May 2019

INDEPENDENT PRACTITIONER TODAY

The business journal for doctors in private practice

In this issue

Helping

access to self-pay

Self-pay is on the rise, but the confusion around doctors’ prices needs to be cleared up P21

Giving voice to the private sector

The new president of the Independent Doctors Federation reveals his hopes for the organisation n See page 18

What are you doing to attract patients?

Some advice on choosing the right marketing strategy to grow your practice P26

Boosting

my cash flow

A consultant describes how outsourcing ensured his growing practice remained in good financial health P36

Tougher controls loom

By Robin Stride

A Royal College of Surgeons of England (RCS) bid to improve private practice safety following the Paterson case has sparked patients’ calls for the launch of a whistleblowing system.

College proposals mean independent consultants face tougher clinical governance to cover monitoring of practising privileges and scope of their practice.

Better sharing of consultant performance information between the NHS and private sectors is also being urged.

But the Private Patients Forum (PPF) claimed a new early warning system for patients and doctors was urgently needed, with the latter possibly using confidential whistle-blowing to share concerns with all providers.

It said: ‘This would mean a more effective and urgent use of quality, safety and complaints information than is currently the case and would require a whole-system approach.’

College president Prof Derek Alderson said the entire healthcare sector needed to do more to prevent rogue doctors from ever causing harm again.

‘This starts with being able to collect and analyse good-quality patient safety and outcomes data. There must be stronger oversight and protection for patients, regard-

less of whether they have their operation in an NHS hospital or in the independent sector.’

The independent sector must report data around unexpected deaths, never events and serious injuries to the Care Quality Commission. The RCS wants this published in future.

It said the private sector did not yet have a data set equivalent to Hospital Episode Statistics – which publishes how many and what procedures have happened in the NHS – although talks between the Private Healthcare Information Net work (PHIN) and NHS Digital

aim for independent sector data to be included.

The RCS added that the independent sector had not been enabled to contribute to most national clinical audits that collect data on care outcomes.

It has been working with the Health care Quality Improvement Part nership (HQIP) and the Independent Healthcare Provider Network (IHPN) to review which existing national clinical audits the independent sector can contribute to and what barriers need overcoming.

IHPN boss David Hare said: ‘We

There must be stronger oversight and protection for patients, regardless of whether they have their operation in an NHS hospital or in the independent sector

PROF DEREK ALDERSON, PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND

have successfully lobbied to ensure that independent sector providers are permitted to submit more data to key national safety systems and participate in more clinical audits and, as the RCS report makes clear, there is real momentum behind this work.

‘However, further work is needed to allow the sector to participate in the full range of NHS datasets and clinical audits and it is now vital that all those involved in better aligning NHS and independent sector data maintain the momentum.’

➱ continued on page 4

TELL US YOUR NEWS Contact editorial director Robin Stride

Keep in the loop

Data transparency is transforming the life of doctors, but more needs to be done, says David Hare of the Independent Healthcare Providers Network P14

Email: robin@ip-today.co.uk Phone: 07909 997340 @robinstride

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EDITORIAL COMMENT

MACs to offer protection

A Royal College of Surgeons of England (RCS) position paper, ‘Recommendations for assuring standards in the independent sector’ ( see story on page one ) is another milestone in the ongoing greater transparency drive.

Unlike most documents passing doctors’ desks, it is not too long and we think it is well worth reading its seven pages, whatever your specialty.

Coming hot on the heels of a Care Quality Commission report (Independent Practitioner Today, April), criticising nearly half the private consulting doctors’ services analysed, it advocates farreaching changes aimed at improving patient safety.

These will surely happen and affect independent practitioners for the better in years to come.

The RCS report will nestle nicely alongside the muchawaited Consultant Oversight Framework, the initiative from

the Independent Healthcare Providers Network (IHPN).

This aims to improve consistency in the governance of doctors across the private sector by identifying and codifying best practice in a range of areas, including the medical advisory committee (MAC) chairman’s role and how committees function.

Being prepared by former NHS England medical director Sir Bruce Keogh, its publication is now unlikely before July or September – way beyond the original Spring deadline.

But the RCS report hints at what MAC changes could be afoot. One is a clearer remit to ensure they can better advise on patient safety standards.

Private doctors can expect the MACs’ remit to be more clearly defined to ensure they are better able to advise the registered manager on patient safety standards and granting consultants’ practising privileges.

Keep your lifeblood flowing

Accountant Susan Hutter gives her five top tips for freeing up and managing cash flow – the lifeblood of any business P16

Be an ‘expert’ witness

If you are working as a medical expert witness, there are a host of things that can trip you up. Here’s 20 to watch out for, outlined by a leading barrister P32

Up, down and turnarounds

Markets are meant to fall. An expert in investment shows how you should keep the falls in share prices in perspective and learn to hold your nerve P38

Pass it on when passing on

Half the population dies intestate, but don’t copy them. Lawyer Fiona Wilson shows why a will is one of the most vital documents you will ever write P40

‘Business Dilemmas’

A medico­legal expert from the MDU advises on three ethical quandaries, beginning with advice on removing a rude troublemaker from your list P43

PLUS OUR REGULAR COLUMNS

Start a private practice: Home truths

Accountant Ian Tongue looks at the taxation issues of being a property owner and investors P46

Doctor on the Road: This Skoda gives you the last laugh

Motoring correspondent Dr Tony Rimmer shows why the days of Skodas being the butt of jokes are long past P50

Profits Focus: The cost of working hard

Our unique benchmarking series looks at the financial fortunes of anaesthetists P52

Circulation figures verified by the Audit Bureau of Circulations

Ministers refuse to cut pension tax

By Edie Bourne

The Government has ruled out changing legislation to ease the pension tax burden on senior doctors, following an official Parliamentary review.

Scottish Tory MP Paul Masterson raised the debate, sharing concerns about the impact the tapered annual allowance was having on consultants and others with many choosing to reduce their hours or retire early from the NHS.

He argued the result was having a disastrous effect on the health service workforce.

The restriction on the amount you can contribute to your pension free of tax is known as the ‘annual allowance’. New rules governing a ‘tapered annual allowance’ now decrease the standard annual allowance of £40,000 to as low as £10,000 a year for doctors with a ‘threshold income’ of more than £110,000 –and this includes income from all sources except pension contributions.

Excess pensions savings above the allowance will generate a tax bill charged at your marginal rate of income tax.

Mr Masterson told Parliament that the tapered annual allowance was resulting in ‘many consultants being hit with unexpected fivefigure tax charges’.

He argued that while he appreciated the debate focused on ‘people who earn a lot of money and who have good pension schemes’, he believed there was a ‘serious potential knock-on effect of very senior doctors turning down hours or taking early retirement’.

Health and Social Care Minister Jackie Doyle Price acknowledged that the tax rules were having an ‘impact on the behaviour of practitioners by increasing voluntary early retirements’, but did not believe high-earning NHS staff should be exempt from the tax rules, hence the ruling.

Dr Benjamin Holdsworth, director of specialist financial planners Cavendish Medical, said: ‘We are seeing large numbers of consultants having to deal with complex pension tax positions, which undoubtedly is factoring into their retirement planning. This is having detrimental effects on NHS staffing at a time when retaining skills and expertise in the workforce to cope with an ageing population is vital.

‘Very few of our clients wish to stop clinical work altogether with many preferring to continue in some capacity in the careers they love.

‘In reality, the pension tax problems are not usually the main driver of doctors deciding to retire

Dr Benjamin Holdsworth, director of financial planners Cavendish Medical

early, or perhaps not working beyond retirement as they may have done previously. However, given the wider problems in the NHS, this is certainly influencing decision-making.

‘The problem is further compounded because the calculations for the tapered annual allowance are fiendishly complicated for the untrained professional and because the actual figures required are not available until after the relevant tax year has finished.

‘Both factors make it difficult to plan ahead. The annual statements from the NHS Pensions Agency will also require a human sense-check, as we have found many to contain a number of computer-generated errors. It is imperative to seek help without delay.’

What is best way to get feedback?

Doctors are being asked by the GMC for their views on how they should collect and reflect on feedback from their patients.

The GMC’s consultation document suggests that the feedback process should be accessible to as wide a range of patients as possible and that doctors should rely less on structured questionnaires.

Dr Susi Caesar, RCGP revalidation director, said: ‘All doctors should get involved in this consultation and be part of the changes that work better for us.’

The regulator also wants doctors to review their patient feedback annually, rather than every five years when their revalidation is due; to use any unprompted feedback, such as letters, cards or comments; and to consider how to get feedback from a wide range of patients, including those with communication or learning difficulties.

Details on GMC’s consultation website. See our feature next month.

Make sure the private healthcare industry knows who you are, where you are and what you do. Tell us your story. Contact editorial director Robin Stride at robin@ip-today.co.uk or phone him on 07909 997340 ENTREPRENEUR DOCTORS

Doctors will cut work due to tax, BMA warns

The BMA has warned the Chancellor of the Exchequer that doctors will cut their NHS working hours unless there is tangible reform to the NHS Pension Scheme.

It said in a letter that current pension and tax rules were creating a ‘perfect storm’ in the NHS workforce, forcing consultants to cut their hours, retire early or leave the health service to avoid disproportionately large additional tax charges.

BMA consultant committee chairman Dr Rob Harwood said: ‘It cannot be right that doctors working extra hours to reduce waiting lists or

cover rota gaps are then hit with additional tax bills greater than the value of the extra hours worked.

‘Given the refusal of both the Government and NHS employers to take steps to rectify or mitigate this, it is now our responsibility to inform our members that current regulations, particularly the annual allowance and tapered annual allowance, are disproportionately and unfairly impacting them.

‘Unless action is taken, our only option is to reduce the amount of time we work for the

NHS, which will through no fault of our own, be detrimental to our patients and to the country’s health service – exactly what the BMA has been trying to avoid.’

The BMA wants a fundamental review of current pensions taxation legislation.

Its members have also sent over 1,600 letters to MPs on the inequity of current pensions rules for both hospital consultants and GPs. But the responses received so far reveal a worrying refusal to acknowledge the reality faced by individual doctors and the wider NHS.

Patients demand more data sharing

By Douglas Shepherd

Greater transparency about the safety of private hospitals is needed urgently, according to patients’ representatives.

But the Private Patients Forum (PPF) questions whether this would be enough to keep patients safe.

The PPF was reacting to the Royal College of Surgeons of England’s (RCS) list of demands for sharing data between the private and public health services (see story on right).

The RCS’s demands follow the jailing of surgeon Ian Paterson who performed needless breast operations on scores of NHS and private patients. He is now serving a 20­year prison sentence.

In a statement, the PPF said: ‘The RCS says private hospitals should be required to collect and publish their safety records in the

same way as the NHS to prevent similar scandals happening in the future and suggests that stricter clinical governance procedures be introduced in the private sector. The Care Quality Commission also supports the college’s demands.

‘But while broadly welcoming this new intervention, it is a fact that much of this key data is already being collected by The Private Healthcare Information Network (PHIN) and will be published on its website along with a great deal of other information, including the cost of operations in private hospitals and clinics. This will undoubtedly help would ­ be patients to make better choices.

‘This will also go a long way in bringing greater transparency of quality and safety of private healthcare services in line with the NHS, but this alone will not pre ­

vent a future case similar to Ian Paterson.’

It added that most private patients enjoyed the highest standards of care, but complacency was always a danger and a simple checking system, available to all, was needed.

‘The PPF wants to see data on private hospital safety integrated within national reporting systems. We want one common system for all hospitals NHS and private, and so we welcome the recent initiative launched by NHS Digital and PHIN – the ADAPt programme –which sets out the first stages to do just that.

‘Introducing new regulations and collecting data is one thing, but the PPF wants to see that data presented publicly in a simple and clear way in order to inform and protect all patients throughout the UK.’

Plea to stop criminalising doctors

A leading lawyer in the healthcare sector has condemned the public and prosecutors for putting doctors on such a high pedestal that any error will inevitably cause them to fall below the perception of acceptable practice.

Hempsons solicitor Bertie Leigh said: ‘People devoted to their profession should not be criminalised if things go wrong, particularly when dealing with high­risk work where patients do die.’

He told a London Consultants Association meeting that gross negligence manslaughter (GNM)

should only be considered when doctors have gone outside of their care remit and abandoned their principal professional duty of care.

Mr Leigh suggested lack of training or experience should not be criminalised as GNM but should be dealt with by the GMC separately.

He said medicine was always dealing with high ­ risk cases and the public should get to grips with that reality and the complexity of the hospital systems that support – or fail to support – doctors and patients.

Former president of the Royal College of Surgeons, Prof Sir Norman Williams, and Mr Ian Stern QC gave a review of GNM with their experiences acting as chairman and vice ­ chairman on the Govern ment ­ commissioned Williams Report.

It concluded that, rather than altering in the law, the investigation process of possible GNM in a clinical context needed improving though higher­ level training for expert witnesses, Crown Prosecution Service, police, coroners and local authorities.

Patients can now compare prices on

PHIN’s website

College lays out its plan to avoid another ‘Paterson’

➱ continued from front page

The Royal College of Surgeons’ drive to improve private practice safety centres on more sharing of data and having a single repository for a doctor’s record of practice.

It calls for:

 Streamlined clinical governance procedures to enable consistently effective monitoring of practising privileges. Medical Advisory Committees should have a clearer remit so they can better advise on patient safety standards;

 All new surgical procedures/ devices used in either sector to be registered, with data collected in national audits before a routine offering to patients. There could be national guidelines on introducing new procedures and technologies;

 A single repository about a consultant’s practising privileges, indemnity cover, practice scope, identity of Responsible Officer and appraisal status, accessible to all hospitals where they work, enabling prompt action to performance concerns.

 Independent multidisciplinary team ­ working to be reviewed to ensure it includes arrangements for information sharing between sectors.

 Appropriate service­level agreements be set up between private hospitals and NHS trusts for critical care support, plus robust on ­ call emergency cover arrangements for surgeons/anaesthetists in private units if patients have post­operative complications.

Consultants’ fees information for self­fund patients is up for all to see on the Private Healthcare Information Network (PHIN) website.

Visitors can see prices for an initial consultation, procedure and follow­up consultation, plus data on specialists’ activity, their patients’ average length of stay, and hospitals they work at.

fees with the typical range across the UK and in their region.

A comparison tool and consumer guides also help people compare

Consultants have had to disclose their fees following a Competition and Markets Authority call for more transparency.

The Independent Doctors Federation welcomed the RCS’s proposals and said long before the Paterson case that it had worked with the Private Healthcare Infor m ation Network and the Care Qual ity Commission to promote best care. It recently met with the Independent Healthcare Provider Network and London private hospital medical directors and chief executives to ensure PHIN’s requirements were met and there were ‘robust mechanisms’ to prevent any similar case happening.

INDEPENDENT

DOCTORS FEDERATION AGM

IDF fights insurers ‘de-listing’ doctors

By Robin Stride

Consultants’ relationships with the private medical insurers continue to top the list of work being tackled by the Independent Doctors Federation’s specialists’ group.

In his annual written report, the group’s chairman Dr Sean Preston said insurers continued to tighten the financial screw.

And numerous doctors, typically the more senior, had complained of being ‘de­listed’ after deciding not to become fee­assured.

‘On several occasions, we have facilitated dialogue between the two parties, but have yet to be successful in “re­listing”,’ he admitted.

‘Patients are also victims of this process, as they are often prevented from seeing their consultant of choice; particularly ironic if they have signed up to an “open referral” pathway.’

Dr Preston, a gastroenterologist at London Digestive Centre – part of HCA Healthcare UK, reported that younger new IDF members often faced a difficult decision whether or not to sign up to insurers’ significantly lower fees schedules or look for potentially more lucrative and less stressful work as part of NHS waiting list initiatives. He said his committee’s priority had been to open talks with all insurers. ‘The most significant progress has been with AXA PPP, where there has been successful negotiation of procedure fees and recognition of quality matrices and the benefits to all of working in groups.’

