The business journal for doctors in private practice
In this issue
New data law to boost trust Don’t get left behind on your implementation of the General Data Protection Regulation P14
Are they happy with your care?
How the measurement of outcomes is transforming your private practice P25
More big changes are on the way in private practice. Don’t miss our special report next month
Investing’s gender gap
Some wise words to ponder about inequality when investing for the future P44
Private doctors ‘undercharging’
By Robin Stride
Accountants are warning private consultants they could be missing out on thousands of pounds because they have not regularly reviewed their fees.
They say many independent practitioners in London would be surprised to see how far they have fallen behind what others in their specialty now charge self-pay patients elsewhere.
Martin Murray, a partner with Sandison Easson chartered accountants, told Independent Practitioner Today: ‘When I go to Glasgow, I look at it as a benchmark and see consultants charging £200-£220 for an initial consultation and £160-£180 for follow-ups.
‘But in some cases in London, where running costs are higher, they can be charging lower – particularly for follow-up consultations.’
Mr Murray said there was ‘a general reluctance’ among consultants to increase their consultation charges and most specialists were not looking at their fees every 12 months.
They were mostly reviewing them every two or three years, but
they should do it annually. Failure to review could amount to missing out on ‘several thousand pounds a year’.
Turning to fees for private medically insured patients, he recognised new consultants faced insurers’ restrictions on what they could charge, while existing consultants might be ‘fee assured’.
But with many consultants charging more for initial consultations, he believed there was still scope to look at follow-up consultation charges to see if these could be increased while still complying with medical insurers.
Mr Murray told consultants and GPs at the BMA’s private practice conference 2018 that one specialist in England doubted there even was any private practice in Glasgow. ‘I said: “Yes there is – and they are charging more than you. Put your fees up!”’
Doctors were shocked to hear him quoting cases of cosmetic nurses grossing as much as £300,000-£400,000 a year in their highly marketed businesses.
He said the many NHS GPs seeing cosmetic work as their first foray into private practice needed to change their mindset because
they were up against ‘serious competitors’.
The ‘review your fees’ message follows our ‘fee publication fiasco’ front-page report in March spelling out the practicality problems of the Competition and Markets Authority’s demands for consultants to send patients written information about charges before seeing them.
Providers are required to ensure their consultants’ fee information is always given by a letter from the specialist.
At the meeting, BMA private practice committee chairman Mr Derek Machin threw his weight behind the Federation of Independent Practitioner Organisations, which has warned the fees clarity drive will bring increased complexity for consultants and patients.
He called the fee letter requirement ‘completely mad’ and claimed it would ‘whither on the vine’. He said it sounded simple but was complex and unmanageable.
Later he told Independent Practitioner Today : ‘It’s a magnificent shambles. I don’t think anybody is doing it. The CMA’s own survey indicated fees weren’t a big issue to patients.’
n See pages 6 and 7
GOT IT COVERED: A surgeon has patented a device to preserve modesty. See full story on page 10
Poor care at private units
The Independent Doctors Federation is calling for zero tolerance of poor safety and care standards in all independent hospitals and clinics following shock figures from the Care Quality Commission (CQC).
The watchdog found 41% of hospitals required improvement and 1% were inadequate for safety. 30% required improvement and 3% were inadequate for being well led. Specific concerns included some surgeons not following every step of the World Health Organisation surgical check-list and some hospitals failing to prepare for a patient’s condition possibly deteriorating.
The Private Patients Forum urged doctors and other health professionals to demand action immediately if they saw standards slipping.
n See full reports on page 4
In this issue
So farewell, Pardner
With so many doctor retirements around, accountant Susan Hutter gives her guidance on how to handle the departure of a business partner P12
Should i be employed? the question of whether consultants should be employed or self-employed is becoming increasingly debated. accountant ray Stanbridge (left) assesses the pros and the cons P18
Build a relationship with your architect expanding your practice or your home? philip mcQuillen gives some good advice on how to choose and use your architect P20
editorial comment
Watchdog is seeing red
Blue is the colour to look for when you are checking how your present or potential private hospitals are doing in their Care Quality Commission (CQC) inspections. It means ‘outstanding.’
But looking through the watchdog’s report The State of Care in Independent Acute Hospitals – see stories page 1, 4 and 5 – the blues are few and far between.
There are too many orange (‘requires improvement’) and red (‘inadequate’) cards being shown on what should at least be a pitch of highly dominant green (‘good’).
Admittedly, re-inspections have revealed many improvements as providers move to put things right.
But there is still a lot of work to do and the results are extremely disappointing for many doctors who have based their business and good name
at hospitals deemed to be underperforming.
Doctors are rightly now being urged by the Independent Doctors Federation (IDF) to take immediate action if they see any problems, while the customer watchdog, the Private Patients Forum, thinks they and other health professionals should demand immediate action if they see standards slipping.
Working towards making private healthcare shine as a sea of blue must be the target of everyone, but it won’t be easy, especially for some hospitals who are facing financial constraints.
And even the best performers could find themselves losing out on the day with a bad result due to one-off incidents judged unfairly by an unsympathetic CQC referee. See the report at www.cqc.org.uk, particularly page 27 on ineffective oversight of practising privileges.
lifting the language barrier as the UK remains popular with international patients seeking private care, dr rachel Birch outlines steps to minimise the risks in treating those whose first language is not english P30
enhance your value
Hempsons’ solicitor adam tait shows you how to maximise the value of your premises and minimise the time required to do so P32
the rise of the industrious GP author Suzie Grogan continues her series tracing the development of the medical profession. this month: the rise of the general practitioner P38
Business dilemmas: when you have to snitch on patients issues to do with the dVLa take centre stage in this month’s reply to readers’ medico-legal questions P46
Start a private practice: what to look out for if banding together
Working with other colleagues has become a common way of coping with the changes in healthcare P48
Profits focus: Groups are on the rise our unique benchmarking series looks at how anaesthetists are coping with financial pressures P52
tell US yoUr newS Editorial director Robin Stride at robin@ip-today.co.uk Phone: 07909 997340 @robinstride to advertiSe Contact advertising manager Margaret Floate at margifloate@btinternet.com Phone: 01483 824094
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Checking of performance statistics to begin soon Awards saved but not pensionable
By edie Bourne
Doctors receiving new local Clinical Excellence Awards (CEAs) will find the increased pay resulting from recognition of their industry is no longer pensionable after April.
The controversial CEA scheme has received a three-year ‘pardon’ following the BMA’s out-of-court settlement with the Department of Health and Social Care and NHS Employers.
An agreement – which applies to the local part of the scheme only – will secure a funding package of over £300m to ensure the awards can continue annually across all trusts until 2021.
But any new awards will not be pensionable – resulting in substantial losses for doctors’ benefits.
Dr Benjamin Holdsworth, director of specialist financial planners Cavendish Medical, explained:
‘Many doctors will be relieved that the CEAs will continue –even if their longterm future remains uncertain – but removing the pensionable pay from new awards will impact recipients by many thousands of pounds.
dr Benjamin Holdsworth
‘As an example, Level 8 award represents £30,000 of pensionable pay – the impact of losing this could be very significant.
‘Fortunately, existing holders will keep their awards and these will remain pensionable. Nevertheless, there could be problems for doctors who step up to a new award level. We are awaiting details on whether the new section of their award is no longer pensionable.
‘Added to this is the complexity
of many having both final salary and careeraverage benefits within the scheme.’
The Government reduced the funding of the local CEA scheme by over 40% in 2011 with some NHS trusts stopping award rounds entirely.
Dr Holdsworth told Independent Practitioner Today : ‘The new agreement will make deciphering your correct pensionable pay challenging and there are some important nuances to consider.
‘If you lose your CEA, you will be entitled to protect your previous pay level under existing “step down” rules, which could safeguard the value of accrued final salary benefits in the 1995 or 2008 sections. However, the pensionable pay for the 2015 scheme could be substantially reduced.’
Call to alter negligence formula
A defence body is urging the Government to launch a quick-fix revision of the compensation formula responsible for doctors’ rocketing indemnity fees.
The MDDUS said a revised ‘discount rate’ was urgently needed because the current one over-compensated clinical negligence victims and the medical profession could afford no further delays.
Justice officials have indicated that the Civil Liability Bill, which could ease the rate, may not pass until April 2019.
But the defence body said there was concern this might slip due to Parliamentary time pressures caused by legislation linked to Brexit.
MDDUS chief executive Chris Kenny warned it was ‘imperative’ for a new fairer rate to be set as soon as possible.
He said a discount rate set with reference to ‘low-risk’ rather than ‘very low-risk’ investments would more accurately reflect claimants’ choices when investing compensation payments.
The union agrees with involving an expert panel in rate reviews, in line with bill methodology, but argues the first review should not have their input or that would mean more delay.
Mr Kenny said there was nothing to prevent a new rate being fixed now using already available information.
He believes the rate review period should be every five years, not three. ‘The drawback of review over a relatively short period of time is that the review process may be undertaken when it is unnecessary, at an expense
and creating uncertainty in the market.
‘Under the bill as drafted, no sooner has a new rate been fixed than the review process will effectively start again. A five-year review period – as a minimum –would mitigate the risks associated with this, including “gaming” of the litigation process.’
A repeal was also needed of Section 2(4) of the Law Reform (Personal Injuries) Act 1948, which disregards NHS care when calculating future care costs.
‘Awards continue to be calculated on the basis of the costs of private sector care, when all the evidence shows that those who receive damages, quite rightly, use excellent and readily accessible NHS services where they can do so.’
See page 7
Consultants are to shortly be asked by the Private Healthcare Information Network (PHIN) to begin approving the first in a series of performance measures for publication on its public website.
Specialists undertaking private activity as the ‘name above the bed’ should, from 5 June, be able to preview their performance measures for the number of procedures performed and the average length of stay through PHIN’s online portal, ready for publication in July 2018.
Consultants will also be able to build their online profile with information about clinical interests, photos and other profile information. This will be available to patients through PHIN’s website.
PHIN said more than 3,000 consultants have begun viewing their whole-practice data and were working with hospitals where issues have been identified. It asked consultants to continue reviewing their data and begin approving for publication when made available from 5 June.
It has been contacting consultants using their GMC registered email address. To ensure you receive updates and can access the PHIN portal, ensure your GMC registered email address is up to date. More information to follow on www.independent-practitionertoday.co.uk and in next month’s issue.
Organisers of the London Healthcare Conference due to be held at the Royal Society of Medicine, London, on 18 June, have cancelled it ‘due to unforeseen circumstances’.
CQC report on private hospitals
Safety lapses shown in private unit inspections
By Robin Stride
The new body representing private hospitals has tried to put a brave face on Care Quality Commission (CQC) findings, which have been branded ‘unacceptable’ by patients.
A CQC analysis of the quality and safety of care provided by independent acute hospitals across England revealed 41% of hospitals were rated as ‘requires improvement’ on safety issues and 1% were ‘inadequate’.
Nearly a third – 30% of hospitals – were rated as ‘requires improvement’ and 3% as ‘inadequate’ for how wellled they were.
But Dr Howard Freeman, clinical director at NHS Partners Network, gave the findings a more positive tone, saying the organisation welcomed the CQC’s report ‘which highlights that 70% of independent acute hospitals are rated good or outstanding, and play a significant role in delivering caring and responsive services for both NHS and private patients’.
He said providing safe and highquality care was ‘the top priority’ for independent hospitals and the CQC report demonstrated the safety and quality of services.
Dr Freeman added: ‘Where the CQC has identified areas for further improvement in independent hospitals, it is encouraging that it has found that “providers have been quick to respond to inspection findings”, with over half of the independent acute hospitals re inspected improving their rating.
‘We look forward to working closely with the CQC and other bodies to ensure independent hospitals continue to focus on safe, highquality and responsive care
The watchdog’s report said 41% of hospitals required improvement
and the best possible patient experience.’
His organisation, incorporated into the NHS Confederation, now speaks for independent hospitals following the demise of the Association of Independent Healthcare Organisations (Independent Practitioner Today, March 2018).
The CQC’s inspection and ratings of over 200 independent hospitals found 62% were rated as good and 8% were rated as outstanding as at 2 January 2018.
Most patients had prompt access to effective treatment and experienced personalised care ‘from highly skilled and caring staff’. Of the 206 hospitals inspected, 89% were rated as good and 11% were rated as outstanding for how ‘caring’ their services were.
Most were also rated as good (86%) or outstanding (7%) for how ‘responsive’ they were. Patients were more likely to have named consultants and the hospitals managed their flow of patients well, meaning few cancellations or delayed admissions or procedures.
But the CQC said there was clear scope for improvement and safety was one of its greatest concerns.
It reported: ‘In some cases, CQC found that a lack of formalised governance procedures meant that hospitals were not effectively monitoring the work of consultants who operate under ‘practising privileges’ – where a consultant clinician works in a hospital but is not a direct employee.
‘Checks to ensure clinicians were only working within their agreed scope of practice were not always taking place. This meant that there was a risk that poor practices were not always picked up or challenged in the way they should be.
‘Inspectors also saw that safety procedures were not always fully embedded – for example, where surgeons were not following every step of the World Health Organisation surgical check list.
‘Other issues highlighted by CQC include a failure by some hospitals to adequately monitor clinical outcomes to evaluate the effectiveness of the services they were providing, and a lack of preparation for the possibility that a patient’s condition could deteriorate.’
The CQC claimed providers had been quick to respond to
inspection findings taking on board its judgements and proactively addressing areas where further work is needed to improve patient care.
But only seven of the 13 reinspected hospitals had improved. Four improved from an initial rating of inadequate, two going from inadequate to good and the others to ‘requires improvement’.
CQC chief inspector of hospitals Prof Ted Baker said much care and treatment seen was good. Effective local leadership, good staff engagement and a close oversight of services helped ensure highquality care.
But inspectors also identified concerns around the safety and leadership of some services, often resulting from a lack of safety checks and poor risk monitoring.
‘Too often, safety was viewed as the responsibility of individual clinicians, rather than a corporate responsibility supported by formal governance processes. Where we found failings, we have been clear that improvements must be made, using our enforcement powers where needed to protect people.
‘As the independent quality regulator, we hold all providers of healthcare to the same standards regardless of how they are funded. Having inspected all independent acute hospitals in England, we now have a comprehensive picture of the quality of care they are providing for the first time – and, importantly, people can use our reports to help them make choices about their treatment.’
Prof Baker said providers had taken ‘rapid action’ in response to CQC concerns. ‘We want to see this continue and more providers learning from those services that are getting it right.’
Dr Howard Freeman of the NHS Partners Network, which has taken over the Association of Independent Healthcare Organisations
CQC report on private hospitals
Doctors told to report failings
Zero tolerance of poor standards of safety and care in all independent hospitals and clinics is now vital, according to the Independent Doctors’ Federation (IDF).
Private
units
must stick to paediatric standards
Independent sector hospitals who provide children’s care need to be aware of the standards required to care for children effectively, according to a consultant paediatrician.
Dr Simon Clark, workforce officer for the Royal College of Paediatrics and Child Health, said the CQC report gave an opportunity to learn from best practice.
‘This means providing the training and competencies required, including safeguarding awareness.’
He added: ‘While 49% of children’s services when provided in the independent sector were rated as good and 11% as outstanding, this report also shows that 38% required improvement and 3% were graded as inadequate.’
said safety was a concern and 41% of hospitals required improvement, with a further 1% deemed inadequate.
The IDF added that although around half of the hospitals requiring improvement had raised standards since their initial inspection, too many still need to take action.
IDF president Dr Brian O’Connor said the independent sector provided worldclass care and the UK was an increasingly popular destination for patients from all over the world.
‘We recognise that there is never a perfect situation where every facility is without a problem every day of the year. However, patients have the right to the highest standards of care and safety and there should be zero tolerance of anything less.
ensure the highest standards of clinical governance.’
