be offset against your employed income are:
Professional subscriptions (HMRC-approved);
No doubt, you will encounter people who have claimed costs in relation to their fellowship, but the fact that HMRC has not challenged things does not mean the claim was valid; it just means the self-assessment system didn’t pick it up.
For those that may not be completing a tax return yet, you can make a claim for job-related expenditure up to £2,500 a year using form P87. For amounts
Where some costs are incurred for both employed and selfemployed, it is often more taxefficient to claim these against your private earnings; for example, professional subscriptions and indemnity cover
For those who run their private practice as a sole-trader or partnership, there is plenty of scope to claim the ongoing costs incurred in carrying out this work.
These costs generally are direct costs of doing the private work and those that are more of an overhead or have a mixture of private and business use that need special treatment.
Typical direct costs are:
Indemnity cover;
Professional subscriptions;
Secretarial costs;
Room rental;
Medical supplies;
Assistants’ fees;
Wages and salaries;
Professional fees;
Medical equipment and other asset purchases – capital allowances can be claimed.
Limited companies are subject to the same wide scope for claiming expenditure.
A key distinction here, though, is that you are no longer the proprietor/partner of the business and are an employee.
Therefore, payments made through your self-employed private practice that would simply have been regarded as ‘drawings’ and outside the scope of tax would potentially be a taxable benefit or need to be regarded as a repayable loan.
A good example of this is motor and travel costs. Many consultants will consider paying for a car through their company, but this will attract a ‘benefit in kind’.
motor and travel in relation to an employee for a company.
The key journeys that can be treated as business travel are travelling between private hospitals, unexpected emergency call-outs and other business travel, such as to attend courses.
The journey from your NHS base or home to the hospital– and back again, is not usually regarded as a business journey following the Samadian case.
This is subject to restrictions, but the rules are relatively simple:
➲ Entertaining employees – taxdeductible expense up to £150 per head a year allowed. This can be more than one event.
above this and for those registered under self-assessment, these costs are claimed on your tax return.
Where some costs are incurred for both employed and selfemployed, it is often more taxefficient to claim these against your private earnings; for example, professional subscriptions and indemnity cover.
It is important to note that just because your employer may reimburse you for an expenditure or provide an allowance, there may still be tax implications.
A good example here is mileage payments, as the approved rate is 45p per mile (for the first 10,000 miles and 25p thereafter) but many trusts pay more than this (50p per mile +).
In these circumstances, the difference between the rate paid and the approved rate is effectively treated as extra income and taxed using a form P11d, which summarises all benefits you may receive in addition to your salary, such as a fleet scheme car.
Other costs:
Motor and travel;
Use of home as office;
Printing, postage and stationary;
Phone and internet use;
Certain training costs.
Established independent practitioners will know all about the Competition and Markets Authority (CMA) investigation into private healthcare, covered regularly in Independent Pract itioner
Today
The findings were wide-reaching, but in the context of incurring costs, private hospitals now have significant restrictions on what ‘incentives’ they can provide to new and existing consultants.
As a result of this, we have seen a rise for some consultants in their private practice expenditure for costs such as room rental or secretarial, where these were previously provided by the hospital. It is important that all such expenditure is recorded and claimed against your tax return.
In this context, the provision of a car by the company is usually prohibitive, as income tax is paid at your marginal rate of tax (usually 40% or 45%) on the calculated benefit – akin to extra taxable income – which is a product of original list price and emissions.
For those trading as a company, you can claim 45p a mile from the company for business use of your vehicle and this would be tax-free in your hand and tax-deductible for the company.
It is important, however, that you understand what can be claimed as a business journey (see below).
These expenses for a hospitalbased doctor were scrutinised in the Samadian tax case. This case now sets the scene for making claims for business use of a vehicle for those that are self-employed.
For those trading as a company, the position is less clear, but it is fair to say that the general principles and conclusions reached would be considered as applicable should there be an inquiry into
➲ Client/customer entertaining – not usually tax-deductible. The expense can be paid through the business, but the cost is added back when calculating taxable profits.
➲ Personal entertainment –usually forms a benefit in kind for you and tax is payable on the amount paid.
Maximising your tax-deductible expenditure is one of the easiest ways of reducing your tax liability, but care does need to be exercised, as not all costs are allowable as a deduction against income to calculate taxable profit.
Ensure that all costs are recorded and a mileage log is maintained, which will ensure that you are best placed to maximise your expense claim.
Next month: Year two of annual allowance tapering –what now?
Ian Tongue (right) is a partner with Sandison Easson chartered accountants
Any independent practitioner wanting a premium SUV to suit themselves and to serve their family will not be disappointed with Jaguar’s latest offering, says our motoring correspondent Dr Tony Rimmer (left)
As cAr-buyers, we have never had it so good. There has never before been such a wide spread of choice across all types and classes of vehicle.