Big private unit reveals its plans

IDF members were fascinated to hear more about the progress of American hospital group Cleveland Clinic, which plans to open a hospital at Grosvenor Place, London, in the spring of 2021.

Chief executive and surgeon Mr Brian Donley was asked about the consultant working arrangements at the 183 ­ bed hospital and confirmed there would be a mixed model of employment, with some on a salary, others also working in the NHS and others coming in on a day.

With a shortage of 50,000 nurses, he was quizzed about where he thought his nurses would be coming from. He replied that although some would be from the UK, others would come from the US and also Abu Dhabi, where the ‘consultant ­ led’ company had a 360­bed hospital.

Outgoing IDF president Dr Brian O’Connor asked him about where he envisaged the hospital’s patients would be coming from and Mr Donley replied that 90% would be from the UK and 10% overseas.

The Cleveland boss said a big block of patients would be private medically insured, but self­pay, the fastest growing market, would be targeted.

Mr Donley said the hospital would be aiming to develop its international branding and help London be seen more as a destination for patients from overseas.

That would be a positive for the private healthcare market because ‘we won’t be able to do it all’.

 Dr Neil Haughton’s hopes for the IDF’s future – see page 18

Independent GPs are in an ‘exciting time’

IDF GP committee chairman Dr Di Loudon believes private general practice is entering ‘an exciting new paradigm’.

She highlighted a rise in private GP numbers, diversification of work, an increase of digital medicine, working in multidisciplinary teams and the effects of changing secondary care such as the Mayo and Cleveland Clinics arriving in London.

The meeting heard that the committee is working to develop digital pathways to allow better communication with NHS technology.

Dr Neil Haughton said this would enhance communication between sectors, promote safer prescribing and provide safeguarding checks. All this was soon to be required by the Care Quality Commission.

The IDF plans a seminar later this year to explore the growth in digital health. Chief executive Sue Smith, in her annual written report, encouraged doctors to utilise the growing number of portals, apps and delivery of care models to increase their effectiveness and patient care outcomes.

Private GPs now account for a quarter of the IDF’s membership.

Private work ‘helps doctors to balance their lives’

The IDF needs to preserve private practice and encourage doctors to embrace it as a career choice, according to its outgoing president.

Dr Brian O’Connor said: ‘More and more, younger doctors are developing portfolio practices with greater emphasis on work­life balance and less of a 24/7 commitment of doctors of yesteryear.

‘This applies across the board in primary and secondary care and it is incumbent to address the changing reality of work practices among our younger colleagues.’

In his annual written report to the 1,379 membership, he exhorted doctors to shape their working lives in the independent sector by leading on all the big issues.

Dr O’Connor added: ‘The challenges are endless, but the biggest challenge of all is to work with all relevant parties in the independent sector, insurers, hospital providers and regulators to foster a collaborative approach to private practice and to promote London in particular, but the UK in general.’

IDF revalidation work is on a roll

The IDF’s appraisal and revalidation work is blooming, with more than 550 connected members.

The federation provided appraisals for 150 non ­ connected members in the last year and is set to train more appraisers in November.

Doctors interested in this role should contact the Federation.

Dr Brian O’Connor, outgoing president of the IDF

Dr Sean Preston, chairman of the IDF’s specialists’ committee

The secret to building a successful practice

By Robin Stride

If you want your private practice business to prosper, then be likeable.

That was the advice to established private doctors from a consultant urological surgeon.

Quoting from a patient survey for the DocPreneur Institute and Concierge Medicine, the ability to find a doctor they liked and trusted was voted way ahead of cost, convenience and other factors.

Mr Marc Laniado, of Sage Urology, said ‘likeable’ meant being authentic in who you are, enabling people to connect to the real you.

Likeability helped establish trust and, alongside credibility, it could overcome lack of experience and expertise.

He advised doctors to develop a personal brand depicting what they stood for. This was what differentiated them from others. It was about making themselves

known for their skills and talents, but it needed some bold selfexpression.

They should say whom they helped and what they could do to help them. ‘Don’t say “I’m a psychiatrist” – say “I help people get over depression”.’

Mr Laniado, who consults in London, Berkshire and Buckinghamshire, told his audience they should aim to be a ‘category authority’.

One way towards this was to saturate their patients and referrers with evidence demonstrating their expertise. This might be through producing publicly available patient information, being in a network of similar experts and mentoring other professionals.

They should aim to create a great patient experience. He said this started with acknowledgement of a patient – making positive eye contact, smiling and using their name.

Other important factors were to ask: ‘Is there anything else I can do for you? I have the time’; to be on time; share decision-making; have empathy, and to escort a patient to the next location after seeing them.

He said there were various brand-building products available to doctors to help patients: e-books, articles online, magazines and books, and information on disease and specific treatments that met patients’ needs. And they should make it differ from their competition.

Mr Laniado advocated a ‘keepin-touch strategy’ with referrers; for example, through regular email newsletters.

He said all private doctors needed a website with professional photographs. The design should be easy to navigate and the content should give patients and referrers what they needed to know. It should show what the specialist could do for patients and referrers.

Websites helped build a consultant’s brand identity, gave them a bigger geographic marketplace, built their database of potential patients and referrers and filtered out unsuitable patients for whom they could not do their best work.

He reminded consultants to keep their details up to date on the finder.bupa.co.uk website.

How much do you know about the private practice marketplace? Test yourself with this quick quiz, presented to the conference by Keith Pollard (right) executive chairman at LaingBuisson International.

1 In 2009, 7.6m people were covered by private medical insurance. How many were covered in 2018?

a. 5.2m

b. 6.9m

c. 7.8m d. 8.5m

4 What proportion of private hospital revenue came from the NHS in 2017? a. 110% b 20%

c. 30% d 40%

2 What is the average price for a selfpay hip replacement package in the UK? a. £8,595

5

3 How many private doctors are there in Harley Street?

206 independent hospitals inspected by CQC … what proportion were deemed to need improvement?

Mr Marc Laniado, urologist

Key to getting GP referrals

Consultants who give rapid communication back will find favour with the private GP, a leading independent practitioner said.

Other attributes the private GP is looking for from them are:

 Enough clinic availability;

 Admitting rights to good hospitals;

 Availability on a mobile phone, especially for emergencies

 A private PA;

 Ease of access.

GPs want consultants who display the three ‘A’ requirements of ‘affability’, ‘availability’ and ‘ability’, Dr Neil Haughton, of the Portobello Clinic, London, told the meeting.

A consultant’s reputation and seniority were also important –and the GP’s patients needed to ‘like’ them.

Dr Haughton, speaking ahead of his appointment as Independent Doctors Federation president last month, was critical of the attitude of some NHS GPs towards the private option.

Any GP was obliged to refer for specialist assessment if needed, including privately if the patient requested this.

But he told the meeting: ‘Some GPs give their patients a really hard time when they want to go private and it’s really not fair.’

Dr Haughton said the BMA and RCGP had little data on the scope of private GP work. But his own audit of doctors in his practice showed a referral rate of 20% – 88 out of 439 consultations over two

weeks, which was far higher than in the NHS.

He listed various reasons for this – increased patient expectations, patients more likely to have health insurance, the private GPs were able and more likely to refer earlier, possibly more pathology in private general practice and a need to keep patients happy. Consultants were also keen to get referrals.

Dr Haughton, BMA private practice committee deputy chairman and primary care lead, gave would-be private GPs a wake-up call if they were thinking the lives of private GPs were grand.

He warned them the grass was not always greener and independent GPs were just as stressed and busy as everybody else.  See ‘Giving voice to the private sector’, page 18

The increasing self-pay market is the big ‘good news’ for independent practitioners, doctors were told.

Market expert Keith Pollard said around 18.7% of independent acute medical hospital revenue came from self-pay UK patients. The annual value of the private

HCA offers revolutionary cancer therapy Income from self-pay is rising 10% a year

HCA Healthcare UK has announced the launch of CAR T-cell therapy – a ground-breaking new blood cancer treatment. It is available to patients with certain types of lymphoma –including diffuse large B-cell lymphoma, primary mediastinal large B-cell lymphoma and transformed follicular lymphoma – at HCA UK at University College Hospital and The Christie Private Care, Manchester, part of HCA Healthcare UK.

The hospital group is among the first private providers to offer the

healthcare self-pay market, including cosmetic surgery, had topped £1.1bn and added to this was £620m from self-payers being treated by doctors in NHS private patient units (PPUs).

Income from self-payers had been rising at around 10% a year.

Mr Pollard said waiting lists had fallen apart in NHS hospitals and general practice. Self-pay had been driven by a four million-strong waiting list in England, which appeared to have been forgotten, as the Government was doing ‘nothing at the moment apart from Brexit’.

Talking of the drive for greater fee transparency in the market, he thought there would be a closing of the gap between the cheapest and the most expensive prices charged.

 See ‘Making access to selfpay easy’, page 21

therapy in units accredited by JACIE for administering immune effoctor cells and also rated by the Care Quality Commission as ‘Outstanding’. Patients with other blood cancers can access the treatment later.

Prof Stephen Mackinnon, chairman of the HCA Healthcare UK Blood Cancer Board, said:

‘Blood cancer is the third biggest cancer killer in the UK. However, CAR T-cell therapy is a game-

changing treatment for many patients.

‘So far, some patients who have undergone this treatment have shown a rapid and durable regression and remission that we haven’t observed in other recognised treatments.

‘This is a “first of a kind” therapy and is a big moment for the treatment of cancer.

‘CAR T-cell therapy has the potential to revolutionise the approach to

cancer treatment moving forward.’ CAR T-Cell (Chimeric Antigen Receptor T-cell) therapy uses a patient’s own T-cells to seek and destroy cancer cells – without the use of drugs.

Referred to by many as the ‘5th pillar of cancer treatment’ –following surgery, chemotherapy, radiotherapy and targeted therapies – it brings renewed hope to both patients and the medical world alike, and offers a glimpse of what treatment could look like for multiple tumour types in the future.

Dr Neil Haughon, private GP and Independent Doctors Federation president

Prof Stephen Mackinnon BMA PRIVATE PRACTICE

The right to select hospital is failing

By a staff reporter

Consultants are being denied patients in the private sector because less than half of the public are aware that they can choose where they receive their NHSfunded hospital treatment.

A new poll by Populus found widespread ignorance about treatment options – despite the legal right to patient choice having been in place for over a decade.

While NHS England has committed to ensuring that, by 2020, all patients are aware of the choices available to them when choosing their NHS treatment, just 48% of the public currently know of these legal rights.

Patients have the right to choose to be treated at a public or private hospital in England with hospitals paid the same for the procedure.

Strong commitments around

enabling patient choice were a key feature of both the NHS Five Year Forward View and the recent NHS Long Term Plan

But the Independent Healthcare Providers Network, which commissioned the poll, warned that too few patients know they can choose where to be treated, including finding a provider with lower waiting times.

Meanwhile, it points out, NHS waiting times have risen to their highest in a decade.

Now it is urging the Government to take urgent action to dramatically improve public awareness of patient choice and ensure that patients are supported to make the best treatment decisions for them.

Chief executive David Hare said: ‘When NHS waiting times are at their highest in a decade, it is disappointing that patients’ awareness of their legal right to choose

the fastest possible treatment for them remains so low.

‘Despite strong commitments from both the Government and the NHS to strengthen the public’s choice rights, the poll shows that we are still a long way from all NHS patients knowing that they have the right to choose the best provider for them.

‘Making patients aware of their right to choose is not just the right thing to do but leads to tangible improvements in patient outcomes.

‘We want to see a renewed push to kick­start the patient power agenda so that all patients can receive the fastest possible access to treatment in the setting of their choice.’

Populus interviewed 6,116 adults online in England. This included 2,314 interviews with respondents who had been referred for an outpatient appointment by their GP within the previous 12 months.

Use private units to treat NHS patients, says sector’s chief

It has been three years since the NHS last met its target to treat 92% of elective patients within 18 weeks, according to NHS England’s latest performance figures.

And that means more patients waiting in pain for vital treatment such as hip replacements and cataracts, according to the boss of the representative body for independent sector healthcare providers.

David Hare, chief executive of the Independent Healthcare Providers Network, said the figures represented ‘a worrying decline in the access to NHS care that the public have a legal right to expect under the NHS constitution’.

He welcomed the recent NHS Long Term Plan commitments to increase the amount of planned

surgery delivered year on year, including through making use of independent­sector capacity.

But he said what was now needed from NHS England was a clear delivery plan on how to get waiting times down.

‘This must include utilising the spare capacity available in the independent sector and communicating much more effectively the legal rights that patients have to choose the best provider for them.

‘We are also clear any potential reforms to the 18­week target must be fully tested and driven solely by the needs of patients, not by diluting the target to make it easier to hit.’

 Of patients on the waiting list at the end of February 2019, 87% had

been waiting less than 18 weeks, thus not meeting the 92% standard.

 The number of patients waiting over the 18­week target for referral to treatment rose by almost a fifth in 12 months, from 454,000 in February 2018 to 540,000 in February 2019.

 The number of people waiting more than one year for elective surgery was 1,963 at the end of February 2018 – up from just 539 patients five years ago.

 The Government’s target to ensure 92% of patients wait no longer than 18 weeks from referral to treatment for elective procedures, such as hip and knee operations, has not been met since February 2016.

GMC changes aim to cut the number of full investigations into oneoff mistakes by doctors – known as single clinical incidents.

The move follows a two ­ year trial during which information was gathered quickly, following a complaint or referral, to assess if there was any ongoing risk to patients and before deciding if full investigations were required.

More than 200 single clinical incident cases were closed during the pilot study after the additional information, such as medical records and input from independent experts, doctors’ Responsible Officers and the doctors themselves, was considered at an early stage.

GMC chief executive Charlie Massey said opening full investigations unless absolutely necessary was not in the interests of patients or doctors and caused additional stress and delay.

‘The pilot was to see whether using that approach in cases involving allegations of one ­ off clinical mistakes would allow us to properly assess the risk without the need for a full investigation. It does and, as the pilot was a success, it will now be implemented as our standard practice.’

The new process means that once additional information has been gathered, the GMC will decide whether to open a full investigation or to close the complaint following its initial inquiries.

GMC chief executive Charlie Massey

Healthcode earns top security badge

By Olive Carterton

ogy specialists Healthcode has been accredited by the Government ­ backed Cyber Essentials scheme, which aims to safeguard UK businesses from cyber criminal threats.

It passed an external evaluation to verify its systems and all enduser devices such as PCs and mobiles were robustly protected from cyber­attack and data loss.

Raj Patel, the company’s information governance and data protection officer, said technology should protect the healthcare sector from cyber criminals and not become its Achilles heel as it did when NHS systems were hit by the 2017 WannaCry cyber­attack.

He added: ‘This principle has also led us to develop products and services so practitioners can meet their own ethical and legal obligations to protect patient information.

‘These include our Genera Data Protection Regulation (GDPR) toolkit, which helps practices comply with current data protection law, and healthDrive, our secure file­storing and sharing tool.’

As a provider of managed online services to independent practitioners and hospitals including NHS private patient units (PPUs) and insurers, Healthcode processes

sensitive healthcare and financial data on behalf of its customers and their patients, clearing more than £3bn worth of medical invoices each year.

Managing director Peter Connor added: ‘As well as showing our commitment to protecting our customers’ data, we need Cyber Essentials certification so we can continue to win contracts with NHS private patient units.

‘This is an expanding part of the private healthcare market and we

believe Healthcode’s secure and online services are the perfect fit for PPUs wishing to streamline their billing and administration.’