IDF members are advised to take immediate action if they see problems.
In a statement, the Federation of Independent Practitioner Organisations (FIPO), which represents medical specialty organisations, did not mention the CQC but said it was ‘dedicated to upholding the highest standards of professional integrity within the private sector’.
It added: ‘FIPO strongly promotes robust medically led governance within private provider groups and is supportive of their governance processes in particular by reviewing the scope of practice and outcomes of their consultants and the development of an appropriate multidisciplinary approach to patient management.
While the majority of the 206 private hospitals inspected by the Care Quality Commission (CQC) were providing good or outstanding care, the healthcare watchdog
‘As doctors, we want to see the same high standards across the whole of the healthcare sector, private and NHS, and while we support the continuing efforts of the CQC to help make this a reality, we call on all providers to ensure enough resource is available to
‘Activity and the production of clinical outcome data needs professional oversight to ensure patients can continue to benefit from the specialist care provided within the private sector and that the mistakes of the past are not repeated.’
Patients take action
By Edie Bourne
The Private Patients’ Forum (PPF) is encouraging patients or their relatives to report any concerns about their independent hospital to their consultant and the hospital management.
And it urged doctors to demand immediate action if they saw standards falling.
It advises that if an issue is unresolved, then patients should contact the CQC and report back their experiences to the PPF.
In the wake of the report, which found almost a third of the 206 private hospitals inspected ‘required improvement’, it called on all private hospital and clinic owners and managers to protect patients by ensuring the highest standards of clinical governance and safety in their facilities.
CQC chief inspector of hospitals Prof Ted Baker said: ‘Too often, safety was viewed as the responsi
bility of individual clinicians, rather than a corporate responsibility supported by formal governance processes.’
In its response, the PPF said it noted that around half of those hospitals designated by the CQC as ‘requiring improvement’ had now been found by the regulator to have raised their standards.
But the pressure group still considered this to be unacceptable for patients and demanded that providers took immediate steps to bring standards ‘up to those practised in the majority of independent hospitals across the country’.
A spokesperson said: ‘Clinical governance regulation has been in place across the health sector for years now and every patient has the right to expect the highest standards of safety and care. Nothing less is acceptable.
‘The PPF calls on all hospital owners and managers to ensure sufficient expertise is always avail
able to guarantee the highest standards of clinical governance and safety of patients. We also call on doctors and other health professionals to demand action immediately if they see standards slipping.
‘Patients will soon benefit from the detailed data on treatment success rates being collected and published by PHIN [the Private Healthcare Information Network]. This will improve transparency and expose data showing the actual performance of both hospitals and doctors.
‘In turn, it will enable patients to make better choices and encourage every provider to offer the best quality of care and service.’
For the full CQC report: go to www. cqc.org.uk/publications/ major-report/state-careindependent-acute-hospitals
Private doctors warned not to set fees too low
By Robin Stride
Independent practitioners setting their own fees for self-pay patients were warned against putting them too low.
BMA private practice committee chairman Mr Derek Machin said the cheapest would not get the most patients.
In one case, a female plastic surgeon deliberately set her fees higher than others in the vicinity when she started and was delighted with the results. To her advantage, she was the only woman in that specialty in the area.
Giving a round-up of some key issues currently facing independent practitioners, he told specialists who have recently set up in private practice, or are considering doing so, that pressures in the sector were ‘every bit as bad’ as in the health service, albeit different.
According to his committee’s survey of some members in private practice, their after-tax income after taking into account all the time they put in to the work, plus expenses, amounted to only an average £30-£40 an hour.
He advised people to work out their income on this basis for comparison. Doctors were more aware now of work-life balance issues and they needed to be hardheaded in evaluating whether there was a better way of spending their time.
They should ask themselves if the work would be a burden or something that enhanced their life – and he warned the ‘burden’ could be because they were too successful.
Turning to some of the big issue in private practice, Mr Machin made the following observations:
Insurers
He said they were increasingly putting restrictions on what consultants could do and it was getting to a point where they might be becoming doctors’ employers.
Practising privileges
Doctors could lose their privileges ‘very easily’, so they needed to be careful, he said.
If a hospital got busy, a consultant bringing in low business volumes was likely to be ‘turfed out’.
Marketing
Mr Machin advised that the local press was an underused resource. Newspapers were looking for copy and could not afford journalists, so if doctors submitted an article, it was likely to be used.
They should also consider giving information direct to local GPs, web marketing, social media, marketing companies and business directories.
GDPR
The General Data Protection Regulation, kicking in on 25 May, ‘is worrying the hell out of everyone’
due to rumours of witch-hunts and fines for people found noncompliant, reported Mr Machin. Doctors should be able to demonstrate they complied with the legislation. This might include internal data protection policies such as staff training, internal audits of processing activities and reviews of internal HR policies.
PHIn
The publishing of consultants’ information by the Private Healthcare Information Network, as required by the Com petition and Markets Auth ority, was a source of ‘great worry’. One concern was that patients were listed under the consultant’s name, who was not necessarily the person doing the procedure.
He told doctors: ‘My advice would be you don’t sign off any data unless you are prepared to stand up in front of the GMC and say it’s accurate.’
Later he said: ‘We’ve been looking for years at ways of getting credible outcome data and, frankly, in most specialties there isn’t any credible data.’
Expert tips on attracting new patients
A private practice marketing expert used a feature from Independent Practitioner Today (‘The four types of private consultant’ by Mr Dev Lall, June 2013) to encourage the audience to consider which they were most like: the introverted amateur, the shy shopkeeper, the ambitious go-getter and the out and out entrepreneur. With most putting themselves in the final two categories, he then gave them dozens of tips to help them make it.
But Keith Pollard, executive
chairman of LangBuisson International Ltd, firstly warned them that life was getting harder, not easier, in private practice.
LaingBuisson figures for private hospital income showed private medical insurance accounted for 61% of income in 2006 compared to 45% a decade later. NHS work meanwhile rose from 16% to 31%.
With more consultants, there was potentially more competition. There was more global competition too, and patients were better informed than just a few years
ago. But self-pay was the one area of growth and opportunity. His tips for helping get the business included:
Pick some surgeons you know and type their names into a search engine to see what comes up and how they are getting known;
Image is important, so get a professional photographer to take your website photograph. Don’t use a mobile phone;
Use a number of short videos on your website of you talking about conditions you treat;
‘Upgrade’ your letter to GPs; Private consultants generally are not good at responding to emails from patients. Get better; Prepare professional answers to the types of questions patients ask; Influence ‘word of mouth’ promotion. Write to patients later asking how they are doing. He had three treatments recently but not one of the consultants followed it up. One procedure was for a knee – well, he had a second knee too…; Ask patients to write a testimonial.
The BMA’s Mr Derek Machin
bMa PRIvate PRactIce confeRence
Beware not to sleepwalk into private practice
Would-be private practitioners were urged not to ‘sleepwalk into the future’ and to be aware of the big issues facing consultants in the independent sector.
Mr Geoffrey Glazer, chairman of the Federation of Independent Practitioner Organisations (FIPO), highlighted a wide range of difficult areas to take into account, including a hostile litigation environment, rising indemnity costs, economic ‘hospital frailty’, increasing regulation and imminent publishing of their clinical outcomes.
But he did leave them with good news: ‘You can still do well if you give good care.’
Damages claims look ‘set to soar’
By Robin Stride
Doctors were warned that they can expect to see claims against them hit record levels in the not too distant future.
The MDU’s largest claim, £9.2m in 2016, will be dwarfed by more and more claims running to tens of millions of pounds, according to the union’s head of professional standards and liaison.
Dr Mike Devlin said: ‘I hate to blame the lawyers for everything, but they are a lot to blame for what’s going on here.’
He urged doctors to take up the indemnity crisis by writing to their MP.
Dr Devlin said claims frequency had doubled over the last seven years and now specialists were being bombarded by claims.
In 2016, 85% of patients who claimed because they believed they had been negligently damaged by MDU members had, in fact, not been.
This was a bad outcome for everyone and came with substantial costs, he said.
Awards in England were now among the largest in the world and medical negligence claims inflation had outstripped other
forms of inflation over a long period.
He told doctors the 3.25% fall in the discount rate in March 2017 – used to calculate long-term court settlements – had resulted in a massive rise in unaffordable clinical negligence damages, with one case going up 108% from £8.4m to £17.5m.
The medical profession had been landed with a system that promoted litigation over resolving concerns through other routes and the drivers of claims were far removed from the clinical coal face.
Calling for tort reform to con-
I hate to blame the lawyers for everything, but they are a lot to blame for what’s going on here
DR MIke DevlIn,
The MDU’s heAD OF PROFeSSIOnAl STAnDARDS AnD lIAISOn
trol spiralling costs of claims and to keep indemnity affordable, he set out MDU’s solution:
Repeal of the S2(4) Law Reform (Personal Injuries) Act 1948; Personal injury defendants to be allowed to buy health and social care from public providers; The same care to be available to all patients with the same condition – standardised by an independent body;
An ultimate limitation period; A limit on recoverable future loss of earnings;
A discount rate that reflects the way damages are invested.
Big savings on indemnity cover
Private doctors have been saving up to £56,000 by shopping around for indemnity insurance cover, the conference heard.
Savings examples given to doctors at the meeting included:
An orthopaedic surgeon whose bill dropped from £85,000 to £29,000;
A private GP whose £18,000 bill was cut by half;
A urology surgeon who now
pays £9,000 instead of £16,500.
The figures were presented by Andy Foley, founder and managing director of Bespoke Medical Indemnity, a specialist medical malpractice insurance broker.
Speaking alongside a platform of other representatives from the three big medical defence organisations – the MDU, MDDUS and MPS – he said his company could save clinicians 35% of what
they paid the traditional providers. He said his company had been able to rescue specialists who found they could no longer get cover from their previous defence body.
And various GP members of the Independent Doctors Federation were now his customers and saving ‘a significant amount of money’.
Mr Foley said his renewal rate was ‘99%’.
FIPO chairman Mr Geoffrey Glazer
Dr Mike Devlin of the MDU
Andy Foley, managing director of Bespoke Medical Indemnity
bMa PRIvate PRactIce confeRence
Optegra Eye Health Care has brought SMILE – SMall Incision Lenticule Extraction – a £500,000 bladeless, flapless, minimally invasive alternative to laser surgery, to its Didsbury hospital.
Ophthalmic surgeon Mr Shafiq Rehman said: ‘I consider SMILE to be the single biggest advancement in laser vision correction since the arrival of LASIK a quarter of a century ago, so I’m really excited to be helping to lead the arrival of this new treatment for our patients.’
Don’t be ‘guns for hire’, expert witnesses told
By Robin Stride
New and would-be expert witness doctors were advised by a barrister to beware of becoming an advocate for those paying their bills.
Mr Michael Williams, a barrister of the Middle Temple, told them at a training day to remember their duty was to the court, not the party instructing them.
He said judges were not slow to spot when an expert failed in their duty to the court and the consequences could be damaged reputation and also counsel raising the issue in future cases – if the doctor was indeed employed again.
This was one of an armoury of tips given to 160 consultants and GPs at a BMA conference in London aimed at helping doctors to enjoy years of witness-box success.
Mr Williams warned doctors to be sure they told the court if they
felt they were being asked questions outside their field of expertise. There were ‘unscrupulous counsel’ who would try and tempt them into unknown areas.
Practically, an expert witness should do their best to present the best impression possible, but this did not always happen.
Lateness to court was sometimes a problem and put doctors on the back foot before they had even started.
Attention to dress code was vital to create a good impression and yet he had seen tee-shirts, jeans and trainers.
He advised doctors to:
Watch the judge’s pen to see they were not talking too fast;
Refrain from arguing;
Be humble;
Avoid losing your temper;
Keep the evidence as simple as possible;
Avoid jargon and explain any
technical terms if these had to be used.
Witnesses should face the questioner but direct their answers to the judge, jury or chair. This helped avoid a debate starting up with the questioner and also gave the witness some time.
Preparation was the key to being successful in court, but expert witnesses often failed to do this; not even reading their reports before they turned up and thinking everything would all go well. But there was a clear need for them to refresh their memory.
Mr Williams suggested doctors should also prepare by thinking: ‘If I was on the other side, what would I be asking?’
They should not underestimate the cross-examiner. Skilled advocates prepared exhaustively for a hearing and if a witness had a ‘skeleton in the cupboard’, they should be prepared for it to come out.
He added: ‘If you are sufficiently self-critical, you can predict every question that will be thrown at you and can prepare answers to them.’
If witnesses were prepared to admit they had revised a view, then this showed they were being reasonable and added to their credibility. They should not be tempted to fill pauses left by the advocate nor reluctant to say ‘I don’t know/recall’.
Consultant physician and barrister Dr Michael Fertleman advised doctors to find out at the beginning what they would be paid for a report. Lawyers would want to know their hourly rate, so it was wise to ask around to see what others charged. They would then be asked how long the report would take. It was better to overestimate and put in a smaller bill than to ask for double the quote.
ALL SMILES (left to right) Mellissa O’Brien, Optegra diagnostic team leader; Anna Bramley, registered nurse; Mr Shafiq Rehman, consultant ophthalmic surgeon; Emma White, healthcare technician; Anna Bielawska, Zeiss clinical applications specialist
Guidance given for web consultations
By Charles King
The Royal College of General Practitioners (RCGP) has published a list of questions for doctors, patients and commissioners to consider before using or utilising online general practice services. Its move follows criticism from the Care Quality Commission (CQC) about online providers’ quality.
Questions include:
Will they see me whatever my health problem, or exclude me if I have complex health needs?
Will they have access to my full medical record, so that they know my medical history?
What happens if I need to see a GP in person – how far will I need to travel?
RCGP guidance said these were all questions patients should ask themselves if considering using an online provider of GP consulta-
tions, either web-based or via a smartphone app.
It recommends patients ensure the service has been inspected by the CQC or equivalent bodies outside of England; see how their personal information will be kept safe; and consider if it is providing a free NHS service or if a fee will be required.
The guidance comes as a growing number of services offering consultations online, most commonly via a smartphone apps, are hitting the market. Many are private, but some have developed partnerships with GP practices to deliver NHS care.
The new document, which is available to download, also outlines considerations for GPs and GP practices considering using or implementing online consultation services.
Guidance author, RCGP vicechair Prof Martin Marshall, said: ‘Online consultations can seem like a very convenient option for accessing general practice services, particularly for young, generally healthy people who want to see a GP quickly.
‘But the ways some online services are provided raise patient safety concerns. People need to be aware of these and properly understand what they are signing up to.
‘Often, for example, patients will have consultations with unfamiliar GPs who don’t have access to their full patient records.’
Download Online consultations in general practice: the questions to ask from www.rcgp.org.uk/policy/rcgppolicy-areas/online-consultations. aspx
‘First’ unit for menopause opens up in Harley Street
Two gynaecology and menopause specialists have launched what they bill as the first Harley Street clinic dealing primarily with women going through the menopause.
Menopause Clinic London is a collaboration between the minimally invasive surgeon Prof Isaac Manyonda and Mr Vikram Talaulikar, an associate specialist at the Reproductive Medicine Unit, University College London Hospital NHS Trust.
Prof Manyonda said: ‘While many women sail through the menopause and face none of the challenging symptoms including hot flushes and changes in mood, around 25% will be blighted by significantly difficult symptoms that affect their quality of life.
‘This clinic has been established to help those women in a focused environment, ensuring that the best form of treatment is sought and provided.’
Compiled by Philip Housden
new PPU to open at Royal Devon and exeter Trust
The trust is investing £1.8m to convert existing office space into a new 12-bed private patient unit (PPU). The unit will open in November 2018 as a dedicated facility for insured and self-funding inpatients.
