Dr Kathryn Leask reveals the reasons why members contact the MDU for ethical advice P24
The business journal for doctors in private practice
A magic bullet for everyone?
The world of personalised medicine is explored by Dr Tim Woodman of Bupa, who looks at the challenges it faces P30
The implications of restricting consultants’ outcome stats
See page 12
Benjamin Holdsworth gives you the details behind the recent big announcements on pensions P32
Watchdog gets tough
By Robin Stride
‘Fix your failures – but do it quick!’
That is the message to independent consultants and private hospitals from the competition watchdog after it ‘named and shamed’ providers for failing to fully comply with the requirements of its Private Healthcare Market Investigation Order 2014 (PHO).
The Competition and Markets Authority (CMA) wrote publicly to two hospitals citing their failure to provide data for publication on performance and patient outcomes so that prospective patients had information they needed to compare consultants and healthcare providers.
Asked how many more hospitals were about to get similar letters, a spokesperson told Independent Practitioner Today: ‘It’s difficult to give an exact figure, as many hospitals are compliant, while many others are nearly compliant. The same is true of consultants.
‘As a result of publicising these letters, we expect many more will fix their failures but they need to do so quickly.’
Both the Fortius Clinic and Ulster Independent Clinic were told by the Private Healthcare Information Network (PHIN) they were non-compliant. Decisions to name providers also consider factors such as business size and what information is missing.
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The CMA said companies received letters for these reasons:
➲ Fortius Clinic –
n Failing to provide diagnosis coding for admitted patient care, plus 99% of records submitted to PHIN contained no NHS numbers;
n Supplying no data for patient feedback and patient-reported outcomes;
n Not resolving 18 data issues, making information about its consultants incomplete.
➲ Ulster Independent Clinic –n Data submitted in a non-compatible format to the approved standard for admitted patient care; n No data to PHIN for adverse events, patient feedback and patient-reported outcome;
n Not resolving 51 data issues, leaving consultant information incomplete.
The CMA spokesperson added: ‘Patients and prospective patients would not have access to the sort of information they might need to make an informed decision about which hospital to use.
‘For example, patient-reported outcomes allows patients to compare the quality of care and treatment across hospitals.
'Both of these hospitals failed to supply this important data to PHIN.’
The CMA expects the hospitals to be fully compliant by 30 September 2023, but said both those named aimed to be compli-
ant sooner – The Ulster Independent by August 2023 and Fortius Clinic by May 2023.
PHIN said independent healthcare providers had made ‘huge progress’ to comply with their obligations to submit data.
But some had yet to do so and the lack of data meant patients could not access information that informed their choices when they
are considering private treatment. PHIN has worked with the two providers who have ‘responded positively’ to ensure all data would be submitted.
It added: ‘We are keen to help every provider to meet their obligations under the CMA Order and appeal to any organisation that needs help in submitting data for publication to contact us.’
25% OF CONSULTANTS STILL NEED TO ACT
The CMA's executive director of markets and mergers, David Stewart (right), said: ‘Choosing private healthcare is an important and, at times, difficult choice.
‘So it is vital that private hospitals empower customers, through PHIN, with the information to help them understand and select the best care for them and their families. Some hospitals are not doing this.
‘Consultants must also provide their consultation and treatment fees for publication, and threequarters have already done so.
‘So we are now ramping up enforcement action to ensure that the remaining hospitals and consultants that are breaking the rules will face the consequences, so patients don’t lose out.’
The CMA said it would seek the swiftest possible way to address noncompliance. These could be through hospitals’ voluntary actions, but legally binding directions or court action if necessary.
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The Competition and Markets Authority (CMA) action in publicly rebuking two independent hospitals for failures to comply with its private healthcare order should come as no surprise.
Independent Practitioner Today warned in November last year that the competition watchdog was about to get tougher against those dragging their feet in complying with the law to submit more information for prospective patients considering independent sector treatment.
Now we wait to see how much this stimulates remedial action by other hospitals to satisfy the data hungry Private Healthcare Information Network (PHIN) in time to prevent being on the list of the named and shamed.
The CMA’s David Stewart, executive director of markets and mergers, announced six months ago there would be a
stricter approach when he spoke to consultants’ representatives, hospital providers and insurers at the well-attended LaingBuisson Private Acute Healthcare Conference.
It is perhaps surprising the CMA has trodden so gently until now, but clearly the latest events (see page one) are a sign it is losing its patience.
Some hospitals are still not giving the required data and it will be an own goal for the sector if court enforcement action is necessary.
What worries us more now is that as many as a quarter of consultants have apparently not divulged their consultation and treatment fees for publication.
Presumably, recalcitrant large groups will be named publicly first if this continues.
We’ve run a wealth of articles on ways to ensure you get your name and practice information out there – but don’t let it be for the wrong reasons.
Why not broaden your career?
Could expert witness work be a job for you? Dr Rebecca Whiticar of Medical Protection shares experiences in the role and explains what is involved P14
PPUs can help private practice boom
Private patient units are often misunderstood and unloved. But they are a potentials £1bn opportunity for the NHS, argues Hugh Risebrow P17
Keeping staff is as vital as recruiting
International recruitment specialist
Robert Landor says it’s time to act and seek solutions to the nursing shortage hitting private healthcare P20
How a database of doctors was born
The boss of SpecialistInfo tells the story of how an online directory of more than 100,000 consultants and GPs has become and invaluable resource P22
Let the experts fit the bill
Outsourcing billing and collection is increasingly the most effectice route for consultants in private practice. Simon Brignall examines the reasons why P26
What can we learn from GMC cases?
We can learn a lot from the big GMC cases, but there’s much to be usefully gleaned from the run-of-the-mill hearing, says solicitor Tania Francis P36
PLUS OUR REGULAR COLUMNS
Business Dilemmas: Does the GMC need to know?
Dr Kathryn Leask responds to private doctors’ queries in the latest of our medico-legal series P40
Accountant’s tips: How to create a happy business
Richard Norbury of accountants Sandison Easson gives key tips to boost the success of your practice P42
Doctor on the Road: Niro is no emperor
Our motoring correspondent Dr Tony Rimmer tests the Kia Nero EV, but fails to be electrified P46
Ensure your tax-free bit of pension is protected
Lifetime tax-free pension savings limit removed, but protection still exists
By Edie Bourne
Doctors may no longer face a limit to their overall tax-free pension savings following the Budget, but should check if their tax-free lump sum amount has been safeguarded.
The lifetime allowance tax charge has been removed for 2023-24 and is due to be abolished altogether from April 2024. But the tax-free cash amount – formally called the pension commencement lump sum – will be frozen at £268,275. This represents 25% of the former lifetime allowance of £1.073m.
Any cash taken above this amount will be subject to a tax charge unless individuals have lifetime allowance ‘protection’ in place and can therefore retain their right to take a higher tax-free lump sum.
The last protection scheme to be introduced was ‘Fixed Protection 2016’ which retained the lifetime allowance at £1.25m, for those who met the criteria, when it was reduced to £1m.