The company demonstrated its adherence to national best practice standards in five key areas:

 Ensuring secure access to networks;

 Configuring systems to minimise vulnerability to cyber­attack;

 Restricting access to data and services to authorised users;

 Ensuring all applications are equipped with the latest security updates;

 Maintaining up ­ to ­ date virus and malware protection.

Better news for the private medical insurance and cash plan market is forecast by the head of the professional group who advise on and sell these products.

Stuart Scullion, chairman of the Association of Medical Insurers and Intermediaries (AMII), said whether Britain left the EU with or without a deal, he was confident the need for members’ professional advice would remain.

He told the group’s annual conference: ‘There will still be a demand for the healthcare products and services offered by our members, and none more so than in a tight employment market, where employers will have to offer a range of benefits to attract the best talent.

‘When that day comes, you need to be ready to articulate the value of our proposition in your message’.

He reported that the AMII was pleased by the Chancellor’s announcement of HM Treasury’s intention to conduct a review into the fairness and application of insurance premium tax (IPT), which is charged at 12% on health insurance policies.

Mr Scullion said his association strongly encouraged Mr Hammond to review findings from the Centre for Economics and Business Research around the negative impact of the tax, plus the positive contribution private healthcare made to the nation’s health.

Health cover salesmen are upbeat about the future PPU

Compiled by Philip Housden

Kingston Private Health launched

Kingston Hospital NHS Foundation Trust has followed the recent successful trend of NHS trusts bringing their private patient services under in­house control.

From the beginning of last month (April), the service moved from a management contract

through BMI Healthcare to the trust.

The service, previously known as The Coombe Wing, has been relaunched as Kingston Private Health. The private patient services include an inpatient ward of 22 beds, private maternity and an assisted conception unit.

The trust’s March board meeting papers state: ‘The management contract has been awarded to TPW Consulting and Training Ltd (TPW). Trust staff have been work­

ing closely with TPW on mobilisation over the past six months and robust plans are in place for the trust to take over the running of private patients’ services.’

In 2017 ­ 18, the trust annual accounts reported private patient incomes of £528,000 – up from £428,000 the previous year.

Philip Housden is a director of Housden Group. See his feature article on southern home counties PPUs on page 48

He added: ‘The private healthcare sector makes an outstanding contribution in support of our overstretched NHS, now more than ever as the NHS allows waiting times to slip under the burden of expectation on its services.

‘It defies logic to penalise those who are willing and financially capable of buying private healthcare to penalise them by the addition of IPT tax at any value. We will continue to lobby for the removal of IPT on healthcare spend, which we believe should be zero­rated as it is in the life cover sector.’

Private healthcare online technol­

WATCH

Peter Connor

CQC inspection fears

By Martha Walker

Although the healthcare inspection watchdog says many private doctors and clinics provide safe, effective, caring, responsive and well-led services, the regulator also has strong concerns – highlighted in Independent Practitioner Today’s story last month.

Prof Ursula Gallagher, lead inspector for independent doctors and deputy chief inspector of primary medical services at the Care Quality Commission (CQC) says ‘a number were not meeting the necessary regulations and not delivering safe and effective care’.

Findings of the body’s 18-month inspection programme of independent doctors and clinics in England were based on 85 reports from a cross-section of 20% of independent services inspected. They included private GPs, slimming clinics, travel clinics and doctors providing circumcision services.

Most concerns fell under the question: Are services safe? The CQC’s main areas of concern related to:

 Safe and effective prescribing;

 Awareness of safeguarding and establishing patients’ identity, particularly for children and their parents or legal guardians;

 Arrangements for clinical oversight, governance frameworks and quality monitoring and improvement;

 Recording details and managing patients’ care records;

 Gaining appropriate consent;

 Sharing information with a patient’s NHS GP or other health professionals in accordance with GMC guidance.

Safety concerns were generally accompanied by worries about effectiveness and being well led. For example, if ‘safe and effective prescribing’ was a safety concern, the CQC questioned the prescribing policy and process – was it created with reference to clinical guidance and best practice in a clinical governance meeting – i.e. effective?

And was it discussed and shared

RATING SYSTEM QUALMS

All independent doctors and clinics will be inspected this year and next and will be rated ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’ against five key questions: safe, effective, caring, responsive and well-led.

An overall rating will also be given.

Those rated overall ‘good’ or ‘outstanding’ can expect to not be inspected again for three to five years. But those rated ‘requiring improvement’ or ‘inadequate’ face re-inspection much sooner.

While most doctors welcome the ratings system, the process is being greeted with some trepidation because whether something is good or outstanding can be subjective – and no two inspectors are the same.

with all relevant staff to deliver appropriately – i.e. well led?

This inspection programme acted like a base line for the CQC’s introduction of ratings for inde pendent doctors and clinics from 1 April.

Findings were used to amend the key lines of enquiry (KLOEs) and assessment framework for inspec tors and are now being used in rat ings inspections.

The KLOEs and the framework can be downloaded from the CQC website. Both give prompts and examples of what inspectors will be looking for in future ratings inspections.

Many doctors felt they got a fair

Dr James McKay, head of the IDF’s regulation committee

The UK’s medical aesthetic event

Uniting surgical and non-surgical medical aesthetic communities to raise industry standards

A look back through our journal’s archives of ten years ago reveals that although times change, some issues are not so new

A trawl through the archives: what made the news in 2009

How to avoid costly splits

Independent practitioners in groups were being warned they would put their businesses at risk unless they had proper ‘who owns what’ agreements.

Money rows over this contentious issue were the biggest reason for break-ups, Independent Practitioner Today revealed.

Our special supplement, Groups – are they the future?, said failure to define what income belonged to a group was the major source of argument.

Accountants warned it was essential to decide what remained the doctor’s sole property.

The second most common area of dispute was how to divide up earnings.

But we urged doctors to beware they did not pay way over the odds for their legal agreements. Some had been charged eight times more than others.

Stung for £500k tax

A private doctor was left reeling after being billed nearly £500,000 for an out-of-the-blue tax investigation going back 20 years. And he only avoided having to pay out a further £200,000 because he was so co-operative with investigators and got professional help to defend him.

Accountants warned that the payback, believe to be the highest

ever for a doctor, underlined the need for high-earning private consultants and GPs to take time out to ensure they kept meticulous business records.

There was no suggestion that the specialist, who endured considerable stress and anxiety over the two-year inquiry, was trying to be fraudulent.

Accountants Stanbridge Associates said: ‘This shows exactly why doctors should take out tax investigation insurance.’

Vow to quit UK over tax

Top-earning private doctors vowed to quit the UK rather than see their tax bill rocket by £250,000.

Two specialists told Independent Practitioner Today the following year’s new 50% tax rate was too much, and they would go abroad.

We reported that the private doctors left behind would face an average £5,000 tax hike and

tougher HM Revenue and Customs’ powers to obtain data and inspect offices in their homes.

PMI thrives in recession

A record number of people were ready to turn to a private doctor, despite the recession.

Association of British Insurers figures showed 6.22m people had either personal or corporate PMI the previous year, with a further 1,111,000 covered through healthcare trusts.

7,335,000 people had some form of private health cover in the UK, a 2.7% rise on 2007.

Warning on fees

The BMA warned consultants that they risked losing control of their private practice if they bowed to increased pressure to hand over billing arrangements to third parties.

The association’s private practice committee claimed third-party involvement in setting and controlling fee arrangements ‘undermines the key principle of the independence of consultant practice’.

The BMA’s comments came in a Good Billing Practice guide issued following controversy over action by BMI and Nuffield, which had slashed radiologists’ pay by 20%.

It said: ‘If a consultant hands over the billing arrangements to

any third party, they risk losing control of their practice, which has happened to some radiologists and pathologists.’

The paper also hit out at AXA PPP Healthcare’s move the previous year to bring in new recognition terms requiring doctors to charge at set fee levels.

The committee advised: ‘Consultants need to be aware that this not only removes their freedom to set their own charges with AXA PPP, but also alters their contractual relationship with their private patients.’

Insurance cheats

Private medical insurance faced increased scrutiny due to a record level of fraudulent claims being made in the insurance industry generally.

Figures from the Association of British Insurers (ABI) showed there was a 17% rise in fraudulent claims the previous year, valued at £730m.

In a separate survey of 3,000 adults carried out for the ABI by YouGov, one-in-five people admitted they would not rule out making a fraudulent claim in the future.

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Keep NHS and private sector in the loop

Data transparency is transforming the consultant’s environment in private healthcare –but more still needs to be done, says David Hare (right)

TRANSPARENCY IS rightly viewed as one of the most powerful drivers in improving the quality of healthcare. It is key to ensuring patients can make the right choices for them.

The independent sector has been making great strides in this area in the last few years and particularly in the light of the case of rogue surgeon Ian Paterson, There is growing acknowledgment that, with both patients and doctors moving between NHS and independent providers, a single source of data across the two sectors is needed.

For example, a significant challenge to the effective operation of the whole-practice appraisal process is that no single dataset or repository of a consultant’s whole clinical practice exists across the NHS and independent sector.

Whole-practice appraisal is designed to cover all of a consultant’s practice, wherever they practise, and this is essential in the effective oversight of consultants in the independent sector.

It is crucial to have a two-way flow of information between the NHS and all independent sector

providers where a doctor works, but this is not always consistently in evidence.

Limiting oversight

However, independent providers report that the standard of NHS appraisal varies significantly, as does the amount of summary supporting information they can see

about the consultant’s NHS work.

This limits the ability to have effective oversight of a consultants’ whole practice.

Providers also report a lack of timely sharing of information between some Responsible Officers (ROs) in the NHS and ROs in the independent sector, as well as uncertainty around the sharing of

It is crucial to have a two-way flow of information between the NHS and all independent sector providers where a doctor works, but this is not always consistently in evidence

‘soft intelligence’ that might or might not be included in an appraisal.

Effective governance

Having a single dataset would enable any healthcare provider across all sectors – granted access by the consultant – to see that an appraisal has been completed. They could also view supporting information on the practice that is required for effective governance oversight.

The system could potentially be developed so that an annual appraisal or revalidation could not be signed off until each of the independent hospitals where a doctor works has contributed into it.

Equally, no single repository of information about a consultant’s various practising privileges arrangements exists in the sector.

The Independent Healthcare Providers Network (IHPN) would support the development of a data repository that could include – but not be limited to:  Indemnity cover;

 Scope of practice;

 Identity of RO;  Appraisal status.

This could be accessible to all

independent hospital providers, the consultant’s RO and insurers and it would have the potential to assist in the speed of the identification of poor clinical standards.

Sir Bruce Keogh is looking into this as part of the Consultant Oversight Framework that the IHPN has commissioned him to develop.

Much credit should be given to the Private Healthcare Information Network (PHIN), as its establishment following the 2014 Competition and Markets Authority order is an important milestone in ensuring consistency of data across the health system.

PHIN is now the independent, Government-mandated source of information about privatelyfunded care across private and NHS-operated hospitals.

Last Autumn, it published its initial performance measures for over 2,000 consultants working across private healthcare in the UK. There is now more validated information

There is now more validated information about individual consultants available in the public domain than ever before for people considering private healthcare

about individual consultants available in the public domain than ever before for people considering private healthcare.

Improve quality

In total, 6,000 consultants, collectively undertaking an estimated 50% of admitted private healthcare in the UK, have been working with PHIN and hospitals to check data on their private practice and improve data quality.

PHIN has also been involved in the launch of ADAPt which, for the first time, aims to integrate data on privately funded healthcare into NHS systems and standards.

The programme is jointly led by NHS Digital and PHIN, in partnership with the Department of Health and Social Care, NHS England, NHS Improvement and the Care Quality Commission. The IHPN is delighted to run the official ADAPt provider stakeholder group to facilitate the independent health sector’s input.

Through integrating data from private suppliers into NHS systems the aim is to improve the completeness of records for patients whose care is split across private and NHS providers.

It will hopefully provide new insights into patient outcomes in the private sector and how they compare to the NHS and play a key role in increasing standards of care in both sectors.

Data transparency has already transformed a wide range of industries over the last few decades, from banking to airlines. The independent sector and NHS’s work towards better data collection and sharing is welcome for the benefit of clinicians and patients alike. 

David Hare (right) is chief executive of the Independent Health care Providers Network

Independent Practitioner Today

ACCOUNTANT’S CLINIC: CASH FLOW

Keep your lifeblood flowing

Many consultants and GPs with busy private practices sometimes lose sight of cash flow management. Cash is the lifeblood of a business and those running businesses are advised to remember that ‘cash is king’.

Susan Hutter gives her five top tips for freeing up and managing cash flow

CREDIT CONTROL

GPs and consultants in private practice should ensure:

➣ Invoices are raised immediately after work is done, either to the insurer, the patient –if they are self-paying – or the employer of the patient, if they are paying.

Many consultants get their personal assistants (PAs) to raise the invoice to the patient at the consultation.

Some do not like doing this, as they feel it is unprofessional, but if you are having problems with slow payers, it is worth considering.

➣ You actually collect the money. Sending out the invoice is one thing, collecting the debt is another.

It is vital that you stay on top of the outstanding invoices situation and check, or get someone else to check, at least every 30 days and chase up the late payers.

Many consultants use a billing service which not only raises the invoices but also deals with debt collection.

➣ Some GPs and consultants have difficultly collecting debts from embassy patients. There are debt-collecting agencies who specialise in this and, if it is a large part of your practice, it is a good idea to use their services.

FACTORING DEBTS

This follows on from using debt collection agencies. If things are still bad, you may wish to look at factoring debts, where a factoring company takes responsibility for collecting the money.

It can be quite expensive and therefore not the first port of call. However, if you find the right agency, it is an effective service.

GENERAL CASH FLOW PLANNING

It is recommended that you keep three months’ working capital in the practice bank account. This covers such things as:

 Salaries, including your own drawings;

 Premises expenses;

 Office and stationery expenses.

Try to avoid having to pay large lump sums in one go. That includes personal and corporate tax liabilities, professional defence cover and even accountancy fees. I recommend that a monthly provision is made for personal tax and corporation tax. As far as other items are concerned, where possible, pay on a monthly basis. If you do set funds aside, it is best to put them in a separate bank account otherwise you may be tempted to spend it.

PAYMENT DUE DATES

Although it is important to try and meet all payment due dates, there is no point in paying early unless you have excellent cash flow. Your PA should get in the habit of filing all unpaid invoices in date order with a carry-forward procedure so that they are paid on time. Often, suppliers will charge a penalty if items are paid late and that is no help to cash flow.

CASH FLOW FORECASTING

Most businesses prepare an annual cash flow forecast. This is a sensible course of action, particularly if it is rolled forward on a monthly basis so that you always have 12 months’ forecast in advance.

Try to avoid having to pay large lump sums in one go. That includes personal and corporate tax liabilities, professional defence cover and even accountancy fees

Cloud-Based Electronic Patient Records and Patient Portal

If nothing else, the forecast will highlight the ‘red spots’ when large lump sum payments are going to have to be made, such as the tax liability. There is no point burying your head in the sand; the forecast may give you the bad news, but it will also ensure that you have time to plan.

If you are unsure as to how to start preparing the forecast, it is worth discussing it with the practice accountant who will be able to give you advice and also assist you with the exercise.

Once the first one is done, it is fairly straightforward to update it. But do not just put the forecast in your desk drawer; this is a living document and should be reviewed at least monthly. 

Susan Hutter (below) is a partner at accountancy firm Blick Rothenberg and part of the team that advises medical practitioners

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THE INDEPENDENT DOCTORS FEDERATION

Giving voice to the private sector

The new president of the Independent Doctors Federation, private GP Dr Neil Haughton, reveals his plans and hopes for the organisation in the years ahead

AT THE Independent Doctors Federation (IDF), we have seen the need to adapt our role and services to the independent medical community and my priority in the next three years is to remain relevant and vital to those doctors.