This delivers new bed capacity ahead of next winter and will generate extra income to put back into front-line NHS services.
The trust has enjoyed consistent year-on-year increases in private patient revenues, growing these more than 65% in five years from £0.9m in 2012-13 to £1.5m projected for 2017-18.
This represents around 0.5% of total trust incomes, marginally below the out-of-London average of 0.6%.
The trust’s plans for the PPU are to boost this percentage to over 1% of revenues – over £4m a year – which, if achieved, would put Exeter into the top 15 performing trusts outside London.
Chris Tidman, the trust’s chief financial officer, said: ‘I’m keen for the trust to increase its commercial income, although it’s important to remember that the trust is first and foremost an NHS organisation and this project is being delivered by the NHS, for the NHS.
‘We believe that private patient services delivered professionally will provide much-needed additional income that can be reinvested for the greater good and protection of all our services.’
Philip Housden is a director of Housden Group. Read his feature article on page 36
Report prompts BMA to call for more beds
There are too few NHS beds for safety, according to Dr Robert Harwood, BMA acting consultants committee chairman.
Responding to a report by NHS Providers, examining how the NHS aims to deliver for patients and staff in 2018-19, he said it was a timely reminder of the uphill struggle facing the NHS after decades of underinvestment.
‘The report clearly highlights something that doctors in both secondary and primary care and their patients have long known: that there are now simply too few beds for patients available in the NHS to allow the delivery of safe, effective care at the time it is needed.
‘We’ve endured the most chal-
lenging winter on record with patients facing unjustifiable waits on trolley beds because of unprecedented demand, staff shortages and a lack of resources.’
He urged the Government to work with the BMA ‘and likeminded organisations’ to ensure any long-term funding plan was best suited to the needs of patients and staff.
Independent practitioner entrepreneurs – make sure you get the publicity you deserve! Contact editorial director Robin Stride at robin@ip-today.co.uk or phone him on 07909 997340
PPU waTch
Doctor’s invention to retain modesty
By Olive Carterton
A new and simple apron that keeps women covered while allowing doctors to carry out full upperbody examinations has been designed by orthopaedic spinal surgeon Mr Mushtaque Ishaque.
Produced by Birmingham company Bare-Non Ltd, it is being offered to all female patients undergoing a clinical examination at Spire Little Aston Hospital, near Sutton Coldfield, West Midlands.
Placed over the neck ‘like you would put on a lifejacket’, the apron, made of non-woven polyethylene-backed tissue, consists of two loose panels that effectively cover both breasts but allow clinicians access to carry out thorough inspections.
Mr Ishaque said an examination apron such as this was ‘long overdue’ and had been well received by patients and medical staff alike.
He explained: ‘I got the idea when I was on a plane and watched the stewardess put a lifejacket on. It was when she turned around I realised it was perfect, as it covered the front but allowed the back to be seen completely.
‘I then introduced the split in the middle to allow access to the abdomen when the patient is lying on their back. The final step, which allowed us to patent it as an invention, was the extendable crimped neck line, which means one size fits all.’
Clinical nurse manager Samantha
Jarvis said: ‘There are so many occasions when a woman is asked to remove all clothing above the waist, but there really isn’t any reason why they should have to sit seminaked in a room where not just the doctor but several other people might need to be in attendance.
‘This apron helps them main -
Health bosses fail to ease staff stress
Healthcare business bosses are among the half of managers who do nothing to help ease workers’ stress – even though work is by far the most common cause of it.
A survey of adults in employment in Britain found work responsible for stress in 59%, but staff said 45% of businesses offered nothing to help alleviate this.
The study, quizzing 3,000 UK workers, was carried out by employee benefits company Perkbox.
Healthcare and education industries, both 45%, were among the
list of the top five sectors least likely to see employees offered help or assistance with managing levels of work-related stress.
Perkbox chief executive Chieu Cao said: ‘It’s worrying to see how few businesses seem to be considering stress levels within their workforce their problem. And it is particularly ironic to see that almost one-in-two workers within the healthcare industry say their bosses do not offer anything to help them alleviate stress levels.
Mr Cao said introducing measures that helped cut stress or
tain their dignity and takes away potential embarrassment yet still allows for a thorough examination from front and back.
‘Women expect to remove top clothing for breast examinations, but it is necessary for so many other things, such as ECGs to test the heart and even spinal examinations where the consultant needs to see the full, uncovered back in order to check for alignment problems.’
Pre-op Sister Catherine Chapman added: ‘Recent news events – both home and abroad – have highlighted how women’s dignity has, in effect, been taken for granted.
‘It isn’t good enough to leave patients wrapped in a blanket or just covering themselves with their hands. They want to be examined properly without feeling exposed and uncomfortable.
‘It is fair to say that some women don’t worry about such things in a medical situation, but, in my experience, many more are bothered and have really welcomed the new aprons in a very positive way.’
But it isn’t just women patients who are benefiting from the introduction of the apron. Mr Ishaque said: ‘One patient told me that, unless he was on holiday and wearing swimming trunks, he was quite uncomfortable undressing in front of a woman – which can often happen in hospital.
‘The Bare-Non Modesty Apron – as we have called it – allows men the same sort of dignity it offers women patients which is absolutely as it should be.’
OUR PRIvACY POLICY
encouraged positive coping methods need not be particularly involved nor expensive. Even free things as simple as introducing flexible working, considering requests to work from home occasionally or enforcing one-to-ones with managers to allow employees to discuss concerns and motivations could go a long way to help.
Measures which tackle staff stress head-on worked best – including gym membership or exercise classes, discounted or complimentary counselling and mental health services and even spa vouchers.
As a valued reader of Independent Practitioner Today, your trust is important to us, so we wanted to let you know about our new privacy policy which is now compliant with the EU’s General Data Protection Regulation (GDPR).
You can read the new policy on our website at independentpractitioner-today.co.uk and, if you would like to ask any questions or require a paper copy of the policy, please get in touch with us.
Sister Catherine Chapman (right) shows how the apron allows examination while keeping the patient covered
Above: Spire Little Ashton’s clinical nurse manager Samantha Jarvis with the Bare-Non Modesty Apron
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So farewell, Pardner
With so many doctor retirements around, Susan Hutter (right) gives her guidance on how to handle the departure of a business partner
Many private medical practices these days operate as a group, trading either as a partnership or, more usually, a limited liability partnership (LL p ) and, in some cases, as limited companies.
t herefore, consultants who trade in this manner are no longer answerable only to themselves –they have to work in harmony with their other partners.
On the basis that you never need an agreement until there is a disagreement, it is vital to have an agreement in place if you are trading either as a partnership, the LLp-style partnership or a limited company.
this way, the agreement can be put into place while everyone is on friendly terms.
take legal advice, but the main topics to cover are:
profit-sharing arrangements;
expense sharing;
Capital contributions;
What happens to the patients if one of the principals leave?
What happens to the goodwill of the retiring principal?
notice period;
Holidays;
extended sick leave.
Obviously, some retirements are where the principal is leaving the profession completely.
Restrictive covenant
However, if the principal were to move on to another practice, then there are additional considerations to take into account.
t his includes whether or not they are allowed to practise nearby and also whether or not the principal would be able to take their patients with them.
in real life, the patients will go to
the doctor that they want to see. So these restrictive covenant style clauses are quite difficult to enforce. your lawyer will advise you.
One of the main issues on the retirement of a partner is the valuation of the practice and whether or not the retiring partner is entitled to be paid out for their goodwill.
if the retiring partner is leaving the profession, there could be an argument that they should be paid for the goodwill. if they are setting up elsewhere, then it is debatable.
Residual value
a part from goodwill, there are often other valuable assets in the partnership; for example, imaging equipment or other machines.
Some of these items may have a residual market value. So, in the agreement, it would be sensible to allow them to be valued and for the outgoing partner to receive a payment in lieu of their share.
there have been circumstances where individual partners have signed up to an agreement that they do not really understand. then, when they wish to leave, problems arise as they realise that the financial settlement may not be what they originally envisaged. it is therefore crucial that all partners take individual advice before signing an agreement.
it is worth asking your accountant and lawyers about this, as the accountants will have more knowledge about the financial and tax consequences of the agreement and the lawyers will know more about the legal implications and what is/is not enforceable.
i find it is always a good idea to have a round-table meeting with the lawyers and the practice accountants to go through the agreement before it is signed. if there is no partnership agreement governing the terms of retirement, then, in the circumstances of a retirement, all parties should behave as sensibly as possible. if issues turn into a hostile dispute, the lawyers and accountants’ fees will be costly.
in many cases, when a partner retires, a replacement is not required and therefore the remaining partners will need to look at the expense base of the practice to see whether the over-
heads can be reduced, as there is one less partner to support.
For example, if the retiring partner was quite ‘expensive’ to service, you may be able to cut the cost base of the practice.
With all these issues, planning is key. if there is a formal notice period in the partnership agreement – which is certainly recommended – start working on dealing with the exit of the partner as soon as notice is given in order to give you time to work through all the issues.
Susan Hutter, is a partner at Blick Rothenberg and part of the team that advises medical practitioners
New data law to boost trust
Don’t get left behind on General Data Protection Regulation (GDPR). It’s happening on 25 May. Jane Braithwaite presents a very practical guide for any Independent Practitioner Today readers who have so far failed to react…
I hear you groan. Not another article on the eu’s General Data Protection regulation (GDPr). It’s beginning to feel a lot like the millennium bug. Lots of noise, confusion and uncertainty. a re you tempted to just ignore and hope that it all goes away? Please don’t.
I have attempted to write a very practical guide on GDPr, what it is and what we, as individuals responsible for medical practice management, can do to break through the panic and feel calm and perhaps even a little bit smug that we have it all in hand.
The problem with GDP r , like most regulations, is that there is no definitive solution. It’s like saying to parents that they must, by law, give their children a healthy diet and will be fined if they fail to do so.
each individual interpretation of what constitutes healthy is different and research leads us down
many different alleyways and we struggle to know what is accurate and what constitutes commercial opportunity.
Nobody can give us a set of rules to follow that ensure success. We have to interpret the information and make our own decisions. I am no expert and I do not pretend to be one, but I am sharing my understanding and my thoughts on how we can deal with this important issue.
The GDPr will be implemented from 25 May 2018, replacing the u K’s Data Protection a ct 1998 (DPa).
Now, although private medical practices should already be working in accordance with the DPa to manage patient records, the GDP r has some significant new requirements.
The GDP r applies to anyone who processes personal data relating to eu citizens. In the case of healthcare, this not only includes
patient records, but any data related to employees and suppliers.
The consequences of not meeting the requirements, or failing to notify the authorities of a breach, could be harsh indeed. If a healthcare provider breaches the GDPr, they could face a fine of up to €20m or 4% of annual turnover.
Why is the GdpR being introduced?
The GDPr has two primary aims: to simplify regulation across the eu and to give individuals more control of their personal data.
It’s important to see the GDPr as more than a box-ticking exercise. It is really more of a cultural change to ensure that businesses are accountable and transparent with data.
In addition, healthcare has been shown to be particularly vulnerable to cyber crime in 2017 as evinced by the WannaCry N h S
attack among others. Individuals are more concerned about the security and privacy of their data than ever.
The Information Commissioner’s o ffice (IC o ) is the u K’s Data Protection authority and its role is to ‘uphold information rights in the public interest’. In 2017, the ICo found that 80% of the public didn’t have trust or confidence in the companies storing their private data.
a dherence to the GDP r will help build patient trust, which is something all healthcare providers surely value.
e lizabeth Denham, the u K Information Commissioner in charge of the ICo, commented on the strong links between data privacy and data security.
She went on to underline the positive role of the GDP r : ‘Thinking that GDP r is about crippling financial punishment
misses the point. GDPr is about enhanced rights for individuals.’
Who is responsible for implementing GdpR?
The new regulation applies to both ‘data controllers’ and ‘data processors’. The ICo defines the roles as follows: ‘ a controller determines the purposes and means of processing personal data.
‘ a processor is responsible for processing personal data on behalf of a controller.’
In the context of a private medical practice, a data controller could be the principal consultant and the data processor could be the practice manager, medical secretary, IT consultant or anyone who acts on the processor’s behalf.
What data is included in the GdpR?
Data processed within a medical environment will include names, addresses, email addresses and medical information. For self-pay patients, bank details will also need to be processed in line with the regulations.
Medical photography is considered personal data, as are recorded phone calls and any social media interactions you may have with patients – although any communications made in this way will also be subject to additional guidance set out by the GMC.
you need to apply the same rules to personal data you may hold about employees and suppliers.
What are the main requirements of the GdpR?
although the main principles of the new regulations are still the same as those set out in the previous directive, some of the key changes are:
➲ Consent – Terms and conditions relating to consent need to be accessible and clear, using plain language. Companies can no longer use lengthy and ineligible terms and conditions, and must make it easy for subjects and clients to withdraw their consent.
➲ Breach notifications – The ICo must be notified of any breaches within 72 hours of the data pro-
companies can no longer use lengthy and ineligible terms and conditions, and must make it easy for subjects and clients to withdraw their consent
cessors and controllers becoming aware of the breach. This is a mandatory step where a breach is likely to put at risk the ‘rights and freedoms of individuals’.
➲ Right to access – Data subjects – patients, in the case of private medical practices – have the right to request and obtain from the data controller information relating to whether or not their data has been processed and for what purpose.
The controller is obliged to provide a free electronic copy of any personal data being held.
➲ Data portability – This relates to a subject or patient’s right to request and receive their data, and the right to transfer that data to another company.
➲ Data Protection Officers (DPO)
– The new regulation requires a DPo to be appointed only in situations where the company’s activities include the ‘regular and systematic monitoring of data subjects on a large scale’, or if the company is a public authority.
➲ Penalties – Breaches of the GDPr can result in a fine of up to €20m or 4% of annual turnover, whichever is the larger amount. This amount is in relation to the most serious violations. a company can also be fined up to 2% for less serious breaches.
See the eu GDP r portal for more information on all changes and requirements, including the full criteria for DP o appointments.
How will Brexit affect the GdpR?
The GDPr applies to all companies located within the eu that process and hold personal data. Companies located outside the eu will also need to comply with the regulation if they provide services to people residing in the eu In the international arena of private healthcare, there is a strong likelihood that services will be offered to eu residents. as a result, it would be sensible for practices to ensure they are working within the regulatory framework of the GDP r , so they are compliant even after the u K leaves the eu
There is no magic pill for meeting GDPR requirements, and it’s an ongoing process to ensure that your practice complies
How do i assess my practice for compliance?
The ICo’s online self-assessments are an excellent tool for business managers or principal consultants who are unsure how compliant their practices are.
Top Tip r ead the IC o ’s Preparing for the GDPR: 12 steps to take now . a n 11-page illustrated PDF is a lot easier to assimilate than the full 300 pages of the GDPr itself.
There is no magic pill for meeting GDPr requirements, and it’s an ongoing process to ensure that your practice complies.
But there is a wealth of information available, and the IC o has shown a supportive and positive approach in order to help businesses protect personal data.
Jane Braithwaite (right) is managing director at Designated Medical RefeRences
The Information c ommissioner’s Office: https://ico.org.uk/
The IcO found that 80% of the public didn’t have trust or confidence in the companies storing their private data:
https://ico.org.uk/about-the-ico/newsand-events/news-and-blogs/2017/11/ ico-survey-shows-most-uk-citizens-don-ttrust-organisations-with-their-data/ The Information c ommissioner’s Office (IcO) defines the roles: https://ico.org.uk/for-organisations/ guide-to-the-general-data-protectionregulation-gdpr/key-definitions/ Additional guidance set out by the GMc: www.gmc-uk.org/guidance/ethical_guidance/30173.asp
Preparing for the GDPR: 12 steps to take now: https://ico.org.uk/media/1624219/ preparing-for-the-gdpr-12-steps.pdf
ThE big dEbATE
Employed vs self-employed
The question of whether or not consultants should be employed or self-employed is becoming increasingly debated. There are strong arguments in favour and against. Ray Stanbridge gives an assessment
M AR k ET D yn AMICS are such that the ‘salaried option’ cannot be brushed aside and most new consultants will have to take a view.
new players in the London market such as the Schoen Clinic and the Cleveland Clinic are offering employment contracts as the norm. Existing major players in the hospital market are also looking at the option seriously.