In turn, this secured a higher taxfree lump sum. The trade-off was that individuals could not continue with ongoing pension contributions or accrue further benefits above certain limits.
But since 6 April 2023 this is no longer the case as long as individuals registered for fixed protection by 15 March 2023.
Doctors are being advised that another protection scheme called ‘Individual Protection 2016’ is still open to applications and could be useful to gain a higher pension commencement lump sum.
To be eligible, your pensions needed to be valued in excess of £1m on 5 April 2016 and this scheme then secures your lifetime allowance up to £1.25m.
This means your tax-free cash amount will be up to £312,500 –higher than the new limit set by Chancellor Jeremy Hunt in his Budget.
Patrick Convey, technical director with specialist financial planners Cavendish Medical, told Independent Practitioner Today: ‘The rules surrounding protection schemes such as fixed, enhanced
FREE PENSIONS WEBINAR
Book now for a free webinar for Independent Practitioner Today readers – Your NHS pension: what you need to know –run by Cavendish Medical on Thursday 11 May at 6.30pm. It will cover the new NHS retirement flexibilities available to doctors and Budget tax changes affecting senior consultants and GPs.
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and individual protection have always been complicated.
‘The removal of the lifetime allowance tax charge is good news, but doctors may not realise what protection of their lump sum they already have in place – and what security they could still enforce.
‘As ever with finances, it will pay to run some careful analysis of your particular situation. It is very easy to go wrong with tax allowances and protection schemes, which could result in a very expensive mistake.’
Insurers to boost information to patients
Private medical insurers aim to work closer with consultants and healthcare providers to improve the availability of treatment information for patients.
Representatives of the Association of British Insurers, Aviva, Axa, Bupa, HP Alliance, Vitality and WPA signalled their intentions at a summit run by the Private Healthcare Information Network (PHIN).
PHIN chief executive Dr Ian Gargan said: ‘It was great to hear widespread agreement that it is in the best interests of patients, providers, consultants and private
medical insurers to have healthcare information that is accessible, easy to understand correctly and in context.
‘For patients, this means a better understanding of their options. For consultants and hospitals it can help inform their decisionmaking when providing care.
‘We see that when hospitals and consultants provide more complete data, they get more patient engagement through the website, so there is a commercial benefit too.’
Insurers have a place on the PHIN board and a duty ‘to inform
patients that helpful information as to consultants and private hospitals is available on PHIN’s website’.
At the summit, the insurers supported doing more to promote PHIN to their customers and to engage with the data on its website.
PHIN said it planned to involve insurance intermediaries in future and to organise more focused sessions.
It believes insurers can help ensure a successful delivery of the Competition and Markets Authority’s Private Healthcare Order,
which resulted in its formation as a watchdog for transparency.
How about making the news today? Independent Practitioner Today is always keen to hear from doctor entrepreneurs willing to share their stories in private practice – and from independent practitioners embarking on the journey.
Contact our editorial director Robin Stride at robin@ip-today. co.uk
Patrick Convey of Cavendish Medical
Get ready for new CQC inspections
By Robin Stride
Independent practitioners are being advised to gear up now for this year’s changes in Care Quality Commission (CQC) inspections.
It is recommended they should begin reviewing their systems to extract evidence to demonstrate effective quality assurance.
A management expert who helps private doctors achieve registration with the watchdog is also drawing attention to a new approach from inspectors as they replace inspection-only visits with continuous evidence collection, heralding more targeted future inspections.
New interactive portals later this year aim to enable providers to upload audit, survey and incident investigation data so the CQC can keep a constant eye on activity.
Martha Walker, the Independent Doctors Federation’s (IDF’s)
adviser on CQC matters, says there will be increasing emphasis on dialogue with providers via monitoring calls, which increased last year.
Writing in the Spring 2023 edition of IDF News , she warns that monthly hour-long calls are imminent.
She says: ‘The monitoring call does not involve the doctors sending any evidence to the inspector; however, if the inspector had a cause for concern during the call, they may ask for evidence to be submitted to them or undertake a more targeted conversation or site inspection.’
Mrs Walker, of CQC Consultancy, reports that doctors have found it positive to be able to explain changes to their service or talk about how they handle complaints and unexpected events.
But she adds: ‘I still caution doctors to be mindful of these – and all – conversations they have with the
Happy doctor users help Pharmacierge raise £2.4m
Dozens of happy doctor customers have dipped into their pockets to help healthtech company Pharmacierge raise a further £2.4m. Their investment will be used by the company to power its next phase of growth combining dispensing robotics with AI to manage the vast range of medicines it supplies.
Pharmacierge, a pioneer of medicine delivery apps for private clinicians, said 90% of the funding round was raised from its own users, including 80 prominent clinicians.
Co-founder and chief executive Edward Ungar called it ‘a profound and unique endorsement of Pharmacierge by the very same consultants and GPs who use it most often’.
‘They’ve recognised the huge value in our product and have not only validated that as users, but also as investors.’
The company has now raised nearly £4m, with over 75% from among its 4,000 clinician users.
Consultant rheumatologist Dr Stephanie Barrett said: ‘Having long experienced the time-saving benefits that the Pharmacierge service offers clinicians and patients, it was a simple decision to invest in a business that I both understood and trusted.’
Pharmacierge runs a 2,500ft2 dispensary in Wimpole Street, London. It said the variety of specialties it supports means its formulary contains over double the average range of pharmacy medicines.
CQC, as they are calls to monitor how your practice is performing.’
Private doctors applying to register now face having to provide more quality assurance evidence than previously and can expect ‘at some stage’ to receive a provisional rating of ‘Good’.
The 300-plus ‘key lines of enquiry’, known as KLOEs and introduced five years ago, are also due to be dropped and replaced by 34 quality statements across the five key questions asked about services – are they safe, effective, caring, responsive and well-led.
All four rating categories – outstanding, good, requires improvement and inadequate – remain.
More CQC information on various issues is awaited, including evidence category guidance, which will be crucial ‘because the quality of the evidence will form part of the new scoring system’.
How the scoring system will
IDF CAN HELP YOU
IDF president Dr Phil Batty has asked any doctor members with specific concerns about CQC matters to contact him.
In a message to members, he welcomed plans for a portal where documents and work can be uploaded for live inspection.
But he said he had voiced concern to the watchdog that some inspectors might have unconscious, or conscious, bias against private practices.
Dr Batty reported: ‘I am assured there have been communications that all practices should be inspected in the same way, whether they are NHS or private.’
work to determine ratings is another unknown and Mrs Walker throws up another important concern for independent doctors: ‘With substantial weight being placed on data to demonstrate the quality statements and provide supporting evidence, and EMIS apparently being the CQC’s preferred practice management software, how will the majority of independent doctors be assessed, as EMIS for private health care is not the market leader in the independent sector?’