NHS challenges will only increase and having a strong, cohesive private sector to supplement NHS care is essential.

But we are an easy target, so we must exceed the requirements set down by legislation, regulation, appraisal and revalidation and clinical governance.

The IDF has shown it can take on that responsibility already and is ideally placed to promote excellence, represent its members and enhance the reputation of independent practice to the profession and indeed the nation.

So how can we achieve this?

Embrace

technology

We seem to be at a crossroads where technology may answer the needs of future medical care. Advances in diagnostics, online and digital consultations, artificial intelligence and communication are constantly increasing patient empowerment and accessibility to their healthcare needs.

The NHS is certainly investing millions in technological innovation and the Health Secretary Nick Hancock has made it a priority of his time in office.

Many of our members already feel the same and the IDF is keen to be part of that journey and represent doctors in digital medicine and actively promote such advances.

We are also pursuing direct links with NHS systems to improve communication between sectors. NHS England is already working with us on this project with support from

the Royal College of General Practitioners.

The IDF will also increase its social media presence and online educational services. Education has long been a priority for us and we already have a wealth of topleague specialists and educators among our membership.

This is a huge resource that can be utilised further, but the choice of educational products has increased dramatically in recent years and the IDF must rise to that challenge and be relevant to our members’ needs now.

Doctors are time-poor and understandably might want to prioritise their family over yet another evening lecture, so we can come to you. Our Online Educational Programme will be launched this year and anybody wishing to take part should contact our administrative team.

Regulation

One of the most significant achievements of the IDF in my time on its council and executive has been our ongoing contact with the Care Quality Commission (CQC).

Through this connection, we have helped to educate this inspection watchdog, adjust its policies and influence training of its inspectors concerning the independent sector.

Now, I know this remains a problem for some members who may feel they have not been treated fairly, but the alternative could have been much worse and we assert that constant dialogue is preferable to outright confrontation.

We continue to have monthly phone conferences and regular meetings for members with the

MY PRIORITIES FOR THE IDF DURING MY PRESIDENCY ARE TO:

 Remain relevant and vital to independent doctors

 Launch our Online Educational Programme

 Enhance communication between the NHS and private sector

 Engage with all healthcare regulators, including the Health Secretary

 Engage with all royal colleges

 Represent all private doctors in any setting

 Promote diversity

 Ensure financial security of the organisation

 Always promote the autonomy of doctors and patient choice

executives of CQC. That contact remains vital if we are to be regulated fairly.

Our appraisal and revalidation system has been hugely successful and remains a great draw for many new members who would struggle to find an alternative representative body. Through this, we maintain strong links with the GMC and can guide members through the challenges they sometimes face.

Representation

Doctors are changing. Many will have portfolio careers in both the NHS and private sector, might run their own businesses or be employed by an online GP service or large international hospital organisation.

The colleges and BMA seem to have little grasp of what doctors are actually doing. Even their forms requesting employment information are out of date, given the range of settings doctors may now work.

But the IDF can fill that gap and provide support for specialists and GPs in any independent setting. We are already in conversation with such providers to promote what we can offer and support doctors in those roles.

I believe passionately that the IDF should maintain and increase its representative role to the private medical insurers, the colleges, the GMC and government.

The Secretary of State for Health also has responsibility for the private sector in England and I intend to make contact and promote a dialogue between the IDF and the Department of Health.

The more we reach out to such organisations, the more we will be seen as the ‘go to’ organisation to advise on the independent sector.

We have a strong relationship with the Royal College of General Practitioners and have had many mutually useful meetings, so it seems logical to reach out to other royal colleges with whom we must share members to see how we can benefit each other and increase our profile even further.

This should not just include London, of course, and we have several regional meetings set up to promote our organisation to the many doctors in independent practice across the country.

The colleges and BMA seem to have little grasp of what doctors are actually doing. Even their forms requesting employment information are out of date, given the range of settings doctors may now work

THE FUTURE OF THE IDF

We have existed for over 30 years now and have a strong legacy to uphold, but that is nothing if we do not look forward to the future of private healthcare. We know it will be different and likely better for our patients in many ways, but we are here primarily for the profession.

We will always promote the autonomy of doctors and their entrepreneurial ideas, many of which have led the way in providing enhanced and innovative patient services.

They will then be able to organise their own regional meetings to promote a local network of private specialists and GPs.

We aim to represent any private doctor in any setting – inclusive, not exclusive.

There are also some political outcomes for the country that will need robust defence of our sector if we are to survive.

IDF services

As well as appraisal and revalidation, the IDF has in the past three years sought to provide accessory services to its members, including access to a bespoke indemnity insurance scheme, which may become ever more important if planned changes to the sector are implemented.

We are also developing compliant payment schemes, advice on setting up in practice, mentoring schemes and a new – albeit frustratingly delayed – website, as well as adapting our mandatory training.

These are innovative services and will only survive if we use and promote those services ourselves. I am also open to any new ideas members may have to improve our offering.

Networking

The IDF was set up as a networking organisation and it has been undeniably successful, often combining educational and social events.

In the past, we have, however, been criticised for being too ‘exclusive’ or even ‘unapproachable’. I hope that the coming years will dispel those myths and allow ever more members – especially younger doctors – to benefit from our events as we have done in the past.

We will also always support patient choice as the bedrock of independent healthcare; that is the point of private care and competition between providers raises standards and improves efficiency.

We may not have been good at showing it in the past, but we are getting better at providing the evidence in primary and secondary care to prove the quality of the service we provide.

We are lucky, remember. Our NHS colleagues have the lowest morale for decades and our country seems to veer from crisis to crisis. We have made choices about our careers, get greater job satisfaction and provide the service to our patients that we were trained for. We can now pass that experience on to a new generation of doctors.

Above all we should ‘promote excellence’ – our longstanding motto. By maintaining and improving our standards, embracing regulation and governance, and staying one step ahead of those trying to catch us out, we will remain a strong organisation. The IDF stands for independent doctors, on the side of patients, supporting each other and thereby shaping the future.

We also intend to hold more varied and interesting occasions to tempt you all to join in.

I must also stress the huge contribution our corporate members make to the IDF, without whom many events and services just would not be possible, and I look forward to meeting you all in person in the coming months.

Democracy

This is your organisation and we need your help to contribute to committees, suggest services and help organise events.

There will now be regular elections onto our various committees and board to allow new voices to be heard and inject new blood into the executive.

This must be representative and we welcome applicants from any background; the more diverse we are the stronger our voice will be, and the more representative we will appear.

We will therefore actively promote diversity in all aspects of our work and committees.

Financial security

Ultimately we are a business that relies on our members and corporate sponsors for its income. We are constantly striving to increase membership numbers to ensure financial security for the organisation, but must manage our affairs frugally and transparently within the income and reserves we possess and I personally guarantee that this will hold true.

☛ I am delighted and honoured to take on the IDF presidency this year and sincerely hope I can live up to the achievements of previous holders of the post. I need to thank especially Dr Brian O’Connor (above), who has admirably guided the IDF through a period of necessary change and with his usual professionalism. He has personally helped me in my preparation for the role and he remains a friend and colleague. 

Making access to self-pay easy

The good news for many independent practitioners is that self-pay surgery is on the rise.

The bad news is that the private healthcare sector needs to do much more to make it easier for patients to access. And clearing up price confusion would be a good place to start, argues Keith Pollard (right)

THE INCREASING cost of private medical insurance and growing NHS waiting lists are driving much needed growth in the UK’s self-pay market.

In LaingBuisson’s latest Private Healthcare – Self-Pay UK Market Report , the growth of self-pay is expected to exceed 10%, helping private hospitals to offset the loss of income from insurance and NHS-funded activity.

So, we are seeing renewed investment from all the private healthcare providers in promoting their fixed-price surgery schemes to the uninsured market.

Partly stimulated by the Comp-

etition and Markets Authority’s report into private healthcare, we have entered an era of price transparency in the private healthcare market.

Hospitals are publishing their prices; consultants are publishing their consultation fees. We are entering an era of open competition and consumerisation for selfpayers.

Patients and their relatives are shopping around, seeking out prices for surgery and comparing the offers available for the operation they need but are not willing to wait for in the NHS.

We are entering an era of open competition and consumerisation for self-payers

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Let’s imagine you need a hip replacement and you are not covered by health insurance. Your consultant has told you that there are real problems with the NHS waiting list locally and it could be six months or more before you get your new hip.

You have some savings and decide to look around online to see what it might cost. There are many private hospitals to choose from. How easy is it nowadays to compare what is on offer?

You start with your local BMI hospital. From its home page, you get to a ‘Paying for your healthcare’ page and download a price guide quite quickly and find that a ‘Hip replacement (prosthesis band 1)’ is £10,576.

What is a band 1 prosthesis? Is that better than band 2? You try your local Nuffield. You find a price for ‘Hip Replacement’ of £11,945. There’s another Nuffield near you; it is offering ‘Hip

Replacement’ for £12,980. Same company but a difference in price of £1,000. Is the second hospital better than the first? Or just more expensive?

You try a Ramsay hospital. You can get a ‘Hip Replacement (cemented)’ for £12,180. You are not sure what cemented is all about. Presumably, that means it will last longer?

You could travel into London, as that is where all the best consultants are, isn’t that right? A quick search of the HCA website shows that you can get a ‘Total hip replacement’ for £14,050 or a ‘Minimally invasive hip replacement’ for £13,350.

The second option sounds less painful, but if it is cheaper, is it just as good? And what about the cement? Will it last as long?

You then come across a site called GoPrivate.com. This comparison site – operated by LaingBuisson – shows you a range of

So which one does the patient buy? And how do they compare? Is one surgeon or hospital going to be that much better or worse than the other?

prices across the country – from £9,400 to £15,050 for a hip replacement. That is an incredible range in pricing for what is a complex product.

So which one does the patient buy? And how do they compare? Is one surgeon or hospital going to be that much better or worse than the other? If I pay more, am I going to reduce the risk of something going wrong? If I pay more, will my hip last longer before I need it doing again?

5,000 prices

Within the Private Healthcare - SelfPay UK Market Report, we analysed more than 5,000 fixed-price surgery prices across the country. Here’s what we found:

➲ The price of a total knee replacement varies from £9,559 to £15,202. The average price for a hip replacement is £11,468.

➲ The price of cataract surgery for one eye varies from £1,650 to £3,353. The average price is £2,464.

➲ The price of a colonoscopy varies from £1,270 to £2,900. The average price is £1,990.

➲ The price of a hysterectomy varies from £5,000 to £8,435. The average price is £6,663.

➲ The price of a prostatectomy (TURP) varies from £4,180 to £8,295. The average price is £6,007.

Why such wide variations in price? Is it market driven?

Are costs much higher in one part of the country than the other? It is interesting that London is not necessarily the most expensive place to buy a fixed-price surgery package.

It may reflect the devolution of responsibility for pricing to local hospitals within some private healthcare businesses.

Local hospital managers and directors are given the freedom to set their own pricing levels and to negotiate consultant and anaesthetist fees with their local doctors. However, BMI, HCA and Ramsay set company-wide standard prices.

In the longer term, as consumers become more price-savvy and hospital businesses become more consumer-focused, we are likely to see a closing of the gap between the lowest and the highest price for a private operation.

And, hopefully, the loss of some of the jargon and ‘hospital speak’ that surrounds the private healthcare business. Patients do not have procedures, they have operations. Patients do not get admitted, they come to the hospital. Patients do not get discharged, they go home.

The future of self-pay

In 2017, self-pay accounted for over £1bn of hospital revenue and 20% of the market.

Changing demographics, cuts in NHS funding and lengthening waiting lists will continue to underpin this growth. Also driving growth have been developments such as direct access to private GPs, diagnostics and consultants, the increasing use of technology and increased engagement with the consumer.

It is the last element – engagement with the consumer – that the private healthcare providers need to get right.

There’s a vast untapped market out there of middle-income consumers who cannot afford health insurance and do not access private healthcare – they do not understand it and they think they cannot afford it.

We are a long way from an Amazon or an Expedia of private healthcare where consumers go online, search and compare operations and book with their credit card for an operation next week.

A succession of venture and privately-funded start-ups have tried to make that happen. But they have discovered the hard way that healthcare does not work like that.

Most of them have fallen by the wayside because they over estimated the demand or came to realise that to turn consumer interest into a patient booking required a lengthy conversion process and a sales support team.

Currently, that is lacking in some private hospitals. They are

not yet consumer oriented or sales oriented.

The staff are not in place to manage that conversion process or they do not have the appropriate skills and are drafted in from other roles.

The same applies to the ‘point of first contact’ for many private selfpay patients – the consultant’s secretary. They undertake multiple roles: administrator, book-keeper, customer service representative and sales person. Few are best equipped to handle all that.

Lessons from abroad

In the international self-pay market, companies are emerging that are fulfilling the role of facilitator – or ‘hand holder’ – of self-pay purchase.

In Germany, companies such as Medigo and Qunomedical are operating round-the-clock call centres staffed by well trained and multilingual customer service

agents, who handle the booking process on behalf of hospitals in multiple countries.

Dedicated to the task of converting consumer interest into patient booking, they are reducing the drop-out rate of patients who inquire but do not follow through.

Perhaps, in the UK, there is something we can learn from our European colleagues? Now, that would be something different in 2019.

➲ LaingBuisson’s Private Healthcare – Self-Pay UK Market Report can be purchased online for £850. The report includes a unique and comprehensive price comparison of self-pay prices available from the UK’s private healthcare providers, highlighting the wide price differentials that exist.

 www.laingbuisson.com

Keith Pollard is executive chairman of LaingBuisson International

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PRIVATE PRACTICE GROWTH GUIDE

What are you doing to attract patients?

The Private Practice Growth Guide is designed to give independent practitioners the knowledge and tools they need to develop their private practice.

Whether you are an experienced independent practitioner or are new to private practice, this series by Jane Braithwaite (above) serves as a helpful guide to the exciting, and sometimes confusing, world of healthcare marketing.

Across the six-article series, she explores the roles of marketing strategies, social media, content marketing, email marketing and using analytics to know and grow your audience. This month in her second feature: choosing the right marketing strategy to attract new patients and grow your practice

Keep your goals simple and realistic and have them well in mind as you further develop your strategy

IN OUR article last month, we explored the basics of medical marketing and highlighted the importance of establishing your product, target audience and unique selling point (USP) to form the basis of a marketing strategy. Now for a deeper look at how to analyse your strengths and weaknesses to help you develop your marketing plan and choose a strategy to attract new patients and grow your practice.

Fail to plan, plan to fail All marketing strategies, whether promoting a soft drink, a blockbuster movie or the newest iPhone, start with a basic marketing plan to establish your goals and how you intend to achieve them within your marketing budget.

Your plan may change over time and does not need to be definitive, but it will help you to focus your marketing activity.

Essential elements of a marketing plan include:

➲ Goals/objectives – what do you hope to achieve from all your hard work? This may vary from attracting new patients to your practice, introducing new services to offer to your existing patients, increasing conversion rates from consultation to intervention or increasing satisfaction rates to retain your current patients.

Keep your goals simple and realistic and have them well in mind as you further develop your strategy.

➲Market awareness – who are the users of the products/services you offer? Answering this question may require you to segment your patients into broad categories.

For example, an orthopaedic surgeon may treat several patients over the age of 65 for degenerative conditions such as osteoarthritis, but they may also treat a significant number of 18- to 25-year-olds who participate in high-impact sports.

Of each category, identify the size of the market, consider your competition and establish how best to reach your target audience.

➲ SWOT analysis – what are your strengths, weaknesses, opportunities and threats? Perhaps you have the lowest surgical readmission rates or maybe you have to apologise constantly for inefficiencies within your administrative team.