All modern cars are safe, well built and have standard features that would have been considered expensive luxuries only a few years ago.
There is now a myriad of purchasing options with personal contract purchase (PcP) and personal contract hire (P c H) deals dominating the market. so how do we, as medics, focus our buying decisions?
Well, there are some new cars that hit just the right note in their potential appeal to many independent practitioners.
The combination of high quality, practicality and an established and well-respected brand gave
Styling is smart and distinctive for such a big car and it is instantly recognisable as a member of the iconic Coventry brand
Jaguar’s F-Pace a huge anticipatory following leading up to its launch in 2016.
This latest member of the increasingly popular premium sports utility vehicle ( su V) segment has a lot to prove to potential buyers, particularly to discerning private doctors.
Just as other new models in the Jaguar Land r over stable have benefited, there has been huge investment in development of the F-pace by the giant Indian owners, Tata.
The engineers at Jaguar, rather than relying on their colleagues at Land rover, developed the chassis of this four-wheel-drive machine themselves utilising the existing platform used in the Xe and XF models as a starting point. The
available engines are also the ones already found in the Jaguar saloons.
styling is smart and distinctive for such a big car and it is instantly recognisable as a member of the iconic coventry brand. The coupélike roofline and the distinctive rear lights complete the family picture.
Available in four trim levels; Prestige, r - s port, Portfolio and s-trim, the engine options include 2.0litre four-cylinder or 3.0litre V6 diesels and 2.0litre four-cylinder or 3.0litre V6 petrols.
My test car was the 2.0litre diesel Portfolio model. Although this engine is predicted to be the biggest seller, I just wonder if the petrol models will gain ground on the back of the negative press that diesel engines have been suffering in recent months with regard to their particulate emissions.
you step up into the F-Pace and although it is not quite Discovery or range rover-sized, it feels bigger than an Audi Q5 or Porsche Macan. The actual interior space backs this up.
Three adults can comfortably sit across the rear bench, and the boot, accessed by a powered hatch, is vast. certainly, if useable room is your priority, you will not be disappointed.
The dashboard and controls are pure Jaguar and any X e , XF or even F-type driver would feel immediately at home.
e ven the distinctive rising rotary gear selector is present, which lends a sense of occasion to every journey.
The infotainment system has a touch-screen control and all the
JaguaR F-paCE
portfolio 2.0d 180ps awd
Body: Five-seat SuV. Four-wheel drive
Engine: 2.0 litre four-cylinder turbo-diesel power: 180bhp
Torque: 430Nm
Top speed: 129mph
acceleration: 0-60mph in 8.2 secs
Claimed economy: Combined 53.3mpg
CO2 emissions: 139g/km
On-the-road price: £42,860
The dashboard and controls are pure Jaguar and any XE, XF or even F-type driver would feel immediately at home
usual bluetooth, sat-nav and DAb radio features are easily found. It is just a shame that the standard screen is only eight inches wide: the clearer 12.3 inch screen is a hefty £1,200 option.
A full-length sunroof, standard on the Portfolio model, certainly gives the cabin a lighter airy quality, but there is no opening facility. Like other suVs, you sit high off the road and white vans become less intimidating.
What I really wanted to do, more than anything, was to get the F-Pace out on the road. Marketed as a sporty suV, could this Jaguar challenge the Porsche Macan with excellent road manners and provide some fun behind the wheel?
First impressions were good; the new lightweight construction means that , for the most part, the
2.0litre 180bhp diesel engine copes well with a car of this size. Acceleration is brisk but not fast. cruising on the motorway is a really comfortable experience. The ride is nicely smooth and controlled, allied to really low noise levels. The miles fly by. On the twisty bits, the F-Pace behaves well – up to a point. The steering is direct but not perhaps as sharp as it could be.
If you push on a bit, the tall body starts rolling a bit too much for a sporty feel and this is even with the variable damper controls set to ‘sport’.
The F-Pace is no Macan. Perhaps the more powerful V6 petrol and diesel models with better chassis control would give the driver more of a thrill, but you will pay Porsche-level money for those.
This new Jaguar is a really impressive car. I love the styling both inside and out. I love the quality, the impressive passenger space and the comfort.
Any independent practitioner wanting a premium suV to suit themselves and to serve their family will not be disappointed.
Just don’t expect it to drive like a sports car, certainly not in the guise as tested. However, if you compare it to more natural rivals like the Mercedes GLc and Audi’s new Q5, it wins hands down.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
Groups appear to be the best way forward for anaesthetists as their incomes, and work intensity, come under increasing pressure. Ray Stanbridge reports on our latest benchmarking survey
In May 2016, we anticipated a modest growth in the income of anaesthetists between 2014 and 2015. This has broadly come to pass.
Much has changed in the years we have been doing these benchmarking figures for anaesthetists. Incorporation has become increasingly popular, although a series of tax and other changes have, for some, made this means of trading less attractive than it was.