Reaching new heights: the Pharmacierge team
Defence body calls for reform of GMC probes
By Douglas Shepherd
Radical reform to GMC investigations are being urged following new research revealing significant numbers of private doctors are experiencing thoughts of suicide or quitting medicine as a result of their investigation.
Three in four of 56 independent practitioners who took part said the process had a detrimental impact on their mental health, with 95% citing stress and anxiety.
A quarter considered leaving medicine, while a third reported experiencing suicidal thoughts during inquiries.
The figures were released by
defence body Medical Protection Society (MPS) after it surveyed 197 doctors investigated by the regulator in the last five years.
64% of private practitioners said the length of the investigation impacted on their mental health most. With some it lasted years.
55% said the GMC’s tone of communications affected them most.
Doctors commenting anonymously spoke of a ‘guilty until proven innocent’ tone in the initial GMC letter.
MPS medical director Dr Rob Hendry said the GMC had made many improvements to its initial communication with doctors, but more was needed.
Its first letter to a doctor could alleviate some anxiety by setting out the GMC’s legal requirement to investigate all complaints and its policy for dealing with malicious gripes – which were a huge source of stress for doctors and could take months to resolve.
‘The language in the GMC letter and case examiners’ report when an investigation has been closed with no further action can also have a detrimental effect on a doctor’s mental health. Many felt it implied “we’ll get you next time” and I have heard doctors describe this as feeling like they have the sword of Damocles hanging over them.’
He urged the Government to
Prize for Spire’s self-pay expansion
Consultants’ contribution to the self-pay boom helped Spire Healthcare scoop the Transformation of the Year Award at the plc awards 2022.
These accolades are designed to allow all UK publicly quoted companies, of whatever size, the chance to be rewarded for their successes and achievements.
The Transformation Award recognises companies who have transformed their performance and long-term prospects for the better, through strategic, operational and/or financial change.
Voting panellists looked for ‘companies whose long-term prospects have been transformed, with
the accent on sustainable improvements in customer satisfaction, profitability, cash flow, return on capital, balance sheet strength/ efficiency and organic growth prospects.’
Awards organisers said the group had delivered a very strong performance, with outstanding growth in private revenues:
‘The group experienced unprecedented growth in self-pay, signalling a seismic shift for the business and the wider market.
‘Spire Healthcare responded by implementing a true business-toconsumer proposition and investing further in marketing to meet the elevated demand, while creat-
ing excellent opportunities for margin expansion.’
Spire’s chief financial officer Jitesh Sodah,collected the award from the host of the night, broadcaster Louise Minchin.
Insurers and salesforce ditch the CBI
The Association of Medical Insurers and Intermediaries (amii) has terminated its membership of the Confederation of British Industry (CBI).
Its decision comes after allegations about misconduct and sexual assault from CBI employees came to
light. The organisation has now admitted it hired ‘culturally toxic’ staff and failed to fire people who sexually harassed female colleagues.
amii executive chairman Dave Middleton said: ‘We are deeply concerned about the allegations made about the CBI and have
therefore decided to terminate our membership with immediate effect.
‘In light of this, amii cannot continue to support the CBI and we have notified the organisation of our immediate termination accordingly.’
progress GMC reform with urgency to give the regulator more discretion to not take forward investigations where allegations clearly required no action.
Dr Hendry said reforms should reduce the number of doctors pursued on the basis that action would ‘protect public confidence in the profession’. Investigations should surely be focused on those potentially posing a patient safety risk.
He added: ‘The GMC also needs to communicate more clearly that it has been set up to deal with serious concerns, to help reduce the large number of referrals it receives about doctors that do not come close to requiring a sanction.’
Doctor is made president of Cleveland Clinic in London
Dr Robert Lorenz (below) is to be president of the 184-bed Cleveland Clinic London from 1 June.
He has served the group for more than 20 years, completing his residency with it in 2002.
Dr Lorenz was appointed a staff physician and later section head of head and neck surgery, where he built his career as a surgeon, innovator and educator.
Clinic bosses said he had a track record of ‘driving value, growth and innovation’ and would expand services and further collaboration with the NHS.
Since 2020, he has been responsible for the clinical aspects of Cleveland Clinic’s government and commercial contracts.
Cleveland Clinic London is preparing a second outpatient location to open in autumn 2023.
Jitesh Sodah with the plc award
You can help fight climate change
By Olive Carterton
The Royal College of Physicians of Edinburgh is seeking Independent Practitioner Today readers’ help in compiling a climate change digital archive to document the impact of climate change on health.
Archive curator Dr Daisy Cunynghame told Independent Practitioner Today: ‘The climate crisis is already having negative health impacts. We’re keen to hear from doctors in both private and NHS care about their thoughts and experiences on the impact of climate change on health.’
Each interviewee will be reinterviewed annually to capture the developing impact of climate change on their work and on healthcare more broadly.
The online archive contains fulllength interviews and short excerpts focusing on key topics such as what can be done to bring about change, the obstacles and what the future looks like.
Among the participants are Prof Jill Belch, professor of vascular medicine at Dundee University, and Prof Liz Grant, chairwoman of Global Health and Devel opment at Edinburgh University.
Others include Dr Sidrah Lodhi, who talks of her experiences working in Pakistan, and Prof Johannes Hugo, who discusses the extreme temperature increases in South Africa – a sign of future changes the college says we can expect in the UK.
A college spokesperson said: ‘The archive will be useful for future understanding and research, but will also help us to learn and develop solutions now.
‘It contains stories from doctors trying to bring about change during a time of intense underfunding and understaffing. It also explores the future challenges we will face in the UK and suggests some solutions to these challenges.’
Dr Cunynghame added: ‘Many
doctors have spent a great deal of time thinking about this problem and both how they can mitigate it – for example, by reducing the use of disposable items – and also what can be done to prepare for the future.
‘These interviews uncover the extremes of the climate changerelated challenges facing doctors in countries such as Pakistan and South Africa and, in turn, show how doctors in the UK are preparing for similar challenges here.
‘But, overall, what really came across to me was just how much doctors are thinking about the environmental impact of their work, as well as the impact of climate change on people’s health, and developing all sorts of projects to address this. It isn’t all doom and gloom, there is a lot of energy for change.’
The climate change archive can be accessed at www.rcpe. ac.uk/heritage/climate-changearchive
Eye clinic offers help to NHS patients
A new eye clinic in East Sussex offers access to NHS cataract eye surgery and is committing to treatment within just six weeks of referral.
Optegra Eye Clinic Brighton has opened at a time when the cost of living is at an all-time high, resulting in many people avoiding essential eye tests due to cost.
These delays in accessing treatment have led to 40% of optometrists recently surveyed by Optegra believing that people are driving without the legal visual requirement and older people are losing their independence due to poor vision.
Richard Armitage, NHS director for Optegra, said: ‘Those diagnosed with cataracts simply
need to ask their optician or GP to refer them to Optegra Eye Clinic Brighton and we will be in touch straight away to arrange pre-
Cromwell Hospital launches lung check service
A new lung health check to help spot early signs of cancer in people at higher risk of developing it has been opened by Cromwell Hospital.