Understanding what you do well and what you need to improve on is a great exercise to get into the habit of and will help you better target your market.

Keep an eye on your competitors and learn from what they do well and where they can improve.

Also keep your eyes open for new opportunities, particularly if you are targeting a similar audience. Collaborative marketing can help you and your allies to succeed without both shouldering the burden of expensive marketing activity.

➲ Marketing audit – this is your opportunity to reflect on where you are now and will enable you to establish a base line in measuring the success of any future marketing activity.

Do you know how many new patients you saw last year?

Who are your biggest referrers?

What is the most profitable aspect of your practice?

Why do people choose you?

What worked well last year?

Be analytical in your responses and ensure that you develop on previous successes and learn from past mistakes.

Analysis is a vital yet often overlooked part of marketing and you should allocate dedicated time and schedule your activity with monthly, quarterly and annual marketing reports. Ensure that your

admin processes are robust enough to capture important market information, such as referrer details and how and why patients chose you.

Using your marketing plan to develop a marketing strategy

Converting all the information you have obtained as part of your initial plan and developing it into a step-by-step approach may seem daunting at first, but will save considerable time and expense later.

You now know what products

and services you wish to market, your current standing within the market and the audience you wish to target, but how do you get your name out there?

Getting your name out there in four easy steps

Traditional marketing within other industries, such as retail or car manufacturing, is based on four key stages designed to attract the attention of customers and direct them towards a final sale.

In medical terms, we are attracting the attention of patients and referrers instead of customers, and our ‘final sale’ might be an appointment booking for a new patient.

The steps to success remain the same as follows:

1Outreach – the initial contact from you or your practice to potential patients. This may include sponsored ads on Facebook, dedicated website land-

CASE STUDY: APPLYING THEORY TO PRACTICE – HOW TO IMPLEMENT A STRATEGY USING DATA YOU COLLECT

Let us imagine for a moment that you are a consultant dermatologist who has been practising privately for a year.

You practise from a single location in central London and have slowly built up your practice, but are not yet at full capacity. Let us explore the various points of a marketing strategy in a simple study and think of ways to develop your practice.

Goals/objectives:

 Increase number of new patients by 10% each year.

 Increase number of Botox injections administered for hyperhidrosis by 25%.

Market awareness:

 50% of your patients were referred by a GP and the other 50% found you online.

 90% of your patients were women between 30-50 years of age and the other 10% were men within the same age group.

 You received 97% satisfaction on a recent patient feedback survey.

 A rival clinic next door offers Botox injections for 10% less than you charge but charges 10% more than you for consultations.

SWOT Analysis:

 Strengths – Excellent patient feedback, competitive fee for consultation.

 Weaknesses –Intervention more expensive than the competition.

 Opportunities – The self-funding market has grown 10% in the past year.

 Threats – Rival dermatology practices, other practitioners offering Botox injections, market share of male population is low.

Now let’s apply a strategy that helps us to achieve our targets, while considering the various threats and competitors that could hinder our efforts. We will use the sales funnel concept to help structure our strategy, but this is just a guide.

Outreach

Curate ‘evergreen content’ on a range of dermatological conditions and treatments and post these twice a week to our social media channels and website.

Invest in pay-per-click (PPC) ads on Facebook and target our core audience of women between the age of 30 and 50 years with content about hyperhidrosis and the use of Botox as a treatment method. Consider offering packages that include consultation and treatment at a lower cost.

Create targeted content for GPs which leverages our exceptional patient feedback and low consultation fees and provide our top referring GPs with a personal mobile number, so their calls are never missed.

Conversion

Our outreach content directs patients to specific landing pages of our website where they can learn more about the services we offer, prices for treatment and how to make a booking.

All of the information on these pages needs to be up to date and clear, and our administrative team also needs to be aware so it can quickly respond to inquiries. Our administrative team should also know the associated costs of any services or products we are actively marketing, as well as the referral process involved.

Closing

Implement a Livechat feature on our website to quickly answer any questions from website visitors and ensure our phone lines are picked up within three rings, with a call answering service taking any unanswered calls. Provide appointments for acute conditions as quickly as possible and consider reserving slots for emergency or priority bookings. Be mindful that if patients are asking to be seen on certain days or at particular times,

then ensure your clinic times respond accordingly.

Retention

Understanding that 90% of our business is made up of women between the ages of 30 and 50, we create a newsletter that explores why so few men choose to make an appointment with their dermatologist and discuss the dangers of ignoring early warning signs.

To encourage women to refer their husbands, brothers and sons, we introduce a 10% discount on the cost of initial consultation for patients referred by an existing patient.

Analyse results

With our very simple strategy in use, we measure the results of our efforts by monitoring the number of new patients and number of Botox injections on a monthly basis. We should continue to change our strategy as required and keep a clear view of our initial goals and objectives. We should remember also to perform a SWOT analysis at regular intervals to see where the market is moving and learn from the successes and failures of our competitors.

Conclusion

Creating the right strategy to attract new patients and grow your practice does take time and you won’t necessarily get it right the first time.

It is crucial to keep a record of your marketing activity and to continually develop on your previous successes or learn from your mistakes.

Always keep in mind your goals and objectives and ensure these are realistic. Being ambitious is great, but if you continue to set objectives beyond your reach, you might rule out a winning strategy too soon.

ing pages for a new service, infographics and curated content designed to entice patients to your website.

2

Conversion – the process of taking a potential patient direct to your website. The goal is to capture the patient during the outreach phase and entice them to contact your practice for further information/appointment booking. Blog posts, testimonials and case studies are all valuable tools for conversion.

3

Closing – getting the patient booked in. The patient has seen your advert and read your blog and wants to make an appointment. This should be as easy as possible for the patient and you should ensure that your outreach and conversion content contain all of your contact information. Livechat tools on your website are

Each patient who enters your practice brings with them an extended network of friends, family and co-workers, and they can become your greatest advocates if you provide an exceptional service

a great way to expedite this process.

4

Retention – keeping the patient. Depending on your field, your patients may see you only once or they may need to come back over a period of months or even years.

Regardless of their frequency, each patient who enters your practice brings with them an extended network of friends, family and coworkers, and they can become your greatest advocates if you provide an exceptional service.

Ensure you are always obtaining feedback from your existing patients and consider exclusive offers and contests that will keep them thinking about you, even when they don’t need you.

Your marketing strategy will require content for the various stages and you should have this finalised before you begin your marketing push.

A great way to start is by curating ‘evergreen content’ – that is to say, content that you only have to create once but can be applied all year round for a variety of purposes. Evergreen content may include your top tips for injury avoidance or spotting the early signs of a condition. The goal is to be informative and to establish some core pieces of content that can develop alongside your specific marketing goals.

 In our next article, we will explore the newest and fastestgrowing frontier of medical marketing: social media. Readers are encouraged to familiarise themselves with Facebook, Twitter and Instagram to get the most of it.

Jane Braithwaite is managing director of Designated Medical, which offers business services for private consultants, including medical secretary support, book-keeping and digital marketing

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Is your ambulance OK?

Alarm bells are ringing over the state of independent ambulance services, following a Care Quality Commission investigation. Sally Taber (right), director of the Independent Sector Complaints Adjudication Service (ISCAS), puts the spotlight on the problems and gives a check list for ambulance service purchasers to get a safe service for their patients

MANY SMALLER healthcare enterprises, particularly those operating outside the NHS, use independent ambulance service providers.

I fear they may inadvertently be introducing undesirable risks for their patients and for their own practice if they do not thoroughly check standards of delivery.

On the 31 January 2019, there were 246 independent ambulance service providers registered with the Care Quality Commission (CQC), covering 286 locations.

These ambulance service providers are robustly independent businesses, highly individual and intensely competitive. Three trade associations compete for their membership and have in the past been resistant to imposed regulation.

Compared to the modern healthcare scene, many providers come across as quaintly scatty and

rather badly out of date in matters of best patient care. The independent ambulance services sector is often short on healthcare knowledge and practises, and the result is increased risk for patients and those who have them in their care.

The sector could not be left to its own devices and was therefore investigated by the CQC, starting in 2017, measured against markers of safety, effectiveness, caring, responsiveness and good leadership.

‘Significant risk’

I welcome the CQC’s second report, The State of Care in Independent Ambulance Services , published last month ( Independent Practitioner Today , April 2019). It highlights the need for independent ambulance providers to learn through experience how to improve service and safety. It said:

‘From the evidence we have seen, we believe there is significant risk in the sector.’

I was director of nursing at the London Bridge Hospital in the late 80s and early 90s, responsible for ensuring ambulances met our expected standards. I saw at first hand the good, the bad and the utterly unsuitable as they presented themselves for selection.

The good I hired again. The bad generally lacked appropriately qualified staff and could try again. The utterly unsuitable were not even considered.

My next involvement was when the regulator, now the CQC, asked if the Independent Healthcare Advisory Service would consider including independent ambulance services in its membership.

Together with a colleague, Andrew Wilby, who has a regula -

tory background, I joined the meeting between the regulator and ambulance service representatives. It can only be described as a bun fight. Several providers wanted no regulation and saw no need for it. Andrew and I quietly retreated, hoping that realisation would one day dawn upon the ambulances.

Main inadequecies

Our concerns were shared by others. In April 2013, shadow Health Secretary Andy Burnham issued a press released entitled ‘Labour warns on private ambulances’, in which he pointed to inadequacies in staffing and equipment. It took until 2017, by when CQC had worked sufficiently far down its higher-priority risk areas, for it to visit the first 70 ambulance providers. Leading inadequacies found to be commonplace in the sector were

A SIMPLE CHECK LIST FOR CONSULTANTS, GPs, HOSPITALS AND ORGANISATIONS

Personally, I consider the sector redeemable. Especially so if all healthcare professionals with patients in their care will safeguard them by insisting on at least a minimum of safe quality ambulance performance, then providers will respond.

So here is a brief check list by which to distinguish between the lowerrisk and the higher-risk independent ambulance providers you may be doing business with.

 Has the independent ambulance provider been inspected by CQC? Check the report on CQC website. Does it belong to one of the associations? If not, place in the higher-risk category.

 Has the provider got a complaints process with an independent review stage? If not, it is avoiding CQC core service frameworks. Do you want that? How does it learn from mistakes anyway? High-risk.

 Is there a governance framework with clear responsibilities, roles and systems of accountability including driving licence categories? Did it show you this and were you satisfied it is as good as yours? If not, high-risk.

 Is cleanliness, infection control and hygiene seen as a priority? If not up to CQC requirements, place in high-risk category.

 Environment and equipment – has it got the right equipment? Would you trust it to transport a high-dependency patient of yours?

 How does the provider ensure the proper and safe use of medicines? Does it have robust policies for the delivery of medication? Match against your own clinic’s and place any who do not measure up in the high-risk category.

 Ask to see its Home Office licences for the procurement and storage of drugs. If absent, place in high-risk category.

 Have staff got the skills, knowledge and experience to deliver care and to include what training is provided? Do a subjective assessment of their declared skill-set against your professional needs for the care of your patient.

 Is consent to care and treatment always sought in line with legalisation and guidance? See the evidence. If inadequate, place in high-risk category.

 Are patients treated with compassion, kindness, dignity and respect? You can only tell by checking there is a rigorous complaints policy with, if necessary, an independent scheme for resolving unresolved issues.

 Is its leadership capable of delivering high-quality sustainable care? If inspected by CQC, check the CQC report online.

 Is the service delivered under the direction of a registered healthcare professional?

 Does it have a risk register? Is that up to date? If not, high-risk.

 Patient handover protocol has been identified as an area of concern by the CQC. Is this an area that the provider has addressed? If not, high-risk.

 Does it deliver a positive safety culture and ensure incidents are reported appropriately? A written protocol at least should be in evidence.

 Where are the vehicles stored? Would you keep your clinic equipment there?

 Is it providing the service itself and not sub-contracting? If subcontracting, treat with suspicion and expect appropriate protocols evidenced in the sub-contract.

for medicines management, cleanliness and infection control, recruitment practices and safeguarding.

As in every other business, regulated or not, the way an ambulance provider handles complaints is central to their understanding of their place in the eyes of their clients. A complaint is a gift because it shows how others see them as no other test will and, if whatt they see is ugly, then here is a chance to get it right.

That is why I believe that it would be beneficial for private ambulance providers to subscribe to the ISCAS code for the handling of complaints. Shared problems, shared solutions, using the impartial tried and tested route offered by ISCAS, would be very well suited to the independent, competitive nature of the sector.

Private ambulance trade associations

There are three professional associations: the National Association of Private Ambulance Services (NAPAS), the British Ambulance Association (BAA) and the Independent Ambulance Association (IAA).

ISCAS is currently discussing with the BAA its offer of help to install the tried and tested independent sector complaints process and so to help meet the CQC recommendations on learning from complaints and concerns. It will be modelled upon the successful ISCAS process used for the Independent Doctors Federation.

This is how it would work. A BAA member adopts the ISCAS code for handling complaints. This includes consent to the adjudication process, including release of all relevant records from the

ambulance company to ISCAS, such as relevant medical records and complaint correspondence.

The BAA will manage the record collection from its member to facilitate the independence of ISCAS from members and ensure all necessary documentation is provided for adjudication.

The independent adjudicator provided by ISCAS produces a report of the findings and judgements prepared for the complainant and copied to BAA and its member. This is produced within four weeks unless there are delays due to case complexities.

The independent adjudicator is responsible for keeping the complainant informed of progress and ISCAS is responsible for the delivery of the service and general communication, including communication with the BAA.

One must ask: ‘Why three associations?’ It seems that the competitive nature of the sector brings a lack of willingness to share knowledge and learn from other providers.

I hope the associations will start to work forward using techniques practised in other competitive sectors for anonymising information exchange. The recent start of publishing CQC inspection reports for ambulance providers will, no doubt, be a stimulus.

The CQC now rates independent ambulance compliance and publishes its findings openly. This is an essential source of independent information for purchasers of private ambulance services. Let us hope that the sector will work towards one trade association and being party to ISCAS. 

Be an ‘expert’ witness

If you are working as a medical expert witness, then there are a host of things that can trip you up. Here’s 20 to watch out for –outlined to over 100 consultants and GPs at this year’s annual BMA’s medico-legal conference by Augustus Ullstein QC

THINGS CAN – and have – gone horribly wrong for doctors who are called to give evidence as expert witnesses.

It is all too easy to make a mistake and weaken your professional credibility – and your mishaps can be a gift to the other party.

The BMA called in deputy judge Augustus Ullstein, formerly of 39 Essex Chambers, to give some sound counsel. And here are his words of advice.

1

2

Re-read your report before you go to court.

Know where the court is and if it is a big one, then do make sure you find out in advance exactly where your hearing will be located.

3 Go an hour beforehand to get a feel of the court, then you can see what ‘traps’ there could be, such as something in the layout that could embarrassingly trip you up on your way to the witness box.

4

Once in the witness box, wait to be asked to sit down by the judge. Remember, the most important person is the judge. You

should be talking to him when you give your evidence. Move your chair to slightly face him or her.

5 Watch out for the chair in the witness box. Some are on rollers and if you were to push back too hard you would tumble out.

6

When affirming, make sure you are given the right card. There have been occasions when people have picked up the interpreter’s oath card.

7 Keep up your voice volume. 99% of the microphones in court are for the benefit of recording, not for the people in the room.

8 Only answer the question you are asked.

9 Try and speak reasonably slowly. Watch the judge’s pen. If you gabble, then he won’t be able to keep up. Speak in paragraphs.

10 Take nothing at face value. Don’t keep looking for supposed traps, though, when being questioned or you will be constantly digging a hole for yourself.

11

12

Don’t try and defend the indefensible.

If you are referred to a document, don’t try and answer a question without going to it and reading it.