And insurers are looking to see if they can rationalise costs by encouraging the development of groups and locum agencies and for consultants to take employment if they have small practices.
An increasing vocal body of opinion believes that, within the next ten years, insurers will no longer recognise individual consultants.
Four major factors need to be considered by consultants think
ing of an employed or selfemployed option – quality of work, lifestyle, cost incidence and taxation.
Commonly, the taxation argument is given prominence by advisers, but perhaps surprisingly it is the quality of work and lifestyle consideration that is affecting individual decisions more. These four factors are considered below.
1. Quality of work and clinical outcomes
There is circumstantial evidence that the quality of clinical outcome improves when consultants are working as a multidisciplinary team.
And there is also evidence that consultants working together, rather than on their own, are more likely to ask colleagues for advice and support. This corporate collective approach is a potential advantage of the employment model for those
consultants enjoying working closely with colleagues.
It has also been suggested that the collection and resultant analysis of clinical outcome data is better done in the employed environment. Resources are likely to be greater than for an individual.
Peer pressure to produce data will be more intense and the level of intellectual scrutiny and benefit from using a number of minds is likely to be greater.
The suggestion is therefore that, as the quality of work and analysis of clinical outcomes is higher in an employment environment, the financial implications can be better understood.
As a result, the longerterm costs of treatment programmes can be reduced at the same time as the outcome measures are improved.
The contrary view is, of course, that individuals working by themselves can offer very high standards of quality and clinical outcomes which they can measure themselves. The jury is out on this point.
2. Lifestyle
The days of the tyrannical James Robertson Justicetype consultant working 24/7 are long gone.
The mass of new safety and employment protection legislation over the last 20 years, together with the ongoing impact of the Human Rights Act on individual behaviour, have changed the way consultants think.
There is probably far more recognition of hours of work commitment by consultants than historically and also increasing interest in worklifestyle balances.
Family time for many new consultants is probably a far more important and real concept than it was for some of their predecessors. Clearly, those consultants who are employed to undertake their private work are in a far stronger position to manage their worklifestyle balance than those who are self employed and have full responsibility for the management of their patients on a 24/7 basis.
Some observers would say that employment practices and demands in the nHS are seeping into the private sector and this is just changing the perspective of new consultants. This is primarily with respect to those who think strongly about their family commitments and obligations.
A straw poll suggest that the number of very heavily motivated consultants primarily aiming at maximising their private practice income is declining and that lifestyle considerations are becoming increasingly important. To the extent that these dominate an individual’s thinking, the employment model will become more attractive.
3. Cost incidence
One of the major advantages of being selfemployed – and under the rules of the Bhadra v Ellam case, most consultants will satisfy these requirements – is that costs can be claimed against income on the grounds that they are ‘wholly and exclusively’ relevant rather than ‘wholly and exclusively and necessarily’ incurred.
This means that consultants can claim against their income;
SCHEDULE ONE EMPLOYED OR SELF-EMPLOYED KEY TAX & NI RATES
for example, salaries, family employee costs, use of home, training courses and conferences, telephone and internet.
In addition, consultants can claim room hire, hospital fees and external secretarial costs.
Employees are far more restricted in what they can claim. HM Revenue and Customs argues that the ‘necessarily incurred’ condition is sufficiently strong and it prevents many claims under this heading unless they relate to all similar employees. Having said this, employees will not normally pay for room hire, secretarial and office costs or medical indemnity insurance costs. Under the rulings of the Competition and Markets Authority, effective from April 2015, administrative cost burdens have increased significantly for many consultants.
And there has been a continuing rise in insurance indemnity premiums. For many doctors, these costs are a major inhibitor in any decision to start a private practice. For an ‘average’ consultant, the potential saving on costs that
would normally be borne by an employer instead of themselves, as a selfemployed individual, are quite significant.
Few consultants actually remember that when costs are taxdeductible, they only reduce tax on the cost at the marginal rates by 20%, 40% or 45%. They still have to find the cash to meet the balance.
Obviously, the larger the practice, the less the incidence of the costs. However, it seems to be clear that, for small practices, an employed status is better in terms of individual cost saving than a self employed status. The logic will vary over a lifetime’s career.
4. Tax
Many accountants will actually only look at the tax effects of being employed or selfemployed rather than quality matters, lifestyle and cost impact factors, which I actually believe are far more important to many individuals, and their families’ personal decisions.
What is worse, many accountants only look at the marginal tax
employment can claim expenses and obtain tax relief at their marginal rates. They may also be in a position to defer some tax.
Those who trade primarily through the medium of a limited liability company can ‘save’ by deferring tax and paying at lower corporation tax rates. However, if they need the cash – which most young consultants do – the general increases in dividend tax rates over the past few years will reduce the net benefit.
Since tax rates change, advice as to whether or not to be employed or selfemployed (sole trader, LLP or company) is very complex.
Any exercise needs to be personalised and does need to look at the key factors: how much cash is left in the pocket after paying taxes and expenses at the end of the day.
It also needs to be a dynamic exercise rather than just showing things at a moment in time. Different employment status may be appropriate at different times of a career.
rates of alternatives rather than the average tax rate or what is of more importance: cash in the pocket after all expenses and tax charges.
This, in reality, is the most important factor in consultants reaching a decision about how they want to operate.
A schedule of current tax rates – Schedule One – shows the marginal rates (see box above).
Clearly, those who are in self
The decision is not easy. As a general observation, the attraction of employment for those with private practices of less than £60,000 a year outweigh the disadvantages.
For those with large practices over £500,000, the converse is probably true. For those in the range of £60,000£500,000 income, it is a matter of assessing each case on its merits. There is no panacea.
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists Stanbridge Associates
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Build a relationship with your architect
Expanding your practice or your home? Philip McQuillen gives some excellent advice
1 make sure you are appointing a chartered architect
There are companies offering architectural design services who are not necessarily architects. If it is an architect you are looking to work with, then make sure they are registered with the Architects Registration Board (ARB).
The title ‘architect’ is protected under the Architects Act 1997. The Act protects the public from dishonest individuals who deliberately mislead people by calling themselves architects.
2
Choose an architect who is right for you and your project
The ARB is the statutory body for the registration of architects in the UK. Its website (www.arb.org. uk) is a good place to start. It includes advice for members of the public who are intending to appoint an architect. There is a very useful ‘meeting your architect’ form which can be downloaded from the website. It lists the important elements you should review with the architect at the outset.
Another useful source are friends who have worked with architects and who can recommend someone to you.
As with building contractors, word of mouth and recommendations are a great help when selecting your architect. In terms of getting the right architect, consider whether you want an architect with a contemporary style or one who specialises in traditional design.
Also, do you want to deal with a large practice or a smaller firm or sole practitioner?
A kitchen and orangery in a new-build house. All pictures are of architectural projects designed by Philip McQuillen
Study with bespoke joinery in the same detached London house as above
3
Ensure your architect has experience in your type of project and that they specialise in the type of work you are planning to do Another thing to consider is getting an architect who specialises and has experience in the type of work you are planning to do. Do you want your architect to carry out the interior design as well as the architecture?
Ask to see previous relevant projects and visit them and, if possible, speak to their previous clients.
4
Be clear as to your brief
While one of the main reasons for appointing an architect is to use their design expertise, it is essential that the completed project suits the way you live, your style and your tastes.
To get the most out of the first meeting with your architect, prepare in advance. You might want to collate photographs of other projects you have seen that you like or particular features, details or finishes you would like to use on your project.
Spending time going into as much detail as you can in these early stages should generate a clear and detailed client brief, which is the best way of ensuring your architect is clear as to your requirements. These meetings should be minuted and they can form the basis of the outline brief.
5 set your budget
It is important to be realistic about your budget and your aspirations at the outset. If your budget is tight, identify the elements of the project that are important to you.
This will allow your architect to
prioritise and give you the scheme you want. There are also many ways of designing the elements of a project and, armed with your wish list, your architect can look at cost-effective ways of achieving your requirements.
6 decide on the extent of the architectural services you require
Do you need the architect just for the planning application or for planning and working drawings for tender purposes? Or do you require a complete service from briefing/concept stage through works on site right up to completion of the finished project?
7
The devil is in the detail
It is essential that detailed design is resolved. The more detail which is included in the design to be priced by the contractor, the less risk there is of variations and additional costs.
Clearly, there will always be cost risks associated with a building project – hence the need for a contingency figure on all projects –but spending more time and appointing the architect to carry out a detailed design should reduce the impact of these risks.
More money spent on design fees before tender is generally a lot cheaper than additional costs and variations which may occur once the project is on site.
8 measure twice, cut once Time spent to get the design right is generally time well spent. Work with your architect to allocate realistic time-scales to your project – particularly at the planning stage.
Refurbishment and remodelling of an existing apartment in Westminster ➱ p22
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For example, having gained plan ning permission for a scheme, it may be worthwhile submitting a further application to add further accommodation if it looks likely that it may be successful.
The planning officer’s report is a very useful document, which will normally set out the planning authority’s position on any particular issues or concerns raised by neighbours or other interested parties. Moreover, planning can be a lengthy business if it involves a sensitive site or building.
Similarly, allowing for sufficient time and design resources to put together a more comprehensive set of tender and contract information will pay dividends after the contract has been let and works are on site.
While for smaller projects, a full bill of quantities may not be necessary, an itemised schedule of works will show you where the higher costs are. Therefore, if you need to reduce costs, it will allow you to omit or amend certain elements prior to letting the con -
tract. It also allows better cost control and valuation of the contract works on site.
9 Ensure the terms of the appointment are set out in writing
As with any building works, you would be well advised to ensure there is a contract in place for the architectural appointment.
At the very least, the contract should state the extent of the architectural services you require, the scope of the work, a statement that professional indemnity insurance is held, key responsibilities of all parties to the contract, architectural fees and whether there are any special terms for dispute resolution and what to do in the event of a dispute or complaint.
The RIBA Standard Agreement 2010 (2012 Revision) sets out the terms of the architect’s appointment in detail so that you can clearly understand the service you will be receiving.
It is also a good aide memoire for clients to ensure nothing is
missed out from the appointment. Understanding, agreeing and setting out in writing the terms of the architect’s appointment is key to a good working relationship with your architect.
10 Finally, remember: you’re the client
Architects have their own stylistic preferences, but don’t forget that it is your project.
It is fair to say that you will probably have appointed your architect based on the fact that you like their previous projects –and therefore their architectural style. Thus you and your architect will most likely already be aligned in terms of architectural design, but your architect should listen carefully to your requirements and seek to implement them.
Don’t be afraid to tell them what you want – and what you don’t want. Clearly, there may be occasions when it is not possible for you to get everything you want, either for planning, buildability or cost reasons, but your architect will usually explain why
and, perhaps, come up with an even better solution.
Your architect is there to listen to you and interpret your brief and they will want to make sure that you are satisfied with the result. It is a collaborative process and, while at times it may be a little daunting, it should also be fun. Indeed, with the right team of client, architect and contractor, there is no reason why it should not be an enjoyable and rewarding experience for you.
Philip McQuillen (right) is a registered chartered architect and property developer with over 25 years’ experience.
He is the founder and managing director of Earlsmarch (www.earlsmarch.co.uk), an architecture and interior design studio and residential property development company focusing on new build and existing residential projects in prime central London and the South-east
Bar and entertaining space in a house in Surrey
Entrance hall in a new-build detached house in London
Staircase of same house as above, clad in crema marfil stone
Everyone’s talking about it – but are you really ready?
This month sees the arrival of the EU’s General Data Protection Regulation, but there are concerns that many medical businesses remain unprepared. Peter Anderson reports
WITH DATA protection rules facing their greatest shake-up in decades, medical professionals are being warned of the pitfalls of failing to mitigate and manage their potential risks.
Health professionals are among those watching anxiously as the EU’s General Data Protection Regulation (GDPR) comes into force on 25 May, radically overhauling data handling requirements across the Union’s 28 nations.
However, feedback from health administrators has suggested that, with just days to go until its implementation, GDPR continues to cause widespread confusion within the medical profession.
‘With their inevitable focus on day-to-day activities, many private hospitals and, in particular, consultants remain unclear about what the new rules mean for them and their staff, freelance contractors and suppliers,’ said Chris Cloke Browne, a Director at Medical Risk Services Limited (MRSL).
Broad support for doctors
Established in 2004, MRSL offers a broad range of support and cover to medical professionals, with data breach and cyber expertise being part of a much broader service that ranges from public and product liability to specialist medical indemnity insurance.
The company specialises in helping doctors and medical businesses mitigate and manage their risks and reduce indemnity costs.
According to MRSL, insurers have made it very clear that preparing for GDPR isn’t simply a
case of putting data breach cover in place – or beefing up an existing policy.
Chris explained: ‘Doctors and medical teams can’t simply make GDPR go away by taking out an insurance policy. Underwriters are adamant the first step has to be for medical professionals to establish minimum standards of data security.
‘Understanding the new rules and requirements, and ensuring all staff are prepared and trained, has to be the immediate priority in managing and mitigating risks.’
Huge cost implications
The obvious sensitivities surrounding patients’ medical data mean any breaches are likely to generate huge publicity – and considerable hostility among the public, according to MRSL.
‘Doctors are calling us because they have realised that under the new GDPR rules they will not just be receiving complaints about
the adverse medical outcomes of disgruntled patients,’ Chris added. ‘A data breach complaint could cost a private practice millions of pounds. Lawyers will be using that angle.’
Compliance training experts
With preparation for GDPR being so important, MRSL has joined forces with Olive Group, an internationally recognised provider of regulatory and compliance training. Olive, which has offices in a dozen countries, operates a range of courses focused on GDPR compliance, enhancing MRSL’s broad package of insurance, training and data breach risk assessment for private medical businesses.
‘GDPR is the biggest change in data protection laws for 20 years,’ said Olive Group CEO Brendan Kavanagh. ‘The ICO published last quarter that four out of five data breaches are due to human error. Therefore, staff awareness training is critical and a must-do for all organisations.’
One of the concerns for MRSL is that support companies – including those offering secretarial, practice management, transcription and accounting services to consultants – will be impacted hugely by the new EU-wide regulations.
For many medical professionals, the ‘special category’ status given to health data under GDPR has been seen to potentially minimise the risks of private medical businesses facing legal action. However, understanding the regulation will be vital, according to MRSL.
Data in the public interest
‘GDPR sets out very clear rules on the processing of personal health data,’ noted MRSL Director Dr Robert Baylis.
‘While the inclusion for the first time of genetic data and biometric data may have grabbed some headlines, many practitioners are much more likely to be impacted by subtleties such as data being processed in the public interest or for the vital interest of an individual. Privacy Impact Assessments could also be hugely significant.’
Robert, a Consultant Anaesthetist, added: ‘The key issue is understanding the regulation – and that’s where training and guidance will be so important.’
For further information on MRSL or for full details on the company’s comprehensive range of insurance products, please telephone 0203 058 3733, email enquiries@mrslenterprise.com or visit www.mrslenterprise.com
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Are they happy with the care?
How the measurement of outcomes is transforming private practice and how this affects your work as independent practitioners.
Dr Tim Williams (above), founder and chief executive of MyClinicalOutcomes.com, answers questions posed by Independent Practitioner Today
Why should we collect patientreported outcomes?