The service is recommended to people aged over 50 at high risk, who currently smoke or have a history of heavy smoking.
It includes a consultation with a respiratory consultant, a low-dose CT scan, full blood count, full lung function test and patients will have their results assessed by a multi-disciplinary team.
Respiratory consultant Dr Brian O’Connor said: ‘Often people don’t realise they have lung cancer until it’s spread further around the body. This is because lung cancer has little to no symptoms.
‘We want to help those at risk of developing lung cancer by offering them a lung health check. If they need further follow-up treatment or are diagnosed with lung cancer, then we’ll be able to continue their treatment at Cromwell Hospital through our Integrated Cancer Campus, providing access to our specialist lung cancer team.’
Hospital chief executive Philip Luce added:
‘We’re always looking for ways in which we can improve the care and services we offer to patients, and this is a great example of how we do this.
operative tests and a surgery date.’
The clinic was officially opened by The Mayor of Brighton and Hove, Councillor Lizzie Deane.
‘We know that early diagnosis helps to save lives and that’s why if a patient does have lung cancer, we’ll provide quick diagnosis, faster access to treatment and the latest technology to aid quicker recovery.’
Dr Brian O’Connor
PHOTO: DARREN COOL
Philip Luce
The theatre at Optegra’s new Brighton Clinic, with healthcare technicians Anthony Shaw and Evalin Mortiboys-Reid and senior scrub nurse Judith Mercado
Surgical museum opens after refit
By Douglas Shepherd
Surgeons are re-opening the Hunterian Museum in central London on Tuesday 16 May after a six-year closure for a £4.6m redesign. Admission is free.
Created by award-winning design studio Casson Mann, it is part of a larger redevelopment of the Royal College of Surgeons of England’s headquarters at Lincoln’s Inn Fields.
The Museum displays over 2,000 anatomical preparations made by the 18th-century surgeon anatomist John Hunter.
Specimens are displayed alongside instruments, equipment, models, paintings and archive material, tracing the history of surgery from ancient times to the latest robot-assisted operations.
Teamwork is at the heart of a new film of an orthopaedic operation at Wirral University Teaching Hospital. Time-lapse editing condenses a 90-minute operation to just ten, revealing a ballet-like choreography as surgical staff give all their attention to the patient.
New audiovisuals and objects on public display for the first time can also be found on the museum’s website, which is rich with recently digitised collections material, online exhibitions, films, talks, games and key visitor information.
Dawn Kemp, the college’s director of museums and special collections, said: ‘The Hunterian Museum has been a place where history has been made, both for good and bad – the place where dinosaurs were named, where
Charles Darwin came for advice on the fossils he found half the world away, where the pioneer of computing, Charles Babbage, sent his brain to be put on display.
‘It is also where some of those closely involved in the Western “colonial project” developed sinister and awful ideas on racial theory.
‘Its history makes it a unique place to contemplate what it is to be human. A place to reflect and consider our shared and finite natural world and our responsibility to care for the well-being of our fellow humans and all living things. A place to exchange ideas and views and to review our shared histories through the widest possible lens.’
Casson Mann founder and director Roger Mann said: ‘To
Clinic starts first ever hair-tracking app
Harley Street Hair Clinic has launched what it bills as the world’s first ever hair-tracking app.
Hair Track enables people to photograph their hair from three different perspectives – front, top and sides – and then upload to a timeline so they can scroll through a gallery and get a holistic view of how their hair is changing.
Another function, ‘managed by real people rather than artificial intelligence’, enables people to speak directly with a consultant about hair loss concerns.
They can talk via the app or set up a video or in person consultation, to discuss the best course of treatment.
Those who go on to have a follicular unit extraction (FUE) transplant or other treatment can then also log their hair growth success and manage their aftercare plan.
This includes scheduling appointments, being able to set notifications and reminders for
The app allows patients to speak directly with a consultant about hair loss
aftercare treatment and being able to speak to doctors with any follow up questions.
New Harley Street Hair Clinic research found 76% of people who have little or no hair loss are worried they will lose it in the future. Sixty-eight per cent in the UK were
re-imagine the display of the Hunterian Museum’s rich and varied collection was a unique opportunity to create a series of jewel-like galleries full of surprising and curious juxtapositions and wonderful stories.
‘We hope that medical professionals and visitors alike will enjoy this journey of discovery and appreciate the extraordinary contributions of John Hunter and others who pioneered the field of medical and surgical knowledge.’ www.huntarianmuseum.org
NHS aims to collect data on private hospitals
Responses are being assessed following a consultation recommending NHS England should collect and process information on private hospital healthcare activity.
If plans progress, then NHSfunded and private data would be available in one place for the first time. It is argued this would give a more comprehensive insight into the quality of treatment and care across both sectors.
experiencing some form of hair loss and 24% felt they had no one they can talk to about their concerns.
Hair Track app is available via the App Store for Apple users, and Google Play Store for Android users.
The consultation came after an inquiry, following the conviction of breast cancer surgeon Ian Paterson for performing harmful and unnecessary surgery on patients in the NHS and privately, recommended bringing data on all consultant activity together in the same place.
Surgeon anatomist John Hunter painted by Joshua Reynolds
GMC wants to be fairer to doctors
The GMC is taking concrete steps to identify and mitigate bias wherever it appears in its regulation. In a letter to the profession, the council’s chairwoman Prof Dame Carrie MacEwen says building in robust controls to the way it works can assure doctors, the public and itself that its approach is fair at all times and in all circumstances.
‘The ethnic make-up of the UK medical profession is becoming increasingly diverse. In 2021, more international medical graduates joined the medical register than UK graduates and just under half of all trainees were from an ethnic minority background.
‘While we are seeing the demography of doctors evolve, indicators of inclusion and equality remain stubbornly fixed.
‘We recently published data that show that ethnic minority doctors continue to experience significant disparities in exam pass rates, despite increasing efforts to reverse this trend. In specialty exams, Asian trainees have a pass rate of 68%, compared to 79% for white trainees.
‘For UK graduates of black and black-British heritage, the figure is even lower at 62%. These disparities are compounded by socio-economic status, with pass rates of 67% for the most affluent
UK black trainees, compared to 59% for the least affluent.
‘This imbalance persists throughout a doctor’s career, baking in disadvantage across the years. When it comes to the selection of F2 doctors into specialty training, we found that a higher proportion of white trainees were offered posts than those from ethnic minority groups.
‘While those on the receiving end of discrimination may not be surprised by these findings, it is shocking, and salutary, to see this state of affairs documented so starkly.
‘Accurately quantifying these inequalities is crucial if we’re to tackle them definitively. Every year, the national training survey (NTS) of doctors in training and trainers helps us pinpoint where action needs to be taken to ensure that every doctor has the fair, supportive and inclusive working environment they deserve.
‘This year, we’re including new questions specifically on discrimination, from microaggressions and stereotyping, to the availability of mentorship and support.