13

If you try and be clever and answer the question without looking, then the chances are you will misremember what is in a document.

Say: ‘Remind me where that is in the bundle’ – look at it and only then answer the question.

14

If you cannot remember something, it is better to say so rather than make a guess – a guess will probably be wrong.

You may have examined the patient months before the trial. There’s no shame in not remembering.

15

Don’t argue with a legal counsel. It is not for you to say the question is irrelevant. That is a matter for counsel or judge.

16

Don’t be an advocate for your side. Your duty is to the court. Leave the advocacy to the advocates.

17 Don’t be put off what you are saying by any particular habits of the counsel questioning you.

18 One technique in examining experts is to say things they know will be agreed with. When this happens, watch out you don’t end up agreeing accidentally to their killer question.

19

If you need a break, don’t be afraid to ask for one. Judges will normally be perfectly amenable to giving people a fiveminute break.

But don’t ask for a break when you have just been asked a really difficult question.

20 If you are in the witness box and there is a break for lunch, don’t forget you must not discuss your evidence with anybody. So it is best to keep yourself in purdah, because if you are seen with your people, it can raise suspicions that you are discussing the case. 

Augustus Ullstein sits on the Council of the Academy of Experts and has taught expert witnesses for over 20 years

MEDICAL RISK SERVICES LIMITED

Disciplinary threats add to fears of negligence claims

An innovative new service provides practitioners with advice and comprehensive support in the event of aggrieved patients seeking retribution. Peter Anderson reports

FACING COMPLAINTS from a dissatisfied patient can prove a time-consuming and costly experience for any medical practitioner.

Negligence claims can frequently drag on for lengthy periods, leading to hefty legal bills and the potential for considerable reputational damage.

But for many surgeons, there is an equally worrying consequence – that a patient’s grievance could also lead to the loss of a licence to practise.

These concerns are only too clear to insurance specialist Medical Risk Services Limited (MRSL), which has been providing support and advice to medical practitioners for the past 15 years.

According to Roger Houston, MRSL’s co-founder: ‘In recent times, we’ve seen negligence claims becoming ever more closely intertwined with disciplinary complaints. Lawyers acting for aggrieved patients will frequently advise their clients to lodge a complaint with a medical regulator ahead of launching a negligence claim.

‘Their thinking is that a grievance over a practitioner’s alleged negligence will be easier to win if a complaint to a regulator has already been upheld.’

The prospect of a practitioner being brought before the General Medical Council (GMC) or the General Dental Council (GDC) has been a key factor behind MRSL launching a ground-breaking new service for medical professionals.

The company’s Healthcare

Professional Protection provides practitioners with advice and comprehensive support throughout a potential disciplinary complaint or negligence claim. It means medical professionals have proven experts at their side, with MRSL’s extensive experience in the insurance sector meaning that industry-leading, value-formoney indemnity cover is also provided as a back-up.

Meeting high standards

Mr Houston explained: ‘Disciplinary claims against practitioners are all about professional conduct. The overriding issue in any complaint is whether a surgeon or other health provider has met the high standards expected by the GMC, the GDC or the profession at large.’

He added: ‘This means that running a defensible and welldocumented practice is now more crucial than ever – for example, in ensuring evidence is available that individual patients consent-

ed to a procedure only once they were fully aware of the potential risks as well as the benefits associated.’

MRSL, a highly successful provider of insurance, advice and services to practitioners, has been working since 2004 to help doctors and medical businesses mitigate and manage their risks and reduce their indemnity costs.

The launch of the company’s Healthcare Professional Protection has been made possible by MRSL’s extensive experience, together with the unique skill set of its senior team.

Mr Houston is a former director of operations at the NHS Litigation Authority (now NHS Resolution), while other key players include MRSL director Dr Robert Baylis, a consultant anaesthetist and practising pain management consultant.

The team also includes MRSL director Christopher Cloke Browne, a PhD engineer and data analytics expert who joined the

business following a highly successful career in insurance and financial services.

The expertise within the business has been broadened further over recent months through close working collaborations developed with leading practitioners in higher-risk specialties.

These include Mr Munchi Choksey, a highly respected consultant neurological and spinal surgeon with 40 years’ medical experience. A former NHS consultant and assessor for the Intercollegiate Examination in Neurological Surgery, Mr Choksey now works as a private spinal neurosurgeon at the Nuffield Hospital.

Highlighting the scope of MRSL’s new service, Mr Cloke Browne said: ‘Healthcare Professional Protection begins by advising medical practitioners on the elements that make a defensible practice. In the event of a patient grievance being raised, we work closely with practitioners from the very start, to ensure that the accusations are contained and rebutted.’

He added: ‘The focus of the service is to protect a practitioner’s licence and professional reputation. MRSL’s broad experience and expertise mean that indemnity is also provided as a strong backstop in the event that a patient has experienced a genuine, unforeseen injury.’

If there is a risk of a complaint progressing, the MRSL team will utilise its database of current, respected practitioners in order to produce a supportive breach-ofduty report.

Through its extensive dealings with the medical profession, the company is aware of a broad range of potential grievance issues on which practitioners frequently feel vulnerable or uncertain, and on which having access to first-class advice and support is therefore so valuable.

These concerns can range from patients’ complaints about nonsurgical aspects of their care to a consultant’s potential exposure when working as a locum practitioner.

Such grievances throw up a range of issues – for example, a patient’s insistence that their complaint is dealt with by the individual surgeon rather than the hospital or medical establishment itself.

In each of these instances, the scope and wording of a surgeon’s working contract are of paramount importance, whether the initial arrangement comes via a

Above: MRSL co-founder and CEO Roger Houston

hospital, a locum agency or even a long-standing friend or professional acquaintance seeking short-term support.

MRSL’s experts are on hand to offer guidance and practical support, both on the broad legal issues and the fine detail of a specific contract.

Another area of considerable

‘‘We’ve seen negligence claims becoming ever more closely intertwined with disciplinary complaints. Lawyers will frequently advise their clients to lodge a complaint with a medical regulator ahead of launching a negligence claim Roger Houston

‘‘concern for practitioners – and on which Healthcare Professional Protection can advise – involves access to medical notes following a patient complaint.

This has the potential to be a considerably thorny issue – for example, through an individual hospital handling all administration associated with a procedure

but then insisting that notes can only be released to a surgeon with the consent of the hospital’s legal team.

Mr Houston explained: ‘There are countless scenarios under which a surgeon, doctor or other medical practitioner might require advice and day-to-day practical support. For MRSL, it’s all about being the trusted partner at their side.

‘Whether a practitioner faces reputational damage, the loss of their licence to practise or potentially escalating legal bills, we see our Healthcare Professional Protection as offering vital and unparalleled support, expertise and advice.’

For further information on Healthcare Professional Protection and for details on MRSL’s broader range of services, please contact 0203 058 3733, email enquiries@mrslenterprise.com or visit www.mrslenterprise.com

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l

l

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Boosting my cash flow

Consultant cardiologist Dr Dinos Missouris

describes

how outsourcing helped

him to ensure that his growing practice was in good financial health

A LOT OF my time and energy since starting in private practice in 2001 has been focused on growing my private practice and developing my reputation.

As my practice grew, the increased workflow put more and more demands on me and required me to take on a medical secretary to help with practice administration.

More recently, I started to feel that, despite working hard with a busy practice, my cash flow was not mirroring the work I was doing.

When I started to review the

finances of the practice, I found two main problems: I was not getting the visibility that I wanted on my aged debt and the information when provided was not always accurate or up to date.

I discussed this with my personal assistant (PA) and it became clear that one of the issues was the demands of the modern patient.

The need to respond in a timely fashion to patient emails and phone calls meant that the invoicing, reconciliation and chasing of outstanding debt for the practice was always being interrupted or delayed.

The growth of my practice had contributed to it becoming cumbersome to manage

I had not appreciated the considerable amount of time that was being taken up by this task and the impact it was having on the rest of the practice. In fact, the growth of my practice had contributed to it becoming cumbersome to manage.

On top of this, the requirement for some of the insurance companies to only take invoices electronically, combined with the difficulty my PA was having in contacting some of the insurers to resolve issues, had added to the problem.

My age debt was running at 20% and so I knew I had to take some form of action.

Placed in ‘intensive care’ I had heard of Medical Billing and Collection (MBC) through some colleagues, so I contacted Simon Brignall, its director of business development. We had a detailed conversation about my practice and then a meeting with my PA to establish the issues.

My account was initially placed in an ‘intensive care’ process and a dedicated account manager was able to assist my PA with the transition process and to focus on the backlog of outstanding debt that had built up.

The result of having specialised staff focus on this area of my practice meant that after eight months they had collected over 90% of my outstanding backlog of debt. This was great, because some of

THE BILLING COMPANY’S VIEW

Simon Brignall (right) of MBC told Independent Practitioner Today: ‘As part of our “intensive care” process, Dr Missouris’s outstanding invoices were loaded onto our system. These invoices were run through our chasing process and any queries that arose from this were managed in an orderly manner with Dr Missouris’s medical PA.

‘I think the figures speak for themselves. If your practice bad debts are greater than what you would pay a billing company, then you are already losing money.

‘To this figure, add the cost of business lost because the phone was engaged as your secretary is chasing debts.

‘There is always an opportunity cost to having your secretary carry out this role, even if you are paying her. Remember, some secretaries feel uncomfortable chasing money or just have a different skill-set that is not suited to this task.

‘Some consultants feel embarrassed about handing over the accounts that may appear disorganised and they waste time trying to tidy them up. This is not necessary, because the sooner that we have the information, the sooner we can start solving the problem.

‘The fact that our fees are calculated on received income means that you know we share the same objectives.

‘It is important to adapt your business structure as turnover grows and to also ensure that you align different skill-sets to specific tasks to guarantee that your practice is managed effectively.’

this debt went back to invoices raised in 2016, so it was over two years old. And, so far, I have only written off £250 from the backlog.

I also now get the visibility that I wanted, as I have access to up-todate financial data for the practice from an online system which is available 24/7. If required, I can also ask my account manager for a report.

Happier PA

This means I am now confident that the credit management side of my practice is being managed professionally. The fact that I have not yet written anything off since choosing to partner with MBC confirms this.

My PA is also much happier, as he no longer has to carry out the billing and reconciliation function.

This enables him to keep his relationship with the patient focused purely on the clinical side of the practice, having removed the need to chase for money.

The billing company has been able to advise me on all aspects of the financial side of my practice to ensure I am now billing efficiently. It has also added a range of new capabilities such as being able to take payments by debit or credit card without maintaining my own system to achieve this.

What I would pass on to other consultants from my experience is to not to let your practice outgrow your current arrangements or a growing practice hide the fact that your practice is not as financially healthy as it could be. 

Dr Dinos Missouris (right) works in private practice at the Spire Thames Valley Hospital, Slough, BMI

Princess Margaret Hospital, Windsor, and the Bridge Clinic, Maidenhead, Berkshire

LAST YEAR may have been a disappointing year for equities – but it shouldn’t have been a surprise.

December 2018 dished up a rather distasteful present for the holiday period. Many lines were written in the broadsheets about the global equity market falls, but were they really anything out of the ordinary?

‘Stock market slide in 2018 leaves investors bruised and wary’ read a headline in the Financial Times on 31 December 2018.

Since 2009, the bottom of the market during the credit crisis, global markets have delivered positive returns in eight out of the ten calendar years.

The last negative year for equities was back in 2011, when the markets were down around 7%. Over the history we have available to us – on average – one in three years delivers a negative return. Investors have, of late, been extremely lucky.

Since 2008, in every single year, investors have suffered a fall from a previous market high and many of these falls were larger than 10%.

However, even investing at the start of 2008 and suffering the 35% peak-to-trough fall in 2008, an equity investor would have turned £100 into £230 – that is 8% compounded over 11 years – if they had been disciplined and patient – two known areas of human weakness.

Strange view

As humans, we tend to have a strange view of what invested wealth represents and how we feel about it at any point in time.

We tend to be happy as wealth –at least on paper – goes up to some value at a specific point in time and unhappy when we reach that value again, if it is achieved after a market correction.

Remember, the true meaning of wealth is having the appropriate

As humans, we tend to have a strange view of what invested wealth represents and how we feel about it at any point in time

level of assets that you require, when you require them, to meet your financial and lifestyle goals. In the interim, movements in value are noise, somewhat meaningless and part and parcel of investing.

When you invest in equities, you should try to avoid mentally banking the money you (appear to) make on the undulating, and sometimes precipitous, road you are on.

Remember, too, that the headline equity market numbers are unlikely to be your portfolio outcome, as most investors own some sort of a balance between bonds and equities.

Keeping things in perspective Investing in equities is always going to be a game of two steps forward and one step back. What equities deliver from one year to another is of little consequence to the long-term investor, who does

not need all their money back today.

As far as 2019 is concerned, no one who is honest knows what will happen in the markets. The global economy is still set to grow by 3.5% above inflation this year, according to the International Monetary Fund, which is not that bad.

Price movements

Today, market prices reflect the aggregate view of all investors based on the information to hand. If new information comes out tomorrow, prices will adjust to reflect the impact this has on company valuations.

As the release of new information is random, so too must price movements be random, at least in the short term.

Over the longer-term, they reflect the real growth in earnings that companies deliver through their hard work, executing the

PROBLEMS WITH THE TAX MAN?

delivery of their business strategies.

In the longer-term, investing in the stock market is a game worth playing, at least with part of your portfolio. 

Dr Benjamin Holdsworth is a director of Cavendish Medical, specialist financial planners helping consultants and GPs 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.

HMRC tax investigations and disputes create difficult and stressful times.

As an award winning firm of tax experts, our highly experienced partners specialise in resolving problems relating to tax investigations and disputes with HMRC.

To find out, in confidence, how we can help call 0800 734 3333.

‘Here to help. Not to judge.’

KEEP IT LEGAL: MAKING A WILL

Ensure you pass it on when you pass on

Half of the adult population dies intestate. Don’t let that happen to you. A will is one of the most important documents doctors in private practice will ever write. Fiona Wilson shows why

Contrary to what many people think, if you are not married or in a civil partnership, however long you have been living with your partner, they will not be entitled to anything. There is no such thing as a ‘common law husband or wife’

INDEPENDENT PRACTITIONERS

need to carefully consider their financial affairs throughout their professional lives and into retirement, keeping their will under periodic review.

Here are seven good reasons why you should make one.

1 Control

The most important reason for making a will is that it puts you in control so that you choose who benefits from your assets when you die and in what amount.

It also means you can name who you want to administer your estate to ensure it is done properly.

Your will need to take account of any declaration of trust, partnership agreement, limitedliability partnership (LLP) agreement or shareholders’ agreement you may have in place in your practice.

The transfer of shares in a company will often be governed by its

articles of association/shareholders’ agreement. How a share of the value in an LLP is dealt with on death is often set out in a members’ agreement.

Both need to be looked at carefully to ensure they are appropriate and do not contradict the terms of your will – thus inadvertently creating difficulties for your loved ones after your death.

2 Choice

If you don’t leave a will, then everything you own will be divided up in accordance with the statutory intestacy rules.

These also dictate who administers your estate, which could mean that the burden falls on those least able to do so through geography, age or ill-health.

So, in simple terms, if you are currently married or in a civil partnership and you have children and your estate is valued at more than £250,000, your partner will

inherit all your personal belongings together with the first £250,000 of the estate and half of anything that remains.

The other half passes to the children. If there are no children, your partner will inherit the whole estate, but if your partner has already predeceased you and you have children, then they will inherit the whole of your estate.

The exception to this is where there is property owned as beneficial joint tenants where the surviving owner automatically inherits the other’s share irrespective of any will.

Contrary to what many people think, if you are not married or in a civil partnership, however long you have been living with your partner, they will not be entitled to anything. There is no such thing as a ‘common law husband or wife’.