Traditional measures of healthcare quality focus on the processes of care, such as waiting times and length of stay, or the success of hospitals in avoiding unintended harm. These factors clearly need to be measured and managed, but they don’t attest to the actual results of care from the perspective of the people that really matter: our patients.
‘ o utcomes’, as defined by the International Consortium of h ealth o utcomes Measurement (IChoM), are: ‘the results people care about most when seeking treatment, including functional improvement and the ability to live normal, productive lives’.
Patient-reported outcome measures (PR o Ms) are structured condition-specific clinical assessments and are a key tool in measuring and tracking outcomes. systematic collection of PRoMs regularly, remotely and throughout care helps:
Patients to understand the benefits or otherwise of treatment and make more informed decisions;
Clinicians to optimise the care of individual patients, including when to review face to face, when to treat or change treatment, as well as to understand the overall quality of care they are providing to different cohorts of patients;
Managers and payers to ensure clinical resources are prioritised to patients that need it most and that ineffective or harmful activity is minimised.
What is my clinical outcomes?
My Clinical outcomes (MCo) is an innovative web-based technology, created by clinician entrepreneurs, that allows doctors and hospitals to systematically measure and analyse PRoMs as a routine part of care.
It has been used at over 70 Nhs and private hospitals in the u K since 2011, with over 1,000 active clinicians and 20,000 patients.
MCo was borne out of a frustration of its founders about the lack of data on the impact of treatments and interventions to guide doctors and managers to organise ➱ p26
At the heart of medical finance
The Association of Independent Specialist Medical Accountants is a national network of firms advising over 3,700 medical practices across the UK. For some of the best advice available on accounting, taxation and pensions, visit our website and find your nearest AISMA accountant.
clinical capacity most efficiently around the most effective treatments at a time where user-centred digital tools were becoming commonplace in day-to-day life.
The mission of the company then, as now, was to create a digital system to help healthcare organisations, doctors and their patients understand the results of treatment from the perspective of the patient in order to shape treatment decisions and ensure the highest-quality care for all patients.
How does it work?
MCo is implemented according to needs of individual clients to collect outcomes. This includes deciding which conditions, treatments and patient groups will be involved, as well as choosing appropriate PR o Ms and timepoints for longitudinal data collection.
When data collection starts, patients are asked to register and
are then served a combination of PRoMs tailored to them as a baseline. The system automatically prompts patients to update their score at pre-defined future timepoints via email.
Patients can log into their own dashboard at any time to review their progress; their doctors can review results as soon as the data is entered to help plan care and focus face-to-face consultations. Administrators can be given access to which patients are notresponding and pro-actively contact patients to ensure on-going high uptake.
s enior doctors and managers may then use the results in aggregate, depending on the specific arrangement with clients, to target available clinical capacity to those patients who need it most, and to ensure all patients are achieving the best outcomes, so that less effective activity may be reduced.
Patients can log into their own dashboard at any time to review their progress
Why should consultants do this?
The whole u K private sector is changing and is tasked to respond to new requirements set by the Competition and Markets Authority (CMA) to collect and transparently publish outcomes data. This is being done through the new information organisation for the sector, the Private healthcare Information Network (PhIN). This is to improve the ability of patients to make more informed choices of hospitals and clini -
cians, and for payers to ensure value for money.
The onus is on private healthcare providers to work with a partner supplier, or develop a solution in-house, to implement a compliant programme for outcomes measurement.
The first procedures selected are hip and knee replacement, shoulder replacement, carpal tunnel release, transurethral resection of the prostate, cataract surgery, nasal septoplasty, breast augmentation, rhinoplasty, abdominoplasty and liposuction, with data being required to be collected pre-operatively and once postoperatively so that the benefit of the surgery can be assessed.
The lessons of the N hs programme have been drawn on and the emphasis is much more on encouraging providers to adopt a sustainable and clinically useful digital process for outcomes measurement.
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Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.
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As well as bringing benefits in terms of long-term patient engagement and clinical utility, taking a digital approach to outcomes measurement allows clinicians and providers to monitor results as they are recorded.
A digital approach also ensures that the aggregate data that is eventually published will be as accurate and positively representative of clinical performance as possible.
What’s happening in the nHs?
The N hs has had a nationally mandated outcomes programme since 2009 that authorises providers undertaking total hip or knee replacement to collect PR o Ms, before and six months following surgery.
The programme was introduced when digital technology was not widely available, and data is therefore typically collected using pen and paper.
This means that, while useful in terms of gathering data that allows aggregate provider-level analysis to spot outliers, reporting is delayed and individual results are not made available to patients and clinicians such that they may inform the care of those patients themselves.
And engagement has often been rather poor, meaning that response rates are low with no mechanism or incentive to drive uptake by individual patients.
Finally, this resource-intensive approach means that the scope has remained narrow at just four interventions and two time-points of collection.
There is no longitudinal, timeseries data proving insight into the relative timeliness of operative decision-making or sustainability of outcomes – longevity of benefit – between sites, pathways, clinicians or devices, for patients with similar needs.
WELCOME TO THE NEW PINDROP HEARING CLINIC
What do patients think?
Patients find this record of clinical progress a useful reference to inform on-going decisions.
A long-term patient user sums up a common reaction: ‘MCo is a great website and it is easy to use. I find it very reassuring that I am regularly reviewed by my consultant ...
‘As much as I like meeting him face to face, I do feel that my life is so incredibly busy and taking time off from work is not easy, so this way I can be assessed without needing to take time off.’
For the first time, private patients, their relatives and, yes, even referrers will soon, through PhIN, be able to access comparable data about outcomes for the procedure, clinician and hospital they are choosing, to help make more informed decisions about their care.
This will result in overall quality of care rising as providers compete
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on the results they achieve for their patients. This new transparency will also result in a reduction in lower-quality activity. ultimately, private healthcare will become better value for money for patients, whether funded through private medical insurance or selfpaying.
Who is doing what?
PhIN has recently taken first steps on publication of outcomes and has released information about which providers of private healthcare are making the most progress towards being able to publish measures of the improvement patients experienced from common types of surgery.
s pire h ealthcare, a client of MCo, was identified by PhIN as ‘leading the way’ ( Independent Practitioner Today, February 2018). MC o was established across spire healthcare in late 2016, with ➱ p28
activity and scope growing, data being submitted to P h IN and Nhs digital.
More recently, The hospital of st John and st Elizabeth and The london Clinic also became users of our system.
A programme manager at spire healthcare said: ‘The MCo team is quick to respond to support queries, knowledgeable about their product and PRoMs internationally and are keen to ensure that we get fantastic value from the system. set-up was quick and easy, with minimal training required.’
MCo continues its longstanding relationship as an accredited supplier of P h IN. Matt James, chief executive of PhIN, has previously said: ‘We found that the digital-first approach taken by MCo engages patients in the process of measuring outcomes, allows data to be used to inform clinical decisions and allows our members to cost-effectively expand the scope of collected data as necessary.
‘We saw this as not only one of the best services available for compliance purposes, but as an approach that would move the whole market forward and add real value to the clinical process.’
PhIN will publish the first performance measures for individual consultants in private practice from summer 2018.
What does the future hold?
As well as the benefits of collecting and publishing PR o Ms, researchers in several disease areas have started to publish evidence for the specific clinical benefits of doing so, which, we believe, will only make the scope of their use grow.
For example, in June 2017, Basch et al presented evidence of the survival benefit of electronic PRoMs measurement for patients with advanced solid tumour cancer at the conference of the American s ociety of Clinical oncology.
In the work, 766 patients with advanced cancer were randomised to electronic PRoMs monitoring during routine chemotherapy or a comparison group undergoing usual care. The study group had a median survival of 31.2 months compared to 26 months – or five
We saw this as not only one of the best services available for compliance purposes, but as an approach that would move the whole market forward and add real value to the clinical process MaTT JaMes
months less – in the usual care group.
To put that into context, this benefit was greater than for all but one of seven drugs approved by the us Food and d rug Administration for advanced cancer in 2016. And in a context where drugs that increase life expectancy by weeks can cost thousands of dollars, this approach clearly presents a highly costeffective additional tool in the fight against cancer.
This research prompted Jane Maher, chief medical officer of Macmillan, one of the largest cancer charities in the uK, to Tweet: ‘Routine collection of patientreported outcomes improves survival of patients with advanced cancer – so let’s get on with it.’
Funding shift
Another shift we expect to see as a result of these new approaches is changes to the traditional fee-forservice funding model of the independent sector to one where demonstrable quality, in terms of the data a provider can produce to support it, is tied to the payment it receives.
This shift to so-called ‘valuebased healthcare’ is widely anticipated as an antidote to spiralling health costs and variable quality, and it also provides opportunities
for public systems to become more efficient and for the best private providers to thrive, being better re-imbursed for excellent activity and able to market that excellence to patients and payers to grow their market share.
In his 2014 book, The Second Machine Age , Erik Brynjolfsson noted that: ‘In the next 24 months, the planet will add more computer power than it did in all previous history.’ As rapid as the rise of the internet has been, health systems have been slower to embrace the potential of new technology than other industries.
But that is changing and, as it happens, the potential is being realised for systematic digital outcomes measurement to transform patient care, clinical decisionmaking and service delivery and allow health systems to improve clinical quality while making costs more sustainable.
ultimately, the aims of Boston surgeon Ernest Codman, widely acknowledged as the pioneer of outcomes measurement, will be realised when, as he wrote over a century ago: ‘Every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful and then to inquire, “if not, why not?” with a view to preventing similar failures in the future.’
The mandating of PhIN and thus the collection and publication or real long-term outcomes data is not only a point of change, but also brings huge benefits to patients and doctors alike.We believe it will increasingly help to show the real value and achievements of the uK independent sector.
Dr Tim Williams is founder and chief executive of MCO (www.myclinicaloutcomes.com), having previously worked in the NHS as a doctor and healthcare management consultant. He founded MCO in 2011 to help bridge the gap in patient-centred data available to inform clinical care.
He undertook Prof Michael Porter’s Value-Based Healthcare 2014 seminar series at Harvard Business School and is committed to addressing the need for cost-effective digital technology to support the widespread adoption of value-based healthcare.
MCO is a technology affiliate of ICHOM and is accredited by PHIN.
Matt James, chief executive of PHin
mEdico-lEgAl AdvicE
The UK remains a popular destination for international patients seeking expert private healthcare. Dr Rachel Birch (right) outlines steps to minimise the risks in treating patients whose first language is not English
Lifting the language barrier
Ev E r Y YEA r , thousands of patients visit the UK seeking healthcare. 1 Overseas patients form, on average, 2.8% of private hospitals revenues.2
Medical tourism is not new; cases date back thousands of years to when patients trekked from all corners of the Mediterranean to consult the healing god Asklepios in Epidaurus, a city in ancient Greece.3
International patients often seek healthcare in a country where they don’t speak the language, so it is important to consider the possible risks and take steps to make the patient’s care as safe as possible.
Reducing the risks
The GMC emphasises in Good Medical Practice that effective communication is key.4
It states: ‘You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.’
The gold standard when consulting with nonEnglish speaking patients is to have an accredited professional interpreter present. This reduces the risk of misinterpretation and mistakes.
If an interpreter is not present, you could consider a phone or video interpretation service.
When providing written information to patients, including details of procedures or aftercare, this should be translated into the patient’s first language.
Using interpreters
When using interpreters, always look at the patient and not the interpreter − this allows you to monitor the patient’s body language and nonverbal cues, and alleviate any anxiety. Using an interpreter may mean the consultation is longer than usual and steps should be taken to facilitate this.
Questions should be asked in plain English. r emember, some English phrases could have more than one meaning, so if the patient appears confused, try asking the question in a different way. When taking patient consent through a translator, it is particularly important to ensure they are
Remember, some English phrases could have more than one meaning, so if the patient appears confused, try asking the question in a different way
With the patient’s consent, you should provide all relevant information to ensure their care is not compromised. Prepare a detailed discharge letter, incorporating the information needed to continue treatment without risk. This letter should be translated into the patient’s language.
fully aware of the risks and benefits, especially for complex decisions.
Family members as translators
For patients attending with relatives acting as translators, there are potential issues to be aware of. Before starting, ensure the patient is happy to discuss their symptoms in front of their family member.
Some patients are reluctant to disclose certain information, like their sexual history or psychological symptoms. If in doubt, offer a translation service.
Make it clear that the family member must translate word for word what the doctor and patient say.
Family members may add their own personal opinion and information to the consultation. If they wish to do this, suggest they do so separately, after taking a history from the patient, and ensure they translate this information for the patient too.
If you are concerned that the family member is withholding information or coercing the patient, you may decide an independent translator is warranted.
It is not appropriate to use young children as translators and you may need to assess an older child’s capacity to ensure they are aware of their responsibility to translate accurately.
Finally, ask the family member to inform you of any phrase they feel they cannot translate, and document the presence, name of the translator and the discussion.
Hand-over arrangements
Patients that have undergone a procedure in the UK may be keen to quickly return home and be cared for by their local doctor, once safe to do so.
The GMC4 states that all relevant information should be shared with colleagues when handing over the care of your patient.
The simplest way to ensure the patient’s doctor receives this information is to provide the patient with a copy of the letter and ask them to give it to the doctor. This minimises the risk of any inadvertent breach of confidentiality or interception of email.
But patients may ask you to send a copy electronically to their doctor. Confidential personal information should be anonymised wherever possible. Emails should be encrypted and password protected for security. You should ensure the address to which you are sending the information has appropriate security measures.
You should also follow guidance from the Information Commissioner’s Office.5 For countries outside the European Economic Area – with a few exceptions – personal data must not be sent, unless that country has adequate level of protection for the rights and freedoms of data subjects in relation to the processing of personal data. Your medical defence organisation can provide further advice.
Dr Rachel Birch is a medico-legal adviser at Medical Protection
References
1. The truth about health tourism –Independent article, 24 Oct 2013.
2. King’s Fund: Commission on the future of Health and Social Care in England.
3. Epidaurus: Wikipedia.
4. GMC: Good Medical Practice (2013)
5. Information Commissioner’s Office: What does the Data Protection Act say about sending personal data outside the European Economic Area.
Enhance your value
Maximise the value of your premises and minimise the time required to do so. Adam Tait (right) suggests how
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MaxiMising ‘value’ is a common objective for most practitioners in one way or another. ‘ value’ can include the value provided to patients. Or it could be the economic value of the practice and its income stream or the value of the practice ‘brand’ and the exposure received. Whatever form the ‘value’ might take, the premises from which the practitioner practises are a major influence in maximising the value – both to the patient, the practitioner and the staff.
Perhaps second on the list of a practitioner’s concerns is minimising the amount of time they spend doing things they would rather not be doing. How can you manage time better? How can you have more time to see patients? a gain, practice premises can play a major role here: how the practitioner occupies the property they practise from can either save or add a huge amount of extra time.
Of course, it is often a balancing act between maximising value and minimising time spent undertaking those tasks we would prefer to avoid. The ideal scenario for most practitioners – and indeed most people – would be to maximise the value in as little time as possible, leaving more
time to take that trip abroad they’ve been dreaming about for the last few months.
But while we might strive for the ‘maximum value–minimum time’ model, the reality tends to be closer to either ‘maximum value and maximum time’ or ‘minimum time but minimum value’.
How can you maximise value and minimise time doing ‘less desirable’ tasks?
The way in which you occupy your practice premises may have a significant bearing on this – and we will consider the following options in support of this goal: Paying for a private consulting room on a sessional basis; Buying and occupying property as an owner/occupier – by means of either buying new premises specifically for your practice or converting property you already have. aside from the initial capital outlay required to buy or convert a
new property, many of the considerations we consider below will apply equally to either scenario; Occupying as a tenant under a lease.
private consulting room: minimising time but limited ability to maximise value?