‘The results of the NTS, which we will get in the summer, will provide detailed, granular data.
‘This will help those responsible for education and training to target initiatives that improve all aspects of doctors’ workplace and training experiences, no matter who they are or where they work. These efforts are a critical part of helping us achieve our target to eliminate differential attainment in medical education by 2031.
‘Tackling deep-seated disadvantage in medicine requires a concerted, sustained effort from all involved in the health system. For us at the GMC, that means working with our partners to effect change, but also looking inward at our own work.
MDU reveals rise in workplace stress
A leading defence body lawyer has drawn attention to how rising workplace pressures on doctors are being reflected in their worsening condition when they seek help following a complaint.
At a time of heightened pressure in healthcare, they are ‘under incredible strain’ when they come for support, according to criminal law specialist Nick Tennant.
But the newly appointed head of legal services at the Medical Defence Union (MDU) said results achieved in supporting members with GMC investigations were a
great example of the uncompromising defence his team provided.
‘In 2022, our in-house team resolved 85% of cases without a tribunal hearing, where we represented members at the case examiner stage.
‘Of those that proceeded to a tribunal hearing, there was no finding of impairment against our members in 55% of cases. This represents a much better outcome for our members when compared to the most recent figures for cases overall from the Medical Practitioners Tribunal Service.’
‘Confidence in the fairness of our processes is at the heart of being an effective and compassionate regulator. Without it, trust is eroded and fear festers.
‘That’s why we’re taking concrete steps to proactively identify and mitigate bias wherever it may appear in our regulation. By building in robust controls to the way we work, we can assure the profession, the public and ourselves that our approach is fair at all times, and in all circumstances.
‘I believe that supportive cultures and inclusive leadership are the most important drivers of compassionate care. Making sure every clinician has a fair chance to reach their full potential is therefore not just vital for them, but also for their patients.
‘We are committed to playing our part, so that every doctor, from every background, has the opportunity to thrive.’
Dr Hugh Stewart, MDU professional services director, said the defence body’s research found nearly nine-in-ten healthcare professionals saying work place pressures had risen over the last year.
He added: ‘The NHS staff survey results also show high levels of burnout, with staff feeling stressed and demoralised. If you then throw a medico-legal investigation into the mix, it can be truly devastating for doctors and other healthcare professionals.’
Mr Tennant, who specialises in criminal and regulatory legal pro-
ceedings, was promoted after 15 years as a solicitor in the organisation’s in-house legal team. He oversees the work of an expert team of 24 solicitors, three paralegals and support staff.
GMC chairwoman Prof Dame Carrie MacEwen
Nick Tennant, newly appointed head of legal services at the MDU
Great Ormond St expands horizons
Page compiled by Philip Housden
The man in charge of private patients at Great Ormond Street Hospital for Children (GOSH) has had his role extended with an appointment as international and commercial managing director.
Chris Rockenbach joined the hospital in 2000 and has worked in, and led, the international and private care service for ten years. For the last three he headed the establishment of the trust’s commercial activity. His new role brings the two elements together. He said: ‘Private practice is extremely important to GOSH, it is fundamental to our business model and enables us to build further expertise in caring for children and young people with rare and complex diseases.
‘I am looking forward to working with our partners in the UK and across the globe offering exceptional care for more children – adopting innovation, new therapies and treatments into clinical practice.
‘Mutual collaboration is impor-
tant to GOSH, be that through patient care in London or joint service programmes in the patient’s own country and I look forward to engaging with our partners, in whatever capacity that might be.’
Clinical director Melanie Horns said he would contribute to an even better offering for GOSH’s partners, with world-class care and research, innovation and educational offerings.
The hospital is also adding to its senior management team by recruiting a head of operations for international and private care.
Its private patient income fell to £24.9m in 2021-22, a 33.4% drop from £37.4m the previous year and well below the record £68.8m achieved pre-pandemic in 2019-20 when the trust was a clear second only to Royal Marsden in private patient earnings in the NHS.
In 2021-22, the trust ranked fifth by income, now overtaken by Guy’s and St Thomas’, Imperial and Moorfields. GOSH’s private patient income represents 4.9% of total trust revenues, third highest of all trusts, but down significantly on the 15% achieved before Covid and 8% in 2020-21.
Moorfields appoints new nursing chief
Jo Johnson has taken up post as head of nursing for Moorfields Private, the private division of Moorfields Eye Hospital NHS Trust. Her role, closely supporting the director of private care, provides clinical leadership across three sites.
Moorfields Private delivers private patient treatment from Old Street and also now from the heart of London’s medical district.
The new Moorfields Private Eye Centre, recently opened at New Cavendish Street, offers diagnostic and refractive procedures.
Moorfields Private Care income was £37.2m in 2021-22, up 53% on the previous year, fourth highest of all trusts and also an increase of around 20% on pre-Covid levels.
Private patient revenues now
Bath’s private unit gets new imaging gear
One of the first leading private hospitals to come under 100% NHS ownership is benefiting from investment.
The Royal United Hospitals Bath NHS Trust’s acquisition of Sulis Hospital – formerly Circle Bath Hospital – in June 2021 had led to a growth in services and increasing capacity for surgery and diagnostics for both NHS and private patients.
The hospital has just invested £4.4m to upgrade and extend imaging with the opening of a Siemens Somatom X.cite CT system.
Hospital director Simon Milner said its imaging facilities would be some of the most advanced in the South-west. A proportion of the CT’s capacity was also ring-fenced for NHS patients.
Buying the hospital enabled the trust to report private patient revenues of £12.7m (and 2.9% of all revenues) in 2021-22, a steep rise on the pre-Sulis income of £585,000 the previous year.
This has enabled the trust to rise to seventh by revenue and eighth by percentage in the NHS in England and, in doing so, to overtake Frimley Health (£9.2m) as the highest earner outside of London.
Surrey’s
new cancer hub
The opening of the new £30.5m cancer centre and research hub in Guildford, Surrey, for NHS and private patients is under six months away.
This is the result of a partnership between the Royal Surrey NHS Trust and GenesisCare to provide cancer patients from across southeast England with access to the latest treatment options including highly targeted radiotherapy using a MR Linac.
represent 14.7% of total trust income, the second highest of all NHS trusts.
Philip Housden is director of Housden Group
They will work on a research and education program, the sharing of best practices, training and development of NHS staff, as well as joint participation in academic research and trials.
Moorfields recently opened its private eye centre in London’s New Cavendish Street
Chris Rockenbach’s appointment combines Great Ormond Street Hospital’s private patient, international and commercial activities
A look back through our journal’s archives of a decade ago reveals that although times change, some issues are not so new
A trawl through the archives: what made the news in 2013
Only 20% earn more than the year before
Only one-in-five consultants doing private practice reported a rise in independent income over the previous year.
Just over a third maintained their earnings at the same level, while 45% experienced lower profits.
The number of specialists reporting earnings of £100,000+ a year dropped.