And what if you are widowed, ➱ p42

Free legal advice for Independent Practitioner Today readers

Independent Practitioner Today has joined forces with leading healthcare lawyers Hempsons to offer readers a free legal advice service.

We aim to help you navigate the ever more complex legal and regulatory issues involved in running and developing your private practice – and your lives.

Hempsons’ specialist lawyers have a long track-record of advising doctors – and an unrivalled understanding of the healthcare system as a whole.

Call Hempsons on 020 7839 0278 between 9am and 5pm Monday to Friday for your ten minutes’ of free legal advice.

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Tania Francis m.rourke@hempsons.co.uk t.francis@hempsons.co.uk

divorced or never married at all and have no children?

Then the situation becomes even more complicated. There is a set list of entitlement ranging from parents to siblings, grandparents to uncles and aunts, all in order.

Each class must be exhausted first before the next can be considered and if any have predeceased you, then their descendants take their place. If there are none, then your estate is said to be ‘bona vacantia’ and will pass to the Crown.

3 Cost

You may think this is unusual, but I have two estates currently, one where there was no will and the other, sadly, where there was a will but the only beneficiary named has already died.

Both estates will now be divided between the descendants of the deceased’s uncles and aunts.

These were elderly clients and so we are looking at uncles and aunts born in the late 19th century when families tended to be large, so we are having to trace all the descendants of up to 15 uncles and aunts in each case.

This is a huge task and an expensive one where the assistance of professional genealogists is essential.

This is very time-consuming and will greatly delay matters, and the expense will greatly reduce the value of the inheritance. A simple will, or in the latter case, a will that made some alternative substitute provisions, would have avoided all of this.

Making a will means that you can distribute your estate in the most tax-effective way possible saving your beneficiaries money.

It may be better, for example, to pass assets down a generation rather than leaving everything to your partner. It may mean that you should make maximum use of the various exemptions to which you are legally entitled.

Everything passing to a surviving spouse or civil partner will be tax-free, but anything else will be taxed at the rate of 40% over and above your tax-free band at death, currently £325,000 – less any prior gifts in the last seven years which reduce this – and the residence nilrate band, if applicable.

Making a will means that you can distribute your estate in the most tax-effective way possible saving your beneficiaries money

6 Charity

If you die without a will, you will never have the opportunity to leave anything to your favourite good causes. And if you don’t have any surviving relatives … and even if you do, you may not wish them to benefit from everything you own.

How best to deal with business assets is also an important factor. Professional advice will ensure that you arrange your affairs in the most appropriate manner.

4 Challenge

Unlike most parts of the world, we have complete testamentary freedom, so we can leave our possessions to whomever we want without any constraints. But wills can be challenged in suitable circumstances if someone considers that they ought to have been a beneficiary and they fit the legal criteria.

An unmarried partner you have been living with may find that this is the only way to make a claim to any part of your estate, which is upsetting and expensive.

But if you really want to avoid leaving something to a family member, a professional can advise you and help you do all you can to reduce the likelihood of a legal challenge to your will.

5 Children

Who will look after your children if they are under the age of 18?

If there is a surviving parent, then that is simple; but what if there is no surviving parent?

A will enables you to appoint those people whom you would like to look after your children should the worst possible scenario arise.

They do not have to be the same as your executors. You may choose executors who are best equipped to deal with the financial aspects of your estate, whereas your children’s guardians could be those whom you know will provide the loving home that you would want for your children – to give them the emotional support they need for the future.

Remember that gifts to charity will generally be tax-free and if you leave at least 10% of your net taxable estate to charity, then this will have the effect of reducing the overall rate of inheritance tax on your estate from 40% to 36%.

7 Calm

How much better it is to know that, when you die, everything will be dealt with in accordance with your wishes.

Otherwise there will be dreadful uncertainty for your family in ascertaining who is going to benefit from your estate and how it is going to be dealt with. And in extreme cases, just think of all the extra time and cost that dying without a will could mean.

If you instruct a solicitor to prepare a will for you, the Law Society will be able to help provide details of local firms close to you, as indeed will the Society of Trust and Estate Practitioners (STEP). The most important thing is to consider whom you want to benefit first, before you talk to anyone. You should preferably prepare a brief list of your assets for them beforehand to get the most out of any meeting. This will not only make it more cost-effective, but time-productive too, so that you can get a professionally-drawn will right away.

If you have a complicated family or assets, then do make sure you get the proper level of advice. A bit more time and money spent will pay dividends in the end. 

Fiona Wilson (below) is head of the private client department and a partner at Hempsons solicitors

Dilemma 1

Can I take father off practice list?

QI have been seeing a family with two children who have been my patients for the last couple of years. The father has always been difficult to deal with, is very demanding and can be quite intimidating.

One of the children has developed asthma which has resulted in the need for them to attend more regularly. There have been a number of occasions when the father has accompanied the child and has been verbally abusive and rude to both myself and the reception staff.

He has unrealistic expectations as to what treatment the child can have and makes unreasonable requests at reception. I am considering ending my professional relationship with the family due to the ongoing problems we are having. What would you advise?

AIt is important to be able to support your decision to end your professional relationship with a patient. While the father is behaving unreasonably, and this may justify you considering ending your relationship with him, the other individuals in the family have not caused you any problems.

It is also important to note that patients with whom you end a therapeutic relationship often make a complaint – for example, to

Patient’s father is very rude

Dr Kathryn Leask advises what to do before ending a professional relationship with a patient

the GMC – or may inform the local press of what has happened.

In this case, the press may suggest that a vulnerable child has potentially had care withdrawn, through no fault of their own.

Be ready to explain your actions. Make sure you have evidence of the father’s behaviour. For example, ensure you have statements from your reception staff and/or recordings of phone conversations, where appropriate.

The GMC gives the example of a patient having been violent, threatening or abusive as a reason why the trust between you may break down or where a patient persistently acts inconsiderately or unreasonably.

Warning the patient

However, the GMC goes on to say that the individual should be warned that you are considering ending the relationship. A warning may allow time for the father to amend his behaviour, allowing the relationship with you to be restored.

You could also consider alternatives to ending the relationship; for example, an acceptable behaviour agreement with the father. Ultimately, your reason for ending the relationship with any patient must be fair and must not discriminate against them.

It would not be appropriate to disadvantage the mother and other children in the family, unless they too acted in a similar manner. You could explain to the father that if his inappropriate behaviour continues, as well as ending your relationship with him, he should

not accompany any other members of his family when they come to see you. But the mother and children can remain as patients. Keep a record of your discussions with the father in addition to following your warning up in writ -

ing. You should explain the reasons for your decisions and how long the warning will remain in effect.

Dr Leask is a medico-legal adviser at the MDU

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When secret really needs to be shared

A private GP faces some heart­searching about whether to disclose information about a patient’s genetic conditions to other family members. Dr Kathryn

Leask gives her opinion

Dilemma 2 Can I tell family of its gene risk?

QI am a private GP with a patient who has recently undergone genetic testing for the BRCA gene mutation. This is due to her having developed breast cancer at a young age, and also there is a strong family history of breast and ovarian cancer.

and welfare of patients who may be unable to protect themselves… [however, clinicians] have a wider duty to protect and promote the health of patients and the public.’

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She tested positive for the mutation, but due to a difficult relationship with her family, she has told me that she does not want this information shared with other family members.

I have cared for some of her relatives and am keen to inform them of the potential risk, as I feel I have a duty of care to them and that they should be offered the opportunity to be tested for the gene mutation.

However, I wish to advise them of a possible risk without disclosing the patient’s identity. How should I proceed?

APatient confidentiality is extremely important and it is in the public interest to ensure patients are able to trust doctors with sensitive personal data.

However, under some circumstances, the issue of patient confidentiality may be outweighed by a public interest in sharing information, where not doing so may result in serious harm to others.

In its confidentiality guidance, the GMC acknowledges that ‘challenging situations can however arise when confidentiality rights must be balanced against duties to protect and promote the health

When deciding whether to breach the patient’s confidentiality, it is important to consider if an individual who is denied the knowledge about their own risk could then miss out on vital preventative measures, such as screening, to identify early signs of the disease.

In your case, relatives who may carry the BRCA gene mutation may wish to opt for prophylactic surgery to reduce their risk of ovarian or breast cancer.

If there is sufficient justification to disclose information without consent, you should advise the patient of your intentions and explain why you believe the disclosure is justified.

Your records should show you have considered any objections raised by the patient and also your reasons for deciding to disclose or withhold the information.

Decisions about whether to disclose information about genetic conditions to family members can create a difficult dilemma. If you are unsure, your medical defence organisation can help you to manage the risks involved.

 General Medical Council: Confidentiality: good practice in handling patient information – Disclosures for the protection of patients and others. See www. gmc ­ uk.org/ethical ­ guidance/ethicalguidance ­ for­ doctors/confidentiality/ disclosures ­ for ­ the ­ protection ­ ofpatients­and­others

Rising requests to access notes is costing me dear

Dilemma 3

Can I charge for copies of notes?

QI am a consultant in private practice and since the changes to the law regarding data protection, I have been receiving an increasing number of requests for copies of medical records.

Some of my patients have been with me for a number of years and their notes are quite voluminous.

I am aware that the new regulations state that, under normal circumstances, a fee cannot be charged when a subject access request is made, but I understand that there are exceptions to this.

Due to the time and cost, including postage, I would like to make a charge in some cases. I have been told by a solicitor, acting on behalf of one of my patients that I am not allowed to do this.

Please can you advise?

AAs you will be aware, the new EU General Data Protection Regulation came into force on 25 May 2018, replacing and strengthening the existing Data Protection Act 1998.

The new regulations do require you to comply with a subject access request, whether this is from the patient themselves or their legal representative on their behalf.

Unlike the previous law, you cannot charge a fee for this and this would include the cost of postage.

According to the regulations, the only exception would be if the request was ‘manifestly unfounded, excessive or repetitive’.1

If the patient, or their solicitor, were to make a complaint about your attempt to charge them for

Fees cannot normally be charged for a subject access request. But the rising number of requests for copies of medical records is costing one practice much time and postage. Dr Kathryn Leask (right) gives her view

what appears to be a reasonable request, you could be criticised by the Information Commissioner.

There is no agreed definition of what constitutes a manifestly unfounded or excessive request or what a reasonable fee would be.

It is important to note that the new regulations do not require subject access requests to be put in writing and a request should be responded to ‘without undue delay and at the latest within one month of receipt’.

This is a reduction in the previous time limit of 40 days and begins on the day after you have received the request, regardless of whether this is a working day or not, until the corresponding calendar date the next month.

If the patient’s records are in an electronic format, the solicitor or patient may be willing to accept these by email, to avoid the need for you to print these out.

It is, however, important to still review the records before disclosure to ensure no third-party information is disclosed without consent.

Reference 1. https://ico.org.uk/for­organisations/ guide­to­the­general­data­protectionregulation­gdpr/individual­rights/rightof­access/

A

PRIVATE

PRACTICE

– Our series for doctors considering the independent journey

Home truths

The vast majority of doctors own property whether it be their home or as a landlord, often both. Ian Tongue (below) looks at some of the more common taxation areas to consider when it comes to property ownership whether that be your home or investment property

YOUR HOME

Your home – or ‘main residence’ as the taxman lies to call it – is usually easy to determine. But, for some, this can be more difficult and time limits do exist if you want to elect for a particular property to be your home if you have more than one. This distinction can be very important.

When you sell your home, the main tax that you usually must consider is the painful stamp duty on the one you are inevitably buying.

However, it is normal for a capital gain to arise from selling your home and this is usually extinguished because of a special relief called principal private residence relief or PPR, as it is known.

This relief usually provides 100% relief from any capital gains tax upon sale of your home, but there can be circumstances when this is not the case and criteria do need to be met.

The most common scenario of capital gains tax being payable on a property that has always been your home is the disposal or part disposal of a large property, as only half a hectare of garden/grounds is covered by the relief.

What if I don’t sell my home when I move?

Historically, it has been common to keep hold of a property that was your home and retain it as an investment on a buy-to-let basis. With increased stamp duty rates, this can be a more expensive option, but is still a viable option for some, no doubt.

If you retain a property that was your home, the most com -

Unlike a buy-to-let, which is regarded as an investment provided certain criteria are met, a furnished holiday letting is regarded as a trade

mon scenario is to subsequently rent it out. When subsequently selling, this situation results in a different calculation whereby you are allowed PPR for the period that you lived in it plus 18 months, but any gain thereafter becomes subject to capital gains tax.

For example, if you owned a property for 3.5 years, vacated it for rental and sold it at the end of ten years, you would immediately be able to reduce the gain made by 50% for the five years –3.5-year occupancy plus 18 months – by dint of PPR.

The remaining 50% will attract a further relief called ‘letting relief’ which can be worth up to £40,000.

After the above has been considered, any remaining gain is subject to either 18% or 28% capital gains tax after any available capital gains tax annual exemption is deducted, currently worth £11,700.

I often find that doctors who sell a rental property that was once their home are surprised how little tax – if any – is payable in these circumstances.

INVESTMENT PROPERTY

the selling price after allowable selling costs.

Remember to keep all receipts for enhancement expenditure or any other capital expenditure, as these are likely to be eligible for adding to the purchase price thereby reducing the capital gain.

PROPERTY RENTAL PROFIT

We are still in a transition period when it comes to how profits arising on rental income are calculated. The main changes relate to the deduction of loan interest as an expense and the removal of the wear and tear allowance for furnished lettings.

The loan interest restriction is in its third year now (2019-20) and is gradually removing the amount of loan interest that you can deduct against income. From 2020-21, there will be no deduction of loan interest against income and you will get 20% tax relief on the interest only. This effectively reduces the tax relief available to 20% from either 40% or 45%. If you have no mortgage on the property, it makes no difference.

Another key change is in relation to the other costs that you can deduct against income when arriving at the taxable profit figure. For a property that was ‘furnished’, you used to receive a flat annual allowance of 10% of the rent to cover you for replacing items called the ‘wear and tear’ allowance.

This was thought to be unfair compared to landlords providing unfurnished lettings and therefore everyone is now on a renewals basis for costs incurred.

marginal rate of tax. If a loss is made, it cannot be offset against other income and is carried forward to use in a later year where you may have made a profit.

One of the key changes from the interest relief restriction is that properties that were lossmaking may now face a taxable profit. If you have stored up losses historically, then speak to your accountant to understand when they will be extinguished and a tax charge will arise.

FURNISHED HOLIDAY LETTINGS

Furnished holiday lettings continue to be popular and have special rules. Unlike a buy-to-let, which is regarded as an investment provided certain criteria are met, a furnished holiday letting is regarded as a trade.

There are numerous advantages from this trading classification from income tax, capital gains tax and inheritance tax perspectives. Additionally, the loan interest restriction does not apply to furnished holiday lettings. Speak to your accountant to obtain further information on these advantages and the criteria which must be met annually.

Owning property can come with various complexities depending on the history of the property and whether you have other properties. It is important that when buying any additional properties you speak to your accountant to ensure that you understand your position fully.

 Next month: A recap on capital allowances

A property that has never been lived in as your home will not attract any PPR or letting relief. Therefore, any gain made from selling the property will be subject to capital gains tax at 18% or 28% after any capital gains tax annual exemption is deducted, depending on whether you are a basic-rate taxpayer or higher/ additional-rate payer.

The calculation of the capital gain is normally straightforward by deducting the cost against

The costs that are allowable can be somewhat of a minefield depending on their nature and whether any enhancement of the property takes place.

Replacement of domestic items – for example, furniture, furnishings, appliances, kitchenware – is now given when you purchase them. Larger items such as fixtures can attract tax relief, but care needs to be taken to replace like for like and not treat them as an improvement.