Paying for a private consulting room is arguably the least timeconsuming option of the three arrangements.
The set-up time is minimal, as all essentials should be provided by the landlord, meaning you simply need to negotiate the terms of the arrangement and turn up. You are able to use the room at the times agreed and as soon as you’ve finished, you leave and the room reverts to the landlord.
The landlord deals with maintenance and repair issues – and probably provides most, if not all, of the equipment you need. They should ensure the premises
are fit for purpose throughout your period of occupation – and you don’t have to go through the process of selling the property when you want to leave.
a ll in all, paying for a private consulting room tends to be the most low-maintenance and least hands-on arrangement of the three mentioned above.
But because the landlord retains ultimate control of the room, you have limited ability to maximise the value of it. You can’t renovate or even redecorate it to project the brand or image you want to provide and you might not even be able to re-arrange the room to better suit your patients’ needs.
You certainly won’t want to expend significant money on it –and as you won’t have anything to sell when you ultimately leave, you will have lost the opportunity to provide for a nice capital injection for your retirement fund. so how else can you try to max-
imise the value of your practice when you pay for the use of a private consulting room?
Top Tips FoR mAximising vAlUE
decide where you want to practise
l ocation can say a lot about a practice. There are premium consulting rooms and there are lowerbudget consulting rooms. if your ‘image’ is an important marketing tool for your practice, the extra cost for a room in a premium location might be worth it in order to maximise the value of your brand in the future.
Keep overheads low While you will have limited ability to develop the premises and project your brand as you don’t own the property, you might more than make up for your lack of control if you have negotiated a good ➱ p34
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Jamie Foster
Tania Francis
deal on the fee for the room and you don’t have to pay for many other costs towards the upkeep of the building or equipment.
invest your saved time wisely
The time you save from this arrangement can be used bringing in more patients through investment in marketing, thereby bringing in more income.
owning your own premises: maximising value and maximising time?
at the opposite end of the spectrum from paying for a private consulting room is owning your own practice premises. This is a very hands-on approach to dealing with the property from which you practise.
While there is, of course, an initial capital outlay if you buy a new property, owning your own premises provides you with the greatest
You can develop the practice to your specification, which will enable you to project the image you want
opportunities to maximise the value of your practice.
From the outset, you can develop the practice to your specification, which will enable you to project the image you want.
You can also raise money from it, both income by granting a lease to another practitioner, and ultimately, capital, by selling the property at a future date.
However, all of this takes a lot of time. i n the first instance, you would have to acquire and perhaps convert the premises, which could include the requirement to secure planning consent.
and ongoing maintenance and repair of the premises can be both time-consuming and costly. i t would be your responsibility to ensure the premises are fit to practise from and up to regulatory standards.
But there are ways to reduce time spent on these tasks and further maximise value.
You should be aiming to ‘sweat the asset’ and allow any spare space to provide you with added income when not in use by you
Top Tips FoR mAximising vAlUE
Buy the right property is the location right? Make sure you’ve carried out appropriate due diligence before buying. is the property structurally sound; is it free from contamination?
is it preferable to spend more on acquiring a property which has already been converted for practice use and only needs minor tweaks or would you prefer the challenge of tackling the complete modification of a building which you can redesign exactly to your own specification?
consider ways to make an income
Can you grant a lease of part of the premises – a designated room – to another practitioner to receive a regular income? a lternatively, could you allow a practitioner to use a consulting room at your
practice for a regular licence fee? You should be aiming to ‘sweat the asset’ and allow any spare space to provide you with added income when not in use by you.
project your brand
Make sure the property projects the image you want to project. Make sure it is fit for purpose and in the best condition it can be. not only can this be a marketing tool and help bring in more patients, but it may also increase the value of the property when you choose to sell.
occupying as a tenant under a lease – the middle ground?
Occupying as a tenant (other than in certain areas of london) is not an overly common way for private practitioners to occupy their premises. it is something of a middle ground between the two options above.
‘Middle ground’ is probably seen
by many practitioners as a negative – it neither maximises value as much as owning your own property, nor saves as much time as paying for a private room on a sessional basis.
But the reverse may be equally true. a tenant under a lease has more ability to maximise value than someone paying a licence fee for a room on a sessional basis, and is more likely to minimise time spent on administrative tasks than an owner/occupier. it is certainly an option worth considering.
Top Tips FoR mAximising vAlUE
negotiate the lease to be as flexible as possible
unlike paying for a room on a sessional basis, a lease will usually allow you to redecorate and make alterations to the property with or without the landlord’s consent. This allows you to maximise
your brand and project the image of your choosing in a similar way to an owner/occupier.
Remember, a lease can have a capital value
While you won’t be able to ‘sell’ a short lease for as much as you could sell a freehold or long leasehold property, a lease does create a legal interest in the property and therefore has a value.
a lease can usually be assigned to a third party and may attract a significant payment. Furthermore, the security of tenure it provides in the premises should enable you to maximise the value of your practice at the point of sale.
consider ways to make an income
Many leases will allow you to grant a sub-lease to share occupation with or to grant a licence to another practitioner – all of which can generate an income.
How can you maximise the value of your practice and minimise your time?
Premises are a key consideration for any practitioner and can be a major way of maximising the value of your practice.
The aim for most practitioners is to practise from premises in a way which strikes a balance between maximising value and minimising the time required to do so.
i f you are considering starting out in private practice or relocating from your current premises, you should carefully consider how you wish to occupy the new premises from which you will practice. a nd even if you are already occupying premises, this article has hopefully highlighted the issues you could consider to enable you to maximise the value of your practice.
Adam Tait is a solicitor at Hempsons Solicitors
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PPUs face rivalry and opportunity
Philip Housden (right) continues his series reviewing the NHS private patient unit (PPU) sector across all regions of England and the rest of the UK by looking at the eight NHS trusts delivering acute care services to the northern home counties of Oxfordshire, Buckinghamshire, Bedfordshire and Hertfordshire
Figures F rom the published 2016-17 annual accounts for this group of trusts show that total private patient revenues grew by £0.9m (4.2%) to reach a new record of £22m (Figure 1).
This represents 0.77% of these trusts’ total revenues, a percentage that has remained static for the past several years. The combined national average outside of London is 0.5%.
These eight acute trusts can be divided into three groups based on analysis of private patient revenue growth and by percentage of overall trust patient incomes (Figure 2):
Growing: Four trusts have grown by more than 10% in the past three years and private patients now account for over 0.6% of total trust revenues. There is a concentrated cluster of trusts that are growing private patient earnings in oxford, Berkshire and Bedfordshire;
Static: Two trusts have held steady through recent years: Buckinghamshire Healthcare and east and North Herts;
Falling: The final group is made up of the two trusts that have between them £700k a year lower revenues than in 2014-15.
o xford u niv ersity Hospitals. oxford has developed local success through utilising specialty capacity across the four main hospital sites.
The brand is to be further enhanced by a stated aim of partnering with the m ayo Clinic in the us to open a London base in early 2019. oxford is ranked 13th highest private patient earner within the NHs and third outside London (Figures 3 and 4).
Crowded market
royal Berkshire has grown by 35% to £3.1m in 2016-17 despite operating in a crowded local independent hospital market by principally concentrating on complex surgery and niche services that the local competitors cannot provide.
This growth has been achieved without designated PP u beds. These include cardiology, complex orthopaedics and interventional radiology. The trust’s incomes have been adversely affected through loss of the radiotherapy and oncology market share due to the new genesis centre in Windsor. The trust has mothballed plans to build a new PPu while an updated site and service strategy is completed.
Four trusts have grown by more than 10% in the past three years and private patients now account for over 0.6% of total trust revenues
0.86% of turnover, albeit from a low value base. Total revenues have grown from £845k to £1.43m in the same time, and without a PP u , this represents capture of diagnostic and lowvolume specialty activity. in early 2018, the trust opened Bridges Clinic for private patients, offering a range of medical specialties, including endoscopy, cosmetic procedures, diagnostic imaging and physiotherapy.
Luton and Dunstable principally delivers private patient services from the Cobham Clinic 13-bed PPu. The trust has enjoyed year-on-year growth for the past six years, reaching a new high of £2.15m income last year. However, this revenue growth has remained stubbornly at just under 0.8% of turnover and has not represented real-terms growth.
Long-term arrangement
Buckinghamshire Healthcare delivers private patient services from both the Amersham and s toke m andeville sites and has reviewed the market potential for private patient growth at both.
The top trust in this month’s analysis by both overall earnings and percentage of turnover is
At Amersham Hospital, the trust has recently sought to work more closely with the B mi Chilterns Hospital, located on campus, with the intention of improving the financial and serpRivATE pATiENT
Bedford Hospital has produced private patient revenues growth in real terms every year since 2011-12, growing from 0.43% to
There may well be opportunities for all these trusts to examine PPU growth, particularly in complex procedures
vice returns to the trust from that long-term arrangement.
east and North Herts offers private patient services across the Lister Hospital in s tevenage, m ount Vernon in Northwood, m iddle sex, and the new Q eii Hospital, Welwyn.
The earnings of the trust have been in marginal decline to just under £3.5m in 2016-17 when they dropped under 1.0% of total revenues for the first time. The potential for growth is adversely impacted by the co-location of Bmi Bishop’s Wood Hospital on the mount Vernon site.
Ongoing decline
The West Hertfordshire Trust Hospitals in Watford, st Alban’s and Hemel Hempstead sit in an attractive market for private patients, but, as a result, they face competition from spire’s Bushey and Harpenden hospitals and a range of other providers.
The financial impact has been an ongoing decline to only £408k revenues in 2017-18, representing a new low of 0.14% of turnover.
milton Keynes similarly has not invested into the PPu market, and earnings are stuck at £0.5m turnover and 0.3% of total trust revenues.
The potential to break into the attractive cancer market was thwarted with the opening of the local g enesis linac and chemotherapy centre around three years ago. The local potential for a PPu has now further receded with spire’s ambitions to open a £70m private hospital in the city in 2020. it is recognised that the northern home counties are a strong market for private patients but also an attractive market for the independent hospital groups.
Present trust earnings are therefore mainly a function of the level of investment in capacity that a trust has made.
g iven the ageing population, increasing patient safety agenda and the limits on range of services delivered by private hospitals, there may well be opportunities for all these trusts to examine PPu growth, particularly in complex procedures.
Next time: the South-west
Philip Housden is a director of Housden Group
Figure 3
Figure 2
Figure 4
Figure 1
Suzie Grogan (below) continues her series tracing the development of the medical profession. This month: the rise of the general practitioner
The Medical and Physical Journal of 1809 first refers to a ‘general practitioner of medicine’ and, in 1813, elaborated on the description, stating that a GP was a ‘general practitioner in medicine surgery and midwifery in which the apothecary would be included’.
The term GP came into common usage between 1810 and 1830, although before that medical practitioners in towns and villages were often still designated as surgeon or apothecary.
Once doctors, or surgeon-apothecaries, began to charge for their service rather than simply the medicines they dispensed, their status depended on how they required their bills to be settled.
Practitioners requiring swift settlement in cash, rather than payment by annual account, had a lower social standing, although this more ‘lowly’ position was often as a result of the generosity of the doctor towards his community; cash payers often being the poorest patients.
Similarly, those who worked for Friendly Societies or attended workhouses were unlikely to be considered ‘gentlemen’. Men could struggle to make a living, while others, working only for wealthy clients, were received into polite society.
however, at the very top, even narrower distinctions were made. i n 1890, l ady Warwick pointed out that ‘doctors and solicitors might be invited to garden parties, though never, of course, to lunch or dinner’.
as the professional standing of
GP or surgeon-apothecary of the time, it is hard to reconcile the two. a ppointments under the Poor law were very important as a source of income, not just to the newly qualified, but also as a regular source of supplementary income to the more established surgeon-apothecary.
Before 1834, when the new Poor l aw was introduced, there were around 15,000 parishes, each of whom could appoint a doctor to serve the population. Men could, therefore, represent more than one parish, and thereby increase their income.
Gradual reduction
the surgeon-apothecary grew, so did the numbers in training and, the profession became overcrowded, causing a drop in the fees a doctor could charge.
The i ndustrial Revolution changed the ways in which the medical profession was required to work. at the beginning of the 18th century, around one in five of the population lived in an urban area, but by the middle of the 19th, more than 50% were town dwellers.
Extending territory
Those working in a country practice often had to travel long distances to attend their patients and transport was generally on horseback or simply on foot. Their motivation was increased by the possibility that, by extending their territory, they could gather in additional patients, even ‘stealing’ them from competitors.
Travel might also be increased if a practitioner developed a specialism for which he was well known, and was thus consulted, even by competitors, at a greater distance.
The life of any ordinary practitioner was a difficult one and quite unlike the working life of the most eminent physician to wealthy patients, who could relax in a carriage or, even if exertion was required, could at least expect to be well paid for his trouble. cartoons of the period concentrate on these elite physicians who would treat their hypochondriac patients with unnecessary medicines and charge them exorbitant fees for the privilege. if looking closely at the regular
paying patients, perhaps sited in a large town or port, was the very bottom end of the medical market. it seems the slightly more fortunate practitioner would treat both the working-class and middle-class population in his area, supplementing his income with a Poor law appointment.
even better was the suburban, middle-class practice with a range of appointments or an area without competition.
Some felt themselves sufficiently well connected, or well qualified, to anticipate a more prestigious appointment as surgeon to one of the burgeoning number of county hospitals.
Some held appointments with as many as 12 different parishes, but the new Poor l aw caused the gradual reduction of these parishes, as they were amalgamated in 600 unions, each with medical districts.
The surgery that relied on cash-
dr J.G. crosse, a GP with a reputation in obstetrics, spent many years fostering the patronage of one d r Rigby before being appointed assistant surgeon to the norfolk and norwich hospital at the second time of trying.
An eighteenth-century painting showing a reluctant patient being prepared for amputation in the days before anaesthesia was invented
even then, his private practice did not grow as quickly as he had hoped, but after three years he was promoted to surgeon and had a successful career as a doctor specialising both in obstetrics and the treatment of the ‘stone’.
This system of patronage as a route to success was, as is usual in any career, a divisive one and there was concern that skill had little to do with success in gaining a lucrative position at a hospital.
i t was one’s connections that held the most weight, and if they involved family, so much the better, because in some areas a post was held by generations of the same family.
elections required a significant amount of work on the part of the applicant for the position, and many continued their training while they waited – often as assistants in positions similar to that of the present day junior doctor –for a vacancy to become available and while they tried to build up a sufficiently lucrative private practice.
Building a successful general practice
For a ‘general practice’ to be successful, it was necessary to build up a significant source of income from private work treating paying patients. This was often not just related to a medical man’s standard of living, but also mattered as an indicator of social standing.
Other sources of income were available to the man determined to make his practice financially viable. These were the ‘appointments’ available in the local area and included that of medical officer to ‘clubs’ – for ‘medical benefit’ – factories, and mines. The most important were appointments under the Poor laws.
irvine louden, in Medical care and the General Practitioner , has undertaken some analysis of the impact of the 1834 Poor law act on medical practice, and his work indicates that it was not only the act itself that changed the environment for doctors and their patients, but the early nineteenth century’s hardening of attitudes towards the poor and the standard of proof they were required to meet when claiming relief.
i n a chilling analogy to the changes to the welfare system in
the Britain of 2016, the 1834 Poor law might refuse relief to a man recently operated on for an ulcerated tumour in his leg, the necessary walk to the hearing which was deciding his claim counting against him: if he could walk that far, he could work.
i rvine l ouden queries l indert and Williams’s estimates of earnings in occupations over the period covered in this book, largely because they underestimate the earnings of a successful surgeon-apothecary GP in the late eighteenth century, setting the average salary at around £88.