These were among the findings of a BMA private practice committee snapshot survey of a random sample of 7,500 consultant members across the UK.
But only 18% responded and 55% of them apparently had no private practice income whatsoever.
22% set their fees according to insurers’ re-imbursement available – a rise from 9% over four years.
The BMA private practice committee chairman told doctors at a conference this was ‘an extremely dangerous trend’.
80% said their fees had been challenged by an insurers and a third said they had been threatened with de-recognition.
Yet another watchdog
Independent practitioners faced scrutiny from a new watchdog under controversial plans being considered by the Government.
Recommendation from a health department ‘Review of the Regulation of Cosmetic Interventions’ said the remit of the Parliamentary and Health Service Ombudsman should be extended to cover the whole private healthcare sector.
The review team, lead by NHS medical director Prof Sir Bruce Keogh, also proposed:
Providers should offer advice on their complaints procedures to their patients;
Where appropriate, this advice should be available on their websites;
Complaints against providers that were investigated and upheld by the Ombudsman ‘should be publicly available’.
But the widened Ombudsman role was set to be strongly resisted by the Independent Sector Complaints Adjudication Service.
It argued it had successfully adopted the role of handling
patient complaints for scores of providers across the UK, while the system already had the backing of the Independent Doctors Federation, medical defence bodies, the CQC, and Wales’s and Scotland’s healthcare inspectorates.
Private GPs surge
Troubled times for NHS GPs sparked a new surge of would-be private practitioners.
Over a quarter of the 100+ doctors at a BMA private practice conference were GPs.
Martin Murray, of Sandison Easson accountants, told the meeting the recession was making people look closer at what they spent on private medical insurance, and self-pay would rise.
Online notes ‘make more work’
Eight-in-ten doctors feared online medical records would increase their workload.
They told an MPS survey that they would have to spend more time explaining the contents of patients’ records.
The survey showed differing expectations about how records should be written.
Three-quarters of patients thought medical records should be written in simple language so they could understand them without assistance or explanation.
But only one-in-five doctors agreed.
An MPS spokesman warned: ‘If this issue isn’t reconciled before online records are introduced, this could lead to tension and confusion between doctors and patients.’
New website for PHIN
A new public website was launched by the Private Healthcare Information Network (PHIN) to publish ‘standardised and directly comparable information drawn from records of both private and NHS treatment’.
The first version of the site showed how frequently a hospital undertook a procedure and how many nights a patient might expect to stay, along with details of whether it was regulated to treat children as well as adults.
PHIN chief executive Matt James said: ‘This first version of the PHIN website marks a significant step forward for transparency and patient choice in private healthcare.’
TELL US YOUR NEWS
How about making the news today? Independent Practitioner Today is always keen to hear from doctor entrepreneurs willing to share their stories in private practice – and from independent practitioners embarking on the journey.
Contact our editorial director Robin Stride at robin@ip-today. co.uk
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Data is too raw for open publication
A Private Healthcare Information Network report last month said there will be a limit to the amount of information that will be freely available to the public about independent practitioners’ private patient outcomes. Although consultants have welcomed this pledge, what does all this mean for them now? Jonathan Finney (right) explains
The focus behind the new Private Healthcare Information Network (PHIN) document is to ensure that not only is the information published on time, but that it:
Is understandable to both patients and clinicians;
Is statistically valid;
Allows comparisons between healthcare providers to inform patient choice.
As PHIN chief executive Dr Ian Gargan has pointed out, contextualisation of performance information is important.
He said: ‘If we published all of the data today like a league table within schools, the patient would just look at the outcome of the mortality of a particular consultant, and they would say that consultant doesn’t have the outcome they want.
‘But that consultant might have dedicated their life to really complex cases like gynaecological surgery, so he shouldn’t, for example, be compared to a surgeon like me, who has specialised in wrists and knees – which is pretty rudimentary in comparison – so my mortality would be low.’
PHIN remains committed to the principle of publishing information for use by patients, but, as set out in detail in the document, that will be contingent on factors such as the quality and statistical power of the inbound data.
Meanwhile, it will continue to publish more detailed and widerranging information on its hospital and consultant ‘portal’ – which can only be accessed by those with the required permission.
The evidence-based assessment
The evidence-based assessment (EBA) presents the results of an assessment project, along with the recommendations for publication of each of the measures contained in Article 21 of the Competition and Markets Authority’s Private Healthcare Order at national, hospital and consultant level.
The document was produced following six months of discussion in a working group involving PHIN’s members and other stakeholders.
It also invited contributions, via a focused engagement and consultation process, to make sure there is sector-wide understanding of
WHAT COMPETITION WATCHDOG WANTS
PHIN has published an evidencebased assessment (EBA) of the steps required to complete the demands of the Competition and Market Authority by the 2026 deadline.
The competition watchdog’s Private Healthcare Order Article 21 measures set out expectations for the publication of information on a range of performance measures about private care in independent hospitals, including several measures at consultant level.
PHIN believes publication on its portal will help drive up the quality and completeness of the required diagnostic information and can be used by hospitals and consultants for quality improvement
These currently include surgical site infections, re-admissions and mortalities per procedure.
As ‘unplanned transfers’ relate to processes at a hospital level rather than at consultant level, this may not currently be publicly reported at procedure level. ‘Adverse events’ (‘never events’ and ‘serious injuries’) also reflect system-wide safety issues, so publication at consultant level is not appropriate.
However, information will be presented about the sites at which a specific consultant works. For ‘returns to theatre’, rates at procedure level (‘as expected’) and rates including case-mix adjustment will be published when possible.
How we reported on PHIN’s decision in our April issue
what these recommendations and guiding principles mean in practice and that the proposals have the support of our stakeholders.
What do recommendations mean for consultants?
The full EBA is available on PHIN’s website (phin.org.uk), but here we take a look at the measures that are impacted by the recommendations. These will be kept under review with stakeholders.
Length of stay measure
While the measure already published meets the requirements of the Order, PHIN was looking to enhance the information presented to further aid patient comparisons – for example, by introducing new views of the information, trends and by including case-mix adjustment. Those ambitions remain, but, for now, it is not possible to include case-mix adjustment due to the lack of available case-mix models and under-reporting of case-mix variables, such as comorbidities and ethnicity.
However, PHIN believes publication on its portal will help drive up the quality and completeness of the required diagnostic information and can be used by hospitals and consultants for quality improvement.
Adverse event measures and PROMs
A similar lack of case-mix models and data completion at present limit what PHIN can meaningfully publish on various incidents at consultant level.
Patient-Reported Outcomes Measures (PROMs) are a very important measure of satisfaction – or the lack of it – but there is not the data coverage to support publication for patients yet.
For each of these measures, the EBA says that consultants should have access to the information attributed to their practice in the PHIN portal and have the opportunity to audit and review as appropriate.
Transparency and trust It may be possible to publish more information for patients in the future.
For now, PHIN hopes that the approach set out in the EBA will reassure consultants that this will be done only when the data is of sufficient quality, the clinical methods are available and the information can be meaningfully used and understood in context.