There has been a significant
growth in groups, both formal and informal. Our evidence suggests that groups have been successful in taking business away from individual sole practitioners in certain areas. We have also seen a significant growth in the number of women anaesthetists.
Squeezing fees
Insurers have become increasingly effective at squeezing fees, and many consultant anaesthetists are working harder for the same financial results. The conaveRage
Insurers have become increasingly effective at squeezing fees, and many consultant anaesthetists are working harder for the same financial results
cept of employment is also gaining ground.
all of these market trends have had an impact on our attempts to provide a reasonable year to year comparison.
But given all the caveats, our view is that, on average a consultant anaesthetist’s private practice income grew by about 2.4% from £81,000 to £83,000 between 2014 and 2015.
Costs have risen, on average, by about 3.8% from £26,000 to £27,000.
as a result, taxable profits have increased by 1.8% from £55,000 to £56,000 – meaning anaesthetists have probably retained their net taxable profit in real terms.
Growth in choose and Book
There is no particular reason we can identify for the growth of fees. There has been some growth in self-pay and anaesthetists working in the sector have seen some growth.
nHS Choose and Book work continues to grow in many areas, and anaesthetists have obviously benefitted from this. On the other hand, for those reliant on insurance company fee rates, there has been a significant market squeeze.
Costs, on average, have shown
RaNge OF gROSS INCOMeS FOR aNaeSTheTISTS
Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)
Source: Stanbridge Associates Ltd.
little change. There has been some increase in motor and travel and ‘other costs’.
There has been a little reduction in courses and conference costs –perhaps attributable to less exotic locations. But, on balance, there has been little change in all costs.
One of the growth areas appears to be pain management and, for those entering into this specialty,
their income has grown and future prospects also look bright.
continue to prosper as an important service function, anaesthetists’ incomes respond to market trends. We see a general increase in incomes with squeezed margins, and this is the probable likely prospect for anaesthetists. Groups will continue to prosper
and we see ever closer links between groups of specialties with less complex fee structures arising and more package pricing.
In the long term, with a few obvious locational exceptions, groups seem to be the best way to preserve incomes in real terms.
n ote that many caveats now accompany our surveys and to reiterate again that it is not statistically significant.
To qualify for entry to our survey, our anaesthetists:
Must continue to work in the nHS and not be in full-time private practice;
Hold either an old-style or a new-style contract with the nHS;
Have been in private practice for at least five years;
Must be seriously interested in pursuing private practice as a business;
Must have generated a gross income of at least £5,000 in the year to 5 april 2015;
May or may not have incorporated their business or become a member of a formal or informal group.
next month: oncologists
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists Stanbridge Accountants
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Make sure you don’t miss our next issue, published on 22 June. you may not receive every issue if you have not yet subscribed to the journal. Don’t risk missing out on vital topics we tackle next time, including:
Private doctors’ earnings in central London, specialty by specialty
Cosmetic surgeons: a former consultant surgeon and now medico-legal adviser discusses how to deal with a patient who is dissatisfied with their appearance
as forming group practices becomes increasingly popular, an expert reflects on the billing issues which can lead to administrative chaos if not properly understood and effectively managed
It is often necessary to share patient data with others involved in providing or funding their care, but how can you be sure this sensitive information will be safe from prying eyes?
‘I’ve become concerned about the clinical practice of one of my senior colleagues and feel that their standard of care to patients is a cause for concern.’ Our Business Dilemmas series advises what to do
a look at the Consent Plus initiative, launched by doctors to improve the consent process and encourage better dialogue with patients.
What makes an excellent expert? Michael R young gives more tips from his series on the effective clinical negligence expert witness
hempsons solicitor Chris alderson presents an in-depth report on the data protection issues affecting online healthcare businesses
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Liability around faulty medical products, such as breast implants and hip replacements. We look at how a patient can claim compensation in such a situation, and how it can impact on the clinician
accountant Susan hutter says incentivising staff, particularly key members, is crucial if you want to ensure they stay for a long time. Could you be providing more when it comes to rewards and benefits?
PPUs – Philip housden continues his a-Z guide
Banish the concept of the marketing budget – consider the marketing pilot instead, says surgeon Mr Dev Lall
In the third article about the gMC’s new confidentiality guidance, Dr Nicola Lennard, MDU medico-legal adviser, looks at the guidance on fitness to drive and how it impacts on medical professionals
Our ‘Doctor On The Road’ columnist Dr Tony Rimmer takes off in the Tesla Model X SUv – with amazing gull-wing doors
Start a Private Practice: more advice for those new to private practice
Top Tips for Busy Doctors
Profits Focus looks at oncologists’ and dermatologists’ earnings
Code Buster! an update on the latest codes
Plus all the latest news and views
aDveRTISeRS: The deadline for booking advertising for our June issue falls on 26 May
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