Better off
Their suggestion that earnings went up significantly in real terms is based on that figure when, louden claims, earnings in excess of £300 were quite feasible. Therefore, it is more likely that average earnings in this branch of medicine remained in line with increased costs at best, and were more likely to have gone down.
The eighteenth-century surgeon-apothecary was almost certainly better off than his general practitioner counterpart in the nineteenth century. certainly, in The Parent’s Handbook, published in 1842, the warning was given: …there is no profession in which it is so difficult to make a beginning than that of medicine, and there is much truth in the saying that by the time when a physician earns his bread and cheese, he has no longer the teeth to eat them with.
a gain, l ouden suggests that this significant turnaround in for-
There is much truth in the saying that by the time when a physician earns his bread and cheese, he has no longer the teeth to eat them with
tunes, despite the speed with which medical care was advancing, was the ‘excess of medical practitioners on market forces’, and that ‘excessive competition’ affected what a man could earn even under Poor law legislation.
incentive scheme
i t seems clear from research undertaken by different researchers at different times that, before 1834, the parishes offered a payment scheme that incentivised doctors to treat the poor with care. They could bill the parish for individual aspects of the care provided and in many cases, the fee would be comparable to that charged to a private patient.
a professional doctor might be called in for the more complicated cases, and in some areas, where the setting of a broken bone might involve weeks out of work, the parish might be willing to provide the equivalent of ‘sick pay’ for the weeks of inactivity.
in some areas, caution prevailed and to prevent weeks of payment to patients recovering after a botched job, the local doctor would be paid a part fee – the whole to be paid when treatment was successful.
a generous parish might pay for the alcohol necessary to dull the pain of an amputation, and then the wooden leg necessary to get a patient walking.
There was little oversight of the care provided, but if the parish were a small one and a doctor’s reputation hard won, there was little reason to scrimp, even though the treatment of wealthier patients may have been undertaken more carefully, with an eye to increasing social stature.
Parish salaries were around £10£15 a year, so to have responsibility for more parishes meant the sums could add up, and with addi-
tional payments for setting broken bones, for example, a parish could pay as much as £100 a year. h owever, in changing times, this benevolent attitude was not to last. despite much blame being attached to the Poor law of 1834, it seems that was but a crystallisation of a change in attitudes towards the poor that began in the second decade of the century.
Reduced care
d espite, or perhaps because of, the rising numbers of medical students qualifying, it was possible for parishes to put the position of surgeon out to tender and take the lowest bidder, often over the much more experienced local man.
The standard of care available to the poor was reduced along with the salaries, and the belief that the poor ‘got what they deserved’ became more widespread.
The replacement of around 10,000 parishes with 2,500 ‘Unions’ (of parishes) resulted in a significant reduction in the number of medical officers employed and a drastic drop in the costs of providing medical care to the sick poor. The union man had four or five times as many patients under his care than the old parish surgeon had for the same money.
But increased workloads and reduction in salary still did not deter men from applying for vacant positions, and it was still seen as an important steppingstone in the career of a young man keen to build up a successful private practice. Many held their positions for only as long as it took to build up a sufficient base of fee-paying patients or more attractive appointments.
The new Poor law required doctors to provide dressings and drugs within the salary they were paid, so it was likely that some treatments might have been withheld from the poorest. Travel expenses could not be claimed separately, so many union doctors never travelled to the further reaches of their parish and patients felt less inclined to call in a stranger in any event. Medical treatment would inevitably suffer. Many of the doctors employed in the role of surgeon to the parish were well-meaning souls who wanted to treat all their patients
An 18th-century apothecary at work in his shop
with equal care; but the union system, which might reduce the payment per patient to as little as 7d per case after expenses made such benevolence impossible.
indifference to patients l ocal Boards were not even responsible for assessing the number of surgeons necessary to adequately cover their populations. That decision was taken higher up – in london – despite there being a ready pool of applicants willing to take on the job, thus more experienced men were undercut and priced out of the market. irvine louden uses the town of huddersfield as an example of the total indifference to, and scorn felt for, both patients and surgeons by a Board of Governors keen to squeeze every penny of value from their appointees. in 1843, a Mr Tatham was medical officer to the northern division of the h uddersfield Union. The
salary was £40 a year and Tatham was required to pay for any medicines he prescribed. i n his first year, he made more than 1,600 journeys and paid for drugs to a total value of £37 18s 7d. Thus his profit was around £2 a year.
When he requested a pay rise, he was refused the requested sum of £70, being allowed just £50, which rose gradually to £80. Tatham was not to enjoy the benefits of any increase, however. The building of a fever hospital and Tatham’s responsibility for admissions to it left him in the red. h e was, in effect, subsidising the union, which, when Tatham asked for an additional salary to cover the costs, turned him down flat. he sued the board, but lost on a technicality, frustrating both judge and jury who considered the board’s treatment of their medical man to be totally wrong. apart from the necessity to gain experience and the willingness of
the newly qualified to take on these roles, what might possess a man to accept the fact that he must be overworked, underpaid and frustrated in any attempt he might make to improve the lot of the poor?
There was the possibility that the position might lead to better connections and a more respected position in society and one’s work ethic could not be queried. in other areas, a man might take on the job to ensure he was free from competition from other general practitioners in his areas. exclusivity being such a valuable commodity in a practice – he would do it simply to make sure no one else could.
☛ Adapted from Death Disease & Dissection – the life of a surgeon apothecary 1750-1850, by Suzie Grogan. Pen & Sword Books Ltd, ISBN 1473823536, Price £12.99
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Collecting cash from self-payers
Latest
figures show self-pay patients now account for a third of most consultants’ income. And this source of earning for independent practitioners continues to be the fastest-growing sector in the private health market.
Findlay Fyfe shows how to make sure you do receive the money due to you for your work
Many consultants think of private practice as the private medical insurers’ market. But in reality it is not that simple.
our analysis on invoices raised through 2017 shows the private medical insurance market accounted for 55% of the total invoices raised.
the other 45% was a mixture of other organisations such as embassies, solicitors (medicolegal) and other commercial organisations.
t he largest share of the nonprivate medical insurance invoicing was self-pay, currently accounting for over 32% of the total invoices raised.
t he figure is an average taken across our 1,000-strong consultant base and can be much higher depending on the specialty and type of practice. In fact, for some of our clients, self-pay is the largest part of their practice.
so what are the main factors for the average of 32%?
insURAncE PoliciEs to maintain and control premium costs, policies have elements which are not covered by the policy. t his will be due to excesses, limits on the policy benefits and co-share policies where the patient agrees to pay a proportion of each invoice.
ovERsEAs PATiEnTs
Particularly for consultants based in central london, this has been a part of many practices, with tourists from outside the uK coming for private health treatment.
nHs
of course, the vast majority of the public do not have a medical insurance policy. But with the pressures that are currently affecting the nHs, this is leading an increasing number of patients to turn to the private market for treatment.
sElF-PAY
While there has always been a market for patients who have
sought private healthcare on a ‘pay as you go’ basis without the benefits of a private medical insurance policy, this has grown substantially in recent years and is expected to continue to grow. Why is this important to your practice? simply that you need to know the statistics of your practice so you can fully understand and manage the billing and collection process.
unfortunately, over our 26 years of experience at Medical Billing and collection, we find this is seldom the case. there can be a lack of understanding about how to chase the practice debt, if indeed it is chased at all.
Typically, the lack of a robust system to deal with the self-pay patient can lead to uncollected debt that can amount to a significant figure
and there can be many reasons for the debt. typically, the lack of a robust system to deal with the self-pay patient can lead to uncollected debt that can amount to a significant figure.
a practice needs to deal with each sector of self-pay separately and I have highlighted below the main groups.
ovERsEAs sElF-PAY
When seeing an overseas self-pay patient, you will need to firstly be clear as to your charging structure so it is 100% clear to the patient what the full costs of the treatment will be.
For collecting the money, consider if you should collect the payment in advance. If the patient returns to his home nation, it may be very difficult to recover the money.
at MBc, we deal with this regularly and collect payment in advance of treatment.
It is possible that the hospital may agree to collect payment on your behalf, although you will need to make sure your invoice is sent out in a timely manner to the correct department or contact to ensure you actually get paid.
UK sElF-PAY
Most consultants’ practices will have an element of u K self-pay patients. therefore, in line with the c ompetition and Markets authority’s article 22, you should have a price list so the patient is fully aware at the extent of the costs of their treatment. this will ensure the patient is expecting a bill on the day of treatment or shortly afterwards.
We have a variety of payment methods available, payments card, cheque and transfer and we can, of course, also take payment on the day or even in advance of the treatment.
If you cannot collect on the day,
you will need to ensure you have a robust system in place to ensure the patient is chased for the debt after an agreed time o n many occasions, these will need to be on a regular basis until payment is received.
sHoRTFAlls s hortfalls on insurance policies can be the largest volume of selfpay invoices for many practices. they are also the hardest to collect.
Why so hard? s imply because many patients do not fully understand the extent of cover their policy gives and expect the full cost to be covered by their insurer. In our experience, many simply ignore the invoice as they feel this should be or is being addressed by the insurer. Without following this up, the invoices will remain unpaid.
t his regularly leads to a situation where the patient starts to contest this with their insurer. Part of what we do is to liaise between patient and insurer to make sure that it is clear where the burden of debt lies.
o nce this process is complete and the patient accepts their policy’s limitations, then payment can be taken.
t he self-pay market by its nature will continue to come under pressure due to the continued economic situation. to manage this, you will need to set up a robust system as I have outlined to ensure you manage and control your debt, otherwise this will continue to rise month on month.
the alternative is to seek out a professional billing company with both the expertise and the all-important time to take away the problem and improve cash flow.
Findlay Fyfe (below) is managing director at Medical Billing and Collection
Investing’s gender gap
Dr Benjamin Holdsworth (below) has some wise words to ponder about the inequality of investing for the future
The gender pay gap is finally receiving the media interest the subject deserves, but according to recent research, women are also investing significantly less than their male peers.
The latest figures released from hM revenue and Customs point to a ‘gender investment gap’.
In 2011-12, the difference between the amount men and women earned from investment income was £9.6bn. In 2015-16,
the gap had increased to £24.1bn.
The taxman’s annual Survey of Personal Incomes has revealed that women with a taxable income of £100,000 or more made £10.7bn from their investments in 2015-16.
Men in the same income bracket made £34.7bn. Investment income includes that received from interest on savings, dividends and property.
The data also showed a growing
gap between the pension income received by both genders. In 2015-16, women received £1.3bn in income from their pensions, compared with £6.6bn received by high-earning men. The gap stood at £3.8bn in 2011-12 – a jump of 39%.
Earn more
Commentators point to the fact that, historically, men have tended to earn more, have not
changed to part-time patterns nor taken career breaks to raise children or provide elderly care. Statistics show that women are also far more likely to retire early for family reasons.
Another issue which can leave women underfunded in retirement is that pensions are often overlooked in divorce settlements – seven out of every ten couples separating fail to consider pensions and yet it is likely
to be the second biggest financial asset after property.
With the topic of equal pay now being addressed, there is a suggestion that the tide will also turn for women being able to plan their retirement incomes more successfully.
h owever, financial behaviour provides a further hurdle. A recent Canadian study has shown that gender has a strong influence on the way in which men and women plan for retirement.
While evidence confirms both sexes share the same dreams of good health and more free time, their planning for later life can be remarkably different.
less confident
According to the research, women are generally less confident in their knowledge about finances and financial products than men. More men than women have a clear financial plan for the future (61% as opposed to 52%).
When it comes to investing, men are more likely than women to take risks. They are also twice as likely to describe their investment style as ‘aggressive’, with women more likely to say they are ‘conservative’.
This readiness to adopt an acceptable level of risk may allow men to achieve higher growth in their retirement savings.
Women were found to be more likely to equate investing with the risk of losing money than men and are more susceptible to warning messages on investment products that highlight these risks.
Some 44% of women view investing as a ‘calculated risk’ compared to 66% of men. Only 7% have topped up a stocks and shares ISA compared to 24% of men, and 35% of women would not invest due to the chance of losing money as opposed to just 18% of men.
When questioned, more women reported a general lack of financial confidence with a focus on day-to-day priorities rather than long-term security.
Men’s eager engagement in financial planning is not always an entirely good thing. Studies have shown they are more likely to closely monitor their finances, updating their financial plan too often.
Women were found to be more likely to equate investing with the risk of losing money than men and are more susceptible to warning messages on investment products that highlight these risks
Women’s steadfast approach to finances and a tendency to hold the course may have helped during turbulent economic years, as they are less likely to react negatively to market fluctuations.
Hopelessly lost
When it comes to taking advice, we all know the anecdotes about men not asking for help with directions or d IY matters and often getting hopelessly lost with both.
With finances, men are also more willing to ‘go it alone’, believing they can navigate complex calculations without the help of an expert. Only three in ten were prepared to admit they might require some assistance.
Clearly, both sexes could improve the outcomes of their retirement by adopting each other’s positive behaviours. This is where a good financial planner can help – guiding all investors to replace emotional, personalityled investing with sound, rational decision-making.
Dr Benjamin Holdsworth is a practising medic and director of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS.
The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.
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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When you have to snitch on patients
Issues to do with the Driver and Vehicle Licensing Authority take centre stage this month. Dr Catherine Wills (right) answers more readers queries
Dilemma 1 What to do about his fainting fits?
QA patient came to see me reporting that he had suffered unexplained syncope earlier in the week.
I referred him for tests and advised him to stop driving and inform the DVLA. He was reluctant but, after discussion, I thought he had agreed.
Today he returned for the test results. He told me he had chosen to wait and see if he had another episode before deciding whether to stop driving.
So far, he has not, and he has not informed the DVLA either. I couldn’t persuade him to stop driving and he didn’t accept my offer of a second opinion.
I told him that his insurance cover may be affected and that I might need to tell the DVLA myself. He still refused, saying that he would lose his job.
What should I do now?
ADoctors have a crucial role in road safety and it is key to be aware of the UK standards on fitness to drive.
You were entirely right to advise the patient to stop driving – unex-
plained syncope is a condition that must be reported to the DVLA.
Doctors are responsible for advising patients about the impact of their condition on safe driving ability and are responsible for advising patients on their legal requirement to notify the DVLA of a relevant condition. A list of relevant conditions can be found in the updated document, Assessing fitness to drive – a guide for medical professionals (DVLA, June 2017). Now you need to decide whether to inform the DVLA without patient consent. The GMC provides guidance in Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA (2017). A further syncopal episode while driving could well put others at a risk of death or serious harm. If the patient continues to drive against your advice, you should contact the DVLA promptly and disclose any relevant medical information, in confidence, to the medical adviser.
You should tell your patient in writing when you have contacted the DVLA and make a note in their records, including an explanation of your reasons.
You can call the DVLA to discuss the patient in confidence with a DVLA medical adviser, but DVLA require written confirmation. As with any disclosure without
A patient came to see me reporting that he had suffered unexplained syncope earlier in the week
consent, you should keep your disclosure to the minimum necessary for purpose. Under no circumstances does the DVLA reveal the source of any notification to the licence-holder.
The medadviser email address (medadviser@dvla.gsi.gov.uk) is secure, but the DVLA will only accept emails from secure (nhsmail, nhs.uk) email addresses.
The patient’s licence might have been revoked immediately. But if the doctor becomes aware their patient continues to drive, your options are to contact DVLA again, at which point it is able to involve the police or to directly approach the police yourself.
So far as the driver licensing database is concerned – to which the police have access – only a licence revocation/restriction will be known; a driver under any DVLA medical inquiries will not have any licence database notes to this effect.
Dilemma 2
Will his diabetes hit his licence?
QI am an endocrinologist working in private practice. My patient has type 2 diabetes and needs to start tablets.
He is a lorry driver, so I know he needs to inform the DVLA. How likely is it that his licence will be revoked?