Publication on the PHIN portal meanwhile will allow hospitals and consultants to address any potential issues identified by the information, without inadvertently causing harm through misinterpretation of data or a lack of context.
We will continue to support consultants and other stakeholders to achieve the ambitions of the CMA Order, improve patient understanding and choice and make information transparent, accurate and meaningful.
Jonathan Finney is member services director at the Private Health care Information Network
PHIN chief executive Dr Ian Gargan
BECOMING AN EXPERT WITNESS
Why not broaden your career?
Expert witness work – could this be a role for you?
Dr Rebecca Whiticar (right) shares her experiences
WE ALL reach a point when we start considering ways in which we can diversify our careers, including exploring challenging and rewarding personal development options that can work around other personal commitments.
Working as an expert witness could be one of those options. Expert witnesses are instructed by a party to provide their specialist knowledge by way of an opinion on a particular issue, set of issues or facts in a case to help resolve a dispute.
An expert witness will have had no personal involvement with the case they are providing opinion on; they are providing opinion because of their specialised knowledge of a specific field relevant to the case.
While an expert is normally instructed by one party, an expert’s overriding duty is to assist the court with the ultimate outcome of a dispute by providing a report that is independent, objective and unbiased.
In my experience, the role of an expert is vital and early involvement in cases can help reduce costs, align claimants with realistic expectations and lead to earlier resolution for all parties. Lawyers will often tell you a good expert can ‘make or break a case’.
What does the role entail?
Expert medical opinion plays a critical role in criminal, civil, coronial and GMC processes.
Such opinion can determine, for example, whether the Crown Prosecution Service pursues a conviction for gross negligence manslaughter against a doctor following an incident or error that leads to the death of a patient. It can also, more broadly, dictate the standards to which doctors are held.
The life of an expert witness can be incredibly varied depending on both the specialty and area in which you work.
In my specialty of emergency medicine, my expert role mostly involves providing written reports that give an objective opinion on a claimant’s allegations of breach of duty at the very early stages of a claim, to aid early resolution if possible.
➱ continued on page 16
Lawyers will often tell you a good expert can ‘make or break a case’
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Most of this work is done in my own time at home, but occasionally the cases will progress to joint expert conferences or conferences with the legal teams. Prior to Covid-19, these were in person, but this is now all possible through video-conferencing.
While most clinical negligence cases will settle before seeing the inside of a courtroom, occasionally experts will be required to attend court following a report, so it is important to be prepared and have the necessary skill set for giving robust and credible evidence in court.
How will I know if I will enjoy the work?
Whether you will enjoy the work as an expert witness will depend on your own skill set and personality. If you enjoy critically analysing medical cases and applying legal principles alongside medical best practice and research, then you may be well suited.
Although this may sound obvious, a ‘good’ expert should enjoy writing reports and be able to read large quantities of medical documentation, with the ability to home in on the important and relevant facts.
Solicitors I have worked with have always stated that the most valuable attribute in a medical expert is a clinician who can write clearly and succinctly, logically explaining their rationale for their opinion, backed by relevant medical evidence.
I would also add that a good expert must act with honesty and integrity, act objectively and independently, have the maturity to declare any relevant conflicts of interest and admit if the instructions from solicitors fall outside their remit of expertise.
What will I need to be a credible expert?
There is no formal training path to become an expert witness or even a requirement for formal qualifications. However, at the end of the day, an expert witness’s overriding duty is to the court and therefore the expert and their evidence must be considered credible to that court.
The Academy of Medical Royal Colleges, in response to a recommendation from the Williams
WHERE DO YOU START?
I created my own path to becoming an expert witness after attending a few one-day training courses and then by becoming dual qualified in medicine and law while still clinically practising in my specialty (emergency medicine), but that is by no means the only way in.
There are plenty of training options and many private providers offer expert witness training.2 Medical Protection is also running webinars3 to help members find out more about the role on 10 and 24 May.
Once the training is completed, instructions from lawyers can often rely on word of mouth, but once you earn the trust of solicitors, the options for medico-legal work may grow exponentially.
There are other options other than word of mouth, however, such as registration as an expert witness with a professional body or with expert witness directories, contacting law firms who act in the fields in which you wish to be considered as an expert, writing articles for professional journals and marketing yourself appropriately – for example, via a website, social media or in a legal journal.
As an expert witness, you are paid for the time it takes to prepare, write, and discuss your evidence. The BMA provides useful guidance on medico-legal fees and factors to consider when negotiating fees.4
In 2011, 400 years of immunity for experts was waived in the landmark supreme court case of Jones v Kaney.5 Therefore, it is important to appreciate that a medical expert can be held accountable and you should have appropriate indemnity arrangements in place, just as you would in your clinical practice.
In summary, the role of a medical expert witness is incredibly varied, challenging and rewarding. In the UK, there is a recognised shortage of medical experts willing to take on this important role and concerns about the lack of diversity in the medical expert witness pool, an issue flagged by Medical Protection in its 2022 report Getting it right when things go wrong: the role of the medical expert 6
If you are looking for work that is varied, can work around existing commitments, will help you stay current within your own medical specialty, and you enjoy writing and applying logic, undertaking a portfolio career in expert witness work may be just up your street.
review into gross negligence manslaughter in healthcare, defined credibility and what is required from doctors acting as experts:1
➤ The necessary clinical knowledge, training and experience to act as an expert witness. What this means in terms of role, qualification or length of experience will vary between professions.
Individual professional bodies may choose to provide further guidance in respect of their profession. However, the Court will need to be satisfied that the professional has the level of expertise for their evidence to be accepted.
➤ Specific training for being an expert witness and the expectations and responsibilities of this role.
It should incorporate the principles of this guidance and be appropriate to the individual clinical profession and specialty.
Training should be kept up to date with appropriate refresher courses or other activities.
➤ Undertake and demonstrate appropriate activity relevant to their clinical expertise and legal aspects of the expert witness role as part of their continuing professional development and this should form a part of their annual appraisal.
Credibility, in my opinion, is linked to experience at a senior level within your relevant medical specialty, combined with an understanding and application of the legal principles of clinical neg-
The most valuable attribute in a medical expert is a clinician who can write clearly and succinctly, logically explaining their rationale for their opinion, backed by relevant medical evidence
ligence and a current knowledge of the systems in which we work.
Ongoing involvement in clinical work helps to ensure that experts are up to date and allows for a more realistic assessment of what is ‘reasonable’, as opposed to ‘textbook’ practice.
Those working within a system are best placed to understand its challenges and imperfections. System issues often play a key role when things go wrong in medicine.
They inevitably impact on the care provided by a doctor and so deserve consideration in all situations where a doctor’s practice is under scrutiny.
For example, I would not myself feel ‘credible’ to provide an opinion on medical negligence cases during the pandemic had I not been working on the front line myself during that period.