After taking the above into consideration, any profit made is subject to income tax at your

Ian Tongue is a partner with Sandison Easson accountants

PRIVATE PATIENT UNITS

An area ready for joined-up working

Following his review of London’s private patient units last month, Philip Housden (right) turns his spotlight onto England’s southern home counties

OUR LAST issue analysed private patient revenue growth for the greater London NHS trusts. This was the first in our revolving series reviewing the NHS PPU sector across all regions of England. This month, it is again the turn of the 17 NHS trusts delivering acute care services to the southern home counties of Kent, Sussex, Surrey, Hampshire and the Isle of Wight.

Analysis of NHS trusts’ 2016-17 annual accounts for this group shows that total private patient incomes declined by 6.8% from £61.4m to £57.2m (Figures 1 and 2).

This now represents 0.93% of these trusts’ total revenues, down from 1.01% in 2016-17. The combined national average including London is 1.1%.

Although this region remains the highest-grossing area outside London, performance in the last 12 months has been patchy, with some trusts moving bed capacity away from PPUs to NHS supply during the winter months. The adverse impact on gross revenues is clear in the trust-by-trust analysis.

The top trust by both overall earnings and percentage of turnover is the same as last year: Frimley Health. Frimley Health’s Parkside brand includes the 37-bed PPU at Frimley Hospital, Surrey, and beds at Wexham Park, Slough, Berkshire. The trust recently also announced the development of further private patient capacity

within the £98m development at Heatherwood Hospital, Ascot.

Frimley remains ranked the 11th highest private patient earner within the NHS, and first outside London despite recording a reduction in revenues of £628k (6.4%) last year.

Sustained growth

Hampshire Hospitals’ Candover Suite in Basingstoke grew £1m in 2017-18 to £6.8m (17%). The 22 inpatient beds and a range of supporting outpatient and diagnostic services has supported sustained growth for several years and the trust has further room to grow in the Winchester market.

Royal Surrey Hospital, Guildford, grew a modest 1.4% to £6.1m delivering complex surgery and

niche services, including radiotherapy, nuclear medicine, brachytherapy and robotic surgery.

Southampton is fourth highestgrossing by revenue in the region despite also having no private inpatient inpatient beds but relying instead on a range of day case and diagnostic capability, including a small number of chemotherapy day case beds. The trust’s private patient revenues declined by 1.1% in 2017-18.

Brighton grew by 3.9% and £177k also without having designated PPU beds. Further growth will be dependent on securing a facility in the hospital rebuild, now underway.

Two trusts have seen significant falls in revenues of £1m or more. Maidstone and Tunbridge Wells in

Kent experienced a £2.4m and 49.4% drop respectively due to the loss on inpatient capacity to NHS demands and also competition from Genesis for private cancer care.

Renewed capacity

This decline has been arrested through investment in a re-opened ambulatory unit as a first stage towards renewed private patient capacity.

Western Sussex Hospitals’ revenues fell £979k (14.9%) due to similar loss of capacity.

Along the coast, Portsmouth Hospitals Harbour Suite, despite enjoying growth through the summer, also fell back by 6.4% (£209k) once beds were redirected to the NHS in autumn 2018. Isle of Wight, too, reduced private patient bed

Figure 1

capacity and lost insurer recognition as a result.

East Kent Hospitals NHS Trust owns Spencer Hospitals, a subsidiary company managing PPU services out of Margate, Ashford and Canterbury of varying size.

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

Spencer provides NHS Choose and Book services and was one of the first multi-site PPU ‘chain’ brands. The trust reported a decline of 18.6% and £635k last year, but this could be due to the accounting treatment of Spencer as a trading subsidiary rather than actual performance.

Epsom and St Helier’s University Hospitals NHS Trust has appointed new management and rose in 2017-18 by 2.3% and £98k. The

trust is looking for further growth out of the Northey Suite at Epsom and the untapped potential of the St Helier site.

Ashford and St Peter’s announced it was reviewing the present arrangements with BMI Healthcare and the onsite Runny mede Hospital. During the past few months, BMI has lost the Kingston Hospital Coombe Wing and is selling a Cheshire unit to the NHS.

Four trusts report under £1m a year revenues and all enjoyed some growth in 2017-18, encouraging but modest in cash terms.

Dartford and Gravesham, Surrey and Sussex and Medway all have potential to develop a modest entry level PPU offer, while Horder Healthcare runs the McIndoe Centre co-located at the regional burns and plastics centre at Queen Victoria Hospital in East Grinstead. Looking ahead, the region can be expected to deliver significant

revenues from private patients. However, the patchy performance across otherwise similar markets suggests that some trusts are backing the sector and other much less so.

Given that insurance and selfpay demand rates are reasonably consistent, at least half of the region’s trusts are most likely miss-

ing out on several million pounds of revenues a year.

This is a market ready for investment in capacity and perhaps joined-up working too.

 Next month: the northern home counties.

Philip Housden is a director of Housden Group

Figure 3

DOCTOR ON THE ROAD: SKODA KODIAQ

This Skoda gives you the last laugh

For independent practitioners with a growing family, the petrol Kodiaq offers a fantastic package and is great value. Our motoring correspondent Dr Tony Rimmer (right) reports

FOR DOCTORS, just like car manufacturers, past negative reports can take years to shake off and regaining patient trust can be a challenge.

In the car world 60 years ago, Skoda had a reputation of poor build quality and unreliability. These 1960s’ cars were basic rearengined saloons that were designed and built in factories in Soviet-ruled Czechoslovakia. In the UK, Skodas bore the brunt of many jokes and buyers stayed away.

Now younger buyers, unaware of previous problems, have taken to the brand, which was boosted when VW took over in 1989. Skoda is currently on a roll. It is regularly releasing impressive new models to a newly appreciative audience. In 2017, it launched the Kodiaq. Named after a large Alaskan brown bear, this model heads up the ever expanding Skoda family of SUVs that includes the smaller Karoq and, most recently, the Kamiq.

Raging success

As the largest and roomiest of the group, it is the only one to offer seating for up to seven people. Since its launch, it has been a raging success and now that it has become available with new petrol engines as an alternative to the ubiquitous VW group’s 2.0 litre diesel units, I was keen to try the latest version.

My test car had the 1.5 litre fourcylinder TSi engine with 150bhp and plenty of torque. It had the optional automatic seven-speed direct-shift gearbox (DSG) and two-wheel drive. Four-wheel drive is available on some of the more powerful versions.

Claimed economy is 34mpg to 36.7mpg using the new and more realistic Worldwide Harmonised Light Vehicle Test Procedure (WLTP) for overall fuel consumption. The other new petrol engine is a 2.0 litre four-cylinder TFSi which produces 187bhp.

If you still want to go down the diesel route, there are three variants of the 2.0 litre unit available producing 150bhp, 190bhp or 240bhp. There are various trim options available ranging from the SE, the SE L, the Sportline , the vRS to the Laurin & Klement model.

Laurin & Klement were the com-

SKODA KODIAQ se l 1.5tsi dsg

Body: Five-door, seven-seat SUV

Engine: 1.5 litre four-cylinder turbo-petrol

Power: 150bhp

Torgue: 250Nm

Top speed: 123mph

Acceleration: 0-62mph in 9.9 seconds

Economy: WLTP combined: 34.0 to 36.7mpg

On the road price: £30,855

pany founders who began by making bicycles in 1895. Skoda’s logo, a stylised Indian head-dress with an arrow, is believed to be inspired by a native American family servant working for them at the time. Standard equipment naturally increases as you go up the trim ladder and my test car, an SE L, probably represents best value.

Features include full LED headlights, 9.2-inch screen sat-nav with Apple CarPlay and Android connectability, electronic boot lid, 19-inch wheels and Alcantara upholstery.

Clever features

There are some really clever Skoda features that are standard. Dooredge protectors pop out and retract automatically to avoid carpark prangs, small umbrellas sit in the door jams of both front doors, an ice-scraper sits in the fuel filler door and a rechargeable LED torch sits in the boot area that is porta-

ble and has a magnetic base; brilliant features to impress even the most stubborn Skoda critic.

So, what is a modern Skoda like? Well, as SUVs go, the Kodiaq is a good-looking car. The slight tapering of the rear bodyshell cleverly disguises the ability to accommodate seven people.

Step inside and any of you who are familiar with VW products will feel right at home. The very easyto-use central infotainment screen backs up the clear dashboard and comfortable driving position.

Fantastic leg-room

Rear-seat passengers are really spoiled by fantastic head and legroom together with seats that can slide backwards. Three adults or large teenagers can sit more comfortably than in any competitor that I can think of.

The two rear-most seats are, predictably, a bit of a compromise. Too restrictive for adults on anything but short trips, they suit children perfectly. Boot capacity with all seven seats in use is on par with a VW Polo. Fold these down and you have a vast space for everything a family of five would need for a holiday.

Out on the road, you might

The very easyto-use central infotainment screen backs up the clear dashboard and comfortable driving position

expect a 1.5 litre engine to struggle a little with a car of this size. However, although it has to rev a bit at times, the torque is plentiful and progress is never impeded.

Sure, if you want something a bit more sporty, then go for the 2.0 litre petrol or a more powerful diesel variant. But realistically, this is not meant to be a sports car, so go for extra economy that the smaller unit offers.

Negatives? Well the ride is a bit firm and the DSG gearbox can be a bit jerky at low speeds and, for my own preferences, the steering is a bit too light. But these are minor niggles in a car that handles well and fulfills its design brief perfectly.

I am really impressed with the Kodiaq. For an independent practitioner who has a growing family, it offers a fantastic package and is great value.

It might well leave enough money in your budget to afford that two-seater sports convertible as a second car.

Ultimately, if you can suppress any prejudices you may have about the Skoda brand, you will have the last laugh. 

Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey

Boot capacity with all seven seats in use is on par with a VW Polo. Fold these down and you have a vast space

All you need to know about accountancy for private practitioners

The cost of working hard

Anaesthetists have overall seen their increased incomes eaten up by rising expenses. Ray Stanbridge reports for our latest benchmarking survey of NHS doctors’ earnings in private practice

THERE ARE large variations in the income patterns of consultant anaesthetists in private practice.

Another interesting factor is that, in many other disciplines, specialists in London enjoy higher incomes than their colleagues. But that is not the situation with anaesthetists.

Where a local anaesthetist has a monopoly or quasi-monopoly of a particular service, incomes can be substantially more than shown in our survey.

At the very least, we can state

that the standard deviation around the mean is very high.

Trying to determine an average indicative figure for this specialty’s earnings is complex because so many doctors are working in different ways.

Different ways of working Groups are growing in number and members’ incomes rise as a result.

Other anaesthetists restrict themselves to ‘Choose and Book’ work, where costs can be very low.

Others trade as limited liability companies, where tax rules on costs and expenses are very attractive in certain circumstances.

So all these factors make it difficult to determine a reasonable ‘average’. But we are not defeated! Our figures suggest that the gross income of anaesthetists in private practice has increased by 4.4% from £88,000 to £92,000 between 2016 and 2017.

That sounds reasonable in the current climate – but costs have increased by a significant 12.9%, going up from £31,000 to £35,000 on average.

As a result, taxable profit has remained constant at around £57,000, with a slight fall in operating margins from 64.8% to 62%.

Explanation for changes

What then are the reasons for these changes? It seems that the growth in income is partially influenced by income enhancement, achieved by those who are members of groups.

The growth in self-pay has also had a positive effect and insurance company re-imbursements are still under significant pressure. But perhaps the most significant factor, though, is that many anaesthetists are working harder

The most significant factor, though, is that many anaesthetists are working harder to receive the same or slightly enhanced incomes

to receive the same or slightly enhanced incomes.

Turning to expenses, staff costs have shown an increase from £13,000 to £14,000 between 2016 and 2017. In truth, this may be an artificial figure. Some anaesthetists do pay family members for administrative work and this can be very advantageous for tax. The figure also reflects service charges imposed by groups and these vary significantly.

Professional defence costs have shown, for the first time in a number of years, a small increase. Anaesthetists are generally less attractive to the ‘new’ insurance providers, as their premiums are relatively low. Many are therefore restricted to fee increases imposed by the traditional medical defence organisations.

Tel: 01992 655940 - option 2

Tel: 01992 655940 - option 2

Mob: 07860 525831 www.ppmsoftware.com | info@ppmsoftware.com

Mob: 07860 525831 www.ppmsoftware.com | info@ppmsoftware.com

A BIG RISE IN COSTS NULLIFIED ANAESTHETISTS’ BOOST

There has been a slight increase in costs of courses and conferences, which have shown an increase from £2,000 to £3,000 on average.

Many anaesthetists enjoy overseas conferences for various reasons, and the rising costs reflect this trend.

Surprisingly, there has been a small growth in bad debts. This is related to the growth in self-pay and is perhaps one of the downsides of a large self-pay business.

Other costs have broadly remained constant with a small decline in marketing and promotional costs.

Our view is that these trends are likely to continue through 201819 and that most anaesthetists will, at worst, enjoy a stable private practice income and, at best, a small growth.

Our survey is not statistically significant, although we are consistent in our qualifications for entry.

To qualify for entry to our survey, anaesthetists must:

 Continue to work in the NHS and not be in full-time private practice;

 Hold either an old- or a newstyle contract within the NHS;

 Must have been in private practice for at least five years;

 Must be seriously interested in pursuing private practice as a business;

 Must have generated a gross private practice income of at least

£5,000 in the year to 5 April 2017;

 May or may not have incorporated their business or become members of a formal or informal group.

 Next month: Dermatologists and oncologists

Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates

HOW ARE YOU DOING?

WHAT’S COMING IN OUR JUNE ISSUE...

Make sure you don’t miss our next issue, published on 20 June. You may not receive every issue if you have not yet subscribed to the journal. Don’t risk missing out on vital topics we tackle next time:

 The five ‘porkies’ you need to know about the NHS Pension Scheme. More doctors are triggering harsh tax bills due to pensions tax. But rash decisions are unwise, warns Cavendish Medical’s Hugh Davies

 Should I Tweet, Share or Like and how will it affect my practice?

Jane Braithwaite’s Private Practice Growth Guide is packed with some excellent tips

 Calls for a single repository about a consultant’s whole clinical practice to be available to the private and NHS hospitals where they work (see page one of this May issue) are backed by the Independent Healthcare Providers Network. Its boss David Hare says this would include data about a consultant’s practising privileges, indemnity cover, scope of practice, identity of Responsible Officer and appraisal status.

 An update on revalidation following Sir Keith Pearson’s review. Some excellent advice from Mr Ian Mackay, Responsible Officer for the Independent Doctors Federation, PLUS..

 Difficulties encountered in the pathway to revalidation include confusion, inaccurate information, conflicting advice and time constraints. Kate Lewis and Darren Wiggins guide you through the maze

INDEPENDENT PRACTITIONER

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 Susan Hutter presents the first in a new A-Z guide of essential matters consultants and GPs need to consider to run their private practices efficiently

 Business Dilemmas! A consultant orthopaedic surgeon has fears for his reputation after relatives bring a claim against him, while another reader is in a quandary over signing a death certificate. Dr Ellie Mein of the MDU gives her advice

 Common issues that can raise your subscription fees – Dr Gabrielle Pendlebury of Medical Protection gives her top ten

 The Montgomery case five year years on. So how has the landscape changed for medical practitioners giving informed consent?

 Oncologists and dermatologists are under Ray Stanbridge’s latest financial spotlight in our Profits Focus series

 A week in the life of the man curing many doctors’ payment woes –

Medical Billing and Collection’s Simon Brignall

 If you work in the northern Home Counties, then check out Philip Housden’s findings of how private patient units there are doing

 Our ‘Doctor On The Road’, Tony Rimmer, tries out the new Peugeot 508

 Plus all the latest news and views

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