AIt is impossible to give an accurate estimate without more clinical information. Overall, for all licence-holders, between 5% and 7% of notifications of a medical condition lead to revocation of the licence.
The DVLA will need to know details about complications and, if the tablet carries a hypoglycaemia risk, details about the patient’s understanding, awareness and self-monitoring and so on.
A patient should not drive while waiting for a decision if their doctor has advised them not to. A patient should be reminded that if they choose to ignore medical advice to stop driving, then their insurance cover may be affected. Doctors should formally and clearly document the advice given.
If a doctor calls the DVLA medical adviser about a patient and has sufficient concerns about road safety due to any medical condition, then the medical adviser can revoke a licence effectively instantly.
Dr Catherine Wills is a medico-legal adviser with the MDU
A pRivATE pRACTiCE: GRoUps
What to look out for if banding together
Working with other colleagues can have various advantages and has become a common way of coping with the ever-changing world of healthcare. It’s a chance to share costs, income or perhaps bid for new contracts. Ian Tongue (right) explores some of the more common ways consultants work together
CoMMITMENT lEvEl is one of the key factors when considering what the group is set up to achieve.
If commitment is low, this usually prevents profit-sharing ventures and results in cost-sharing arrangements. These can be very effective if resources such as secretarial support and rooms are shared.
If commitment levels are higher and individuals are keen to build a business and share profit, it is normal to work in a formal group.
This would require a trading business to be set up which is usually a limited company or limited liability partnership. This allows businesses to have a more formal identity and, when bidding for contracts, gives the group more gravitas.
Cost sharing
This is the simplest way of working together, but will usually
require one party to be driving the arrangement.
These types of ventures are not normally a formal structure such as a limited company or limited liability partnership.
However, if someone is employed via the PAYE scheme, it is usually the responsibility of one of the individuals, so it is worth having an agreement for any related costs that may arise from these obligations; for example, redundancy.
A separate bank account can be maintained and basic record-keeping is required to record the costs and ensure that the cost-sharing agreement is adequately funded.
Within each person’s private practice the shared costs will be shown and tax relief obtained. The main driver is to have an overall lower cost base than each per-
son would have if working autonomously.
Formal group
A formal group can bring various benefits, but the key drivers are usually:
Economies of scale;
Spreading workload;
Flexibility;
Cover and support;
Exploit opportunities;
Bargaining strength in numbers.
once a group of individuals has decided to come together and their objectives are known and commitment is made, it is time to decide the practicalities of the arrangement.
often there can be disparities in private practices or intended time commitment to the venture, so it is important to ensure that flexi-
bility on profit allocation can accommodate this.
Clashing personalities, establishing ground rules and finding the time to deal with matters are all key considerations.
The main structures used for working together are a limited company or a limited liability partnership. They are very different in their operation and how they are taxed and therefore it is really important that you seek specialist advice on the best structure for your group.
A limited company has shareholders (owners) who expect dividends, usually at a fixed percentage. This can create some barriers to profit extraction where the entitlement to profit is not in line with legal ownership percentage.
A company pays tax in its own right, known as corporation tax,
which has its own deadlines to adhere to, which are separate from self-assessment for individuals.
A limited liability partnership does not pay tax in its own right as a trading business and it is the members that are regarded as trading for the purposes of tax. Therefore, if the member was an individual, they would pay income tax; but if the member was part of a limited company, the company’s share of profit would be subject to corporation tax.
As part of the planning process it is extremely important that you take advice from a specialist medical accountant on the most appropriate trading structure for the group.
Legal considerations
Working in groups can often stem from common-room talk, so they start off informally between colleagues and friends. It is important that a solicitor is involved in
the process to ensure that the arrangement is formalised and covers a number of key eventualities that the group may face.
While not exhaustive, the agreement would need to include:
Profit sharing;
Admitting new members;
Removing members;
Death;
Divorce;
Performance;
Ethical and professional standards.
An additional important legal consideration is ensuring that the way the group operates does not infringe any competition laws as regulated by the Competition and Markets Authority.
There was a well-publicised case involving a group of surgeons that suffered a substantial fine for the way in which prices were set, which influenced both local and national pricing. These policies were ruled to be uncompetitive
Wealth Management Guide
and were in breach of UK competition laws. So it is extremely important that you do not stray into working practices and pricing structures that are uncompetitive.
Tax considerations
The tax position for each individual is likely to be different. This can create a preference for one structure over another for some that is not attractive to others. It is important that the nuances around tax efficiency and structure are discussed at an early stage to ensure problems do not arise later.
Due to tax anti-avoidance legislation that was introduced in recent years, one area that can present a problem is the use of limited companies as members of a limited liability partnership.
New arrangements can be particularly affected and therefore these issues need to be considered from the outset. This is an impor-
tant part of the accounting and tax set-up process.
Some groups will have interaction with non-members, perhaps referring to them as associates, and their tax position is important to consider to ensure their status does not give rise to additional risks. Your accountant should be able to advise you on the steps required to protect the group from unexpected risks in this area.
There are many groups of successful consultants and their members enjoy a variety of benefits, from earning more money to easing the pressure of their worklife balance. If you are asked to join a group or are thinking of setting one up, speak to a specialist medical accountant and they can guide you through the process.
Next month – Avoiding capital gains tax traps
Ian Tongue is a partner with Sandison Easson accountants
docToR on ThE RoAd: ThE AUdi RS RAnGE
The halo spins and slips at same time
Homing in on the range –our motoring correspondent Dr Tony Rimmer (right) says ‘howdy’ to five Audis and assesses the best deal
ONe OF the largest private healthcare providers has found there has been a 12% rise in ‘self-pay’ revenue from 2016 to 2017.
It is therefore reasonable to assume that these figures reflect a similar trend across all private services offered by private doctors. Patients, unrestrained by the restrictions imposed by medical insurance companies, are able to choose their own private medical provider.
With a potentially growing selfpay market, it becomes even more important that clinics’ services are well publicised to attract new clients. And one of the best ways of appealing to patients is to focus on the high-quality, successful ‘halo’ services that are on offer. Hopefully, these will encourage the higher-volume services that contribute most to the bottom line.
Car manufacturers have been doing this for decades.
Most TV and lifestyle magazine advertising tends to emphasise their sporty and expensive models. BMW promotes its M models, Mercedes pushes its AMG brand and Audi focuses on its RS models.
Simply dressed up
But are these cars just dressed-up and overpriced versions of more ordinary cars in the range or do they have real substance for the keen driver?
Well, I was invited to try Audi’s RS models and was lucky enough to sample representative ‘halo’ models from each market sector. The newest and key car available was the latest incarnation of the RS4 Avant. This mid-sized fivedoor estate has been recognised ever since its initial launch in
2000 to be a bit of a motoring icon. It is practical super-car, quick but stealthy and understated.
The latest model has swapped its 4.2litre V8 engine for a twin-turbo 2.9litre V6 that produces the same 444bhp but has more torque and better fuel economy.
The interior has been updated to include the latest Audi technology, and supportive sports seats and a chunky thick-rimmed steering wheel complement a superb driving position.
The RS4, just as before, is a rocket ship on the road. All that power is smoothly transmitted to all four wheels via the Quattro system allowing incredible acceleration. It has agile, sure-footed handling and a ride quality that is surprisingly comfortable. This Audi has unbeatable ground-covering ability on any cross-country trip.
The Audi RS 4 Avant: Its interior has been updated to include the latest Audi technology, supportive sport seats and a chunky thick-rimmed steering wheel
Unfortunately, all this talent does not come cheap. The basic price before extras is £62,175, so this is likely to be a £70,000 car.
And despite the new engine delivering more useable grunt, it does so without the special noise and character that its predecessor’s V8 possessed. Driving at normal speeds and in normal traffic, this ‘halo’ model feels just like any Audi A4 Avant. That means, well, just a bit ‘ordinary’.
Swathed in leather
Next up was a drive in the £51,925 SQ5 TFSi, the top model in the Q5 SUV range (Independent Practitioner Today, September 2017).
Fitted with a 3.0litre V6 petrol engine that produces 350bhp and a healthy 500Nm of torque, this useful family SUV can accelerate from 0 to 62 mph in 5.4 seconds. The interior is swathed in leather as befits a top-of-the-range model and large alloy wheels smarten up the exterior.
Although this is a quick car by normal standards, it feels a little unsettled along twisty roads. The suspension has been upgraded, but still cannot disguise the bulk of what is a big car. The similarly priced Porsche Macan is a lot more successful in this respect.
The bigger, heavier and even more expensive £73,945 SQ7 TDI actually felt more sorted on fast back roads.
It was probably helped by the standard adaptive air suspension; an expensive option on the SQ5. Its outrageous 430bhp 4.0litre V8 diesel engine also accentuated a rebellious character that gives it a definite personality and appeal.
I then swapped to the smallest of the RS range, the RS3. In fivedoor Sportback form – it is also available in saloon form – this
compact Audi can rightly claim to be the swiftest hot-hatch currently out there.
Its 2.5litre five-cylinder engine produces an impressive 400bhp, which unlocks a 0-62mph time of just 4.1 seconds and a top speed of 174mph. A sophisticated sports suspension, Quattro drive and upgraded brakes means that the RS3 is a true ‘pocket rocket’.
Great fun
I had great fun punting it along challenging B roads and the bassheavy RS sports exhaust system magnified the experience. Sadly, I think that my driving licence wouldn’t last long if I owned one. Fortunately, the £44,725 starting price is probably enough to restrain me.
Final drive of the day was of the R8 V10 Plus supercar. The R8 has been around since 2006 and this second-generation model since 2015.
The latest version benefits from all the high-tech, comfort and excellent build quality that is a feature of all Audis. This top model produces 610bhp from a 5.2litre V10 engine, which is nearly as much as the McLaren 650S I tested ( Independent Practitioner Today , November 2015).
This is a smooth and super-quick sports car. Interestingly, it is very easy to drive and you could use it day to day. Still, with a list price of £141,130, only a few independent practitioners will get the chance. Audi’s flag-bearing RS range is exciting and impressive. There is no doubt that its existence helps the brand’s image in the eyes of potential buyers, and that includes us medics.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
AuDI RS4 AVANT
Sadly, I think that my driving licence wouldn’t last long if I owned one
Body: Five-seat five-door estate
Engine: 2.9 litre V6 petrol turbo
Power: 450bhp
Torque: 600Nm
Acceleration: 0-60mph in 4.1 secs
Top speed: 155mph (electronically limited)
Claimed fuel economy: Combined 32.1mpg
On-the-road price: £62,175
Audi RS3 Sportback: Can rightly claim to be the swiftest hot hatch out there
Audi R8 V10: This super-quick sports car is easy to drive, but costs £141,130
Audi SQ5 Navarra: This big car feels a little unsettled along twisty roads
Audi SQ7: The biggest of the RS range has a definite personality and appeal
All you need to know about accountancy for private practitioners
Groups are on the rise
Profits are up for anaesthetists, but the pricing of some in this specialty looks set to come in for close attention. Ray Stanbridge reports in the latest of our unique benchmarking series
Some very interesting developments in the marketplace are affecting anaesthetists in private practice.
As we have previously reported, there is an increasing interest in groups as a means of protecting anaesthetists’ interests.
In many cases, groups have been able to provide a more efficient and all-exclusive service to surgeons and hospitals. So it is, of course, appropriate to seek additional rewards.
But, in recent months, there has
been a rising antipathy by some insurers and hospitals in the alleged monopolistic power of some groups. There is a lot of gossip and talk at present, but we might expect to see some closer interest in the pricing policies, particularly of some groups.
Increasing employment
Anaesthetists continue to incorporate and develop groups. There has also been increasing interest in the concept of employment in the private sector, and we would
expect this also to continue in future years.
All of these factors make it increasingly difficult to make a continuous year-on-year comparison as to how anaesthetist’s incomes perform in the private sector.
However, we believe the average anaesthetist in private practice increased his or her gross fees by 6% from £83,000 to £88,000 in the year to 5 April 2016.
Costs increased by 11% from £27,000 to £30,000 on average. As a result, taxable profit rose by 3.6%, going up from £56,000 to £58,000 in the year.
Gross incomes continue to rise slowly on average. There seems to have been continuing ‘Choose and Book’ work that has buoyed results, as well as additional selfpay work. Insured patient fees, however, continue to be under pressure.
These trends seem to have continued, but we have noticed some pressure on anaesthetists undertaking Choose and Book work as a result of the new Ir35 rules for the public sector, effective from April 2017. This development could affect future figures.
Anaesthetists seem to have been barely affected by the
anaesthetists seem to have been barely affected by the impact of the Competition and Markets authority ruling from april 2015
Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)
Source: Stanbridge Associates Ltd. RaNge OF
impact of the Competition and markets Authority (CmA) ruling from April 2015.
Staff costs seem to have risen slowly, although, as I have stated previously, there is a strong correlation between the increase in the personal tax allowance and the staff costs. This is particularly where anaesthetists are employing family members to work with them.
Advertising spend
There seems to have been a modest increase in the use of home costs – where a business office is maintained at home – for reasons we cannot fully explain. other costs have also risen modestly. Some anaesthetists, particularly those specialising in pain management, are increasing their
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advertising/promotion spend and this will affect results.
others have spent a little more on IT equipment and sundry matters. As it can be seen from the table below, most other costs remain fairly static.
What of the future? As we reported in Independent Practitioner
Today in may last year: ‘We see a general increase in incomes with squeezed margins and this is the probable likely prospect for anaesthetists’.
no change
I see no reason to change this view, although the potential effect
of the new interpretation of Ir35 rules may have a more significant impact in certain cases.
We have always stated that our surveys are in no way statistically significant. We have, however, been consistent in the qualifications for entry into our survey. To qualify for entry into our survey, 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;
m ust have generated a gross personal private practice income of at least £5,000 in the year to 5 April 2016;
may or may not have incorporated their business or become a member of a formal or informal group.
next month: oncologists and dermatologists
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates
years ending 5 april
don’t miSS oUr 10th anniverSarY iSSUe
In our landmark 10th anniversary June issue next month, Independent Practitioner Today will be looking back at a selection of the big stories we’ve brought you and there will be a reminder of just how things have changed in private practice over the last decade.
With that in mind, we have asked leading lights in the private sector to gaze into their crystal balls and tell us what they think things will be like in 2018.
Many predict a very different world for independent practitioners. So get a heads-up on what is likely to affect you and your practice and be in the best position to prepare and take advantage of what is coming your way in the years ahead.
If you want to know how good your practice billing system really is, then test yourself with this quiz from Medical Billing and Collection
how can you avoid a gMC referral? Doctor-turned-lawyer Tania Francis says there is probably nothing anyone can do to entirely
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eliminate the risk. Sometimes, it is down to just plain bad luck. It is certainly often nothing to do with your abilities as a doctor, and that’s important to remember if you are unlucky enough to receive the dreaded gMC letter
There has been plenty of doom and gloom about Brexit and how it might affect healthcare, but it’s entirely possible that private healthcare may well see some benefits from the increased competition. Jane Braithwaite reports
Private patient units: this month the spotlight falls on the private patient services in the 17 NhS trusts delivering acute care services to the south-west counties of Dorset, Devon, Cornwall, Wiltshire, Somerset and gloucestershire
Snail water to treat vD? What your predecessors treated with what and how much they were paid
Our motoring correspondent reviews the Nissan Leaf
Business Dilemmas answers more of your medico-legal questions
Our benchmarking series Profits Focus puts the earnings of oncologists and dermatologists under the microscope
Plus all the latest news and views
aDveRTISeRS: 25 May is the deadline for booking advertising in our June issue
aDveRTISINg INqUIRIeS
Margaret Floate, advertising manager Email: margifloate@btinternet.com Phone: 01483 824094
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