From the legal perspective, an understanding of clinical negligence processes, the legal principles of clinical negligence and the civil procedure rules (CPR part 35) which govern the role of the expert are essential and this would be included in training.
Dr Rebecca Whiticar is a medico-legal consultant at Medical Protection
PPUs could service private practice boom
Private patient units – often misunderstood and unloved, but they are a potential £1bn opportunity for the NHS, argues Hugh Risebrow (right)
THERE IS a silver cloud to postCovid NHS waiting lists – it is the growth in private patient activity.
Things were broadly flat in real terms from 2012 to 2019 and any growth in private hospitals – at least outside London – was driven by treating NHS-funded patients. 2022-23 estimates are 25-30% above 2019, with a market now worth c£5bn-c£7bn to hospitals and c£2bn to consultants.
The UK private hospital market is, relative to most international markets, consolidated with five large groups accounting for c75% and few independents outside London. These groups – Spire, Circle, HCA, Nuffield and Ramsay – are well known by consultants and patients.
NHS private patient units (PPUs) collectively account for around 15% of the market and would be number four in the market if they worked as a single entity.
PPUs are all run as individual units by their respective trusts and are heterogenous. This article sets out some data and observations about PPUs, as well as the opportunities and challenges which they present for the NHS and consultants.
Firstly, there are major differences between London and outside London. Unsurprisingly. London, with only 15% of the UK population, accounts for around a third of private healthcare.
Affluence and high employerfunded private medical insurance
NHS private patient units (PPUs) collectively account for around 15% of the market and would be number four in the market if they worked as a single entity
mean that there are a range of sophisticated private hospitals, including new entrants such as Cleveland, ASI and Schoen.
PPUs in London have a c25% share of this market and the largest ten units are all in London and in ➱ continued on page 18
Source LaingBuisson, Latchmore analysis*
* adjusts for inconsistency between LB UK and LB London reports
2019 collectively had more than £400m in revenues. The Marsden is by far the largest and thought to be approaching £150m.
Some of the larger London PPUs have made substantial investments. Marsden, Brompton –since merged with Guy’s – and Moorfields have collectively invested £15-20m over the past few years in satellite sites in the Harley Street district. This level of investment in PPUs is the exception rather than the rule.
Outside London, PPUs have only 8% of the market. Over 80 NHS organisations have more than £1m in private patient revenues, but there is a very long tail of very small PPUs. We would question whether many are profitable, but equally, we see most of the potential opportunity for PPUs as outside London.
With a few exceptions such as Manchester, Leeds, Bristol and Southampton, private hospitals outside London are small – two to three theatres – and have no or very limited HDU/CCU facilities.
They are geared up to provide a superb service for orthopods performing joint replacements on ASA1-2 patients, as well as a limited range of other high-volume specialties.
But, in most areas, there is insufficient private demand to justify investment in equipment, breadth of staff skills and, for example, HDU and CCU to support lowvolume, high-acuity or high-complexity cases.
By contrast, PPUs should be perfectly placed to meet these needs. Many trusts have invested in all manner of specialist equipment for each specialty – robots, Linacs and hybrid theatres, to name but a few – and have ICU and a range of subspecialised nurses, therapists, pharmacists and other support staff.
Having made the investment in these assets and fixed costs in order to meet their primary objective – treating NHS patients – they should be able to make some capacity available for private patients and make significant
financial surpluses which will fund improvements to NHS care.
My company, Latchmore Healthcare Associates, has worked with 16 PPUs and undertaken one-toone interviews with around 300 consultants about their private practice since 2015. See some of our key findings in the box below.
So why don’t PPUs, especially outside London, achieve more?
We have developed the schematic (see bottom of opposite page) for the factors driving a successful PPU.
In our experience, the following factors mitigate against PPU success, especially outside London:
➲
Bandwidth
Having been an executive director at an NHS trust, as well as
Once NHS clinicians have performed their allotted time, they are free to work in the local private hospital or do whatever they want, so why not give them the opportunity to work in the PPU?
chief executive of four private healthcare businesses, I would describe NHS management as a tough gig.
Targets and pressure from regional and central offices are relentless and there is limited bandwidth outside big London trusts to think about private patients.
➲ Optics
Trust execs are keen to avoid adverse publicity. There are plenty of critics, internally and externally, arguing that PPUs are immoral and take capacity from NHS patients.
My view is that clinician time rather than physical capacity is the bottleneck. Once NHS clinicians have performed their allot-
KEY FINDINGS FROM INTERVIEWS WITH c300 CONSULTANTS ABOUT THEIR PRIVATE PRACTICE
We estimate that, mainly outside London, c£700m (hospital value) of potentially private practice is treated by the NHS.
These are patients who have private medical insurance or are willing to self-pay but require a treatment which is just not available in private hospitals in their area – they do not have the facilities or equipment –or in a PPU. These patient do not wish to travel and or have an insurance policy which does not cover London.
But if these trusts could create a private pathway, then they would be getting a cheque for £700m for work which they are doing anyway.
All things being equal, almost all consultants we have spoken with would prefer to undertake their private practice within their PPU due to:
Greater convenience;
Familiar equipment, nurses, IT systems, governance;
Superior medical support 24x7 if things go wrong; and profits support NHS patients.
Things rarely are equal and hence PPUs only have 15% share.
There is a further £600-800m of activity undertaken in private hospitals where consultants would prefer to do it in a PPU due to the staff and equipment available in the NHS. Add 50% of this to the first bullet and you have the £1bn opportunity.
Source: Latchmore Healthcare Associates
Latchmore analysis
ted time, they are free to work in the local private hospital or do whatever they want, so why not give them the opportunity to work in the PPU?
➲ PPU management bandwidth
The bigger PPUs have management teams of similar calibre to private hospitals.
Smaller PPUs often have highly motivated individuals, but they are expected to combine operational management, with consultant relations, private medical insurer negotiations, billing management and the work of seven departments in a private hospital group.
➲ Limited commercial negotiating power and skills
PPUs typically realise prices from private medical insurers 10-20% below private hospital groups. Billing insurers requires specialist skills and our audits have shown underbilling of 10-20+ %
➲ Lack of capital
PPUs really only need capital for private day pods/rooms and consultation rooms, if other facili-
ties are shared with NHS services. Nonetheless, NHS trusts, except the large London ones described above, inevitably prioritise investment in NHS services.
➲NHS access targets
One of the reasons that NHS management is difficult is that ministerial/political targets to reduce waiting lists translate through layers of apparatchiks into a brutal performance regime.
An element of trust funding is dependent upon hitting 104% of 2019 activity, while many beds are blocked by medically fit patients. Many PPU beds have been handed to NHS patients.
If – and it is a big if – trusts can overcome these challenges, they could potentially dramatically grow their share of private patient activity.
Some trusts have recognised the benefits of PPUs, but realising that they lack the capital, have created partnerships with private provid ers. A list of the key partnerships is shown in the box above.
Latchmore analysis
Many attempts to create these partnerships have failed – we have a list, but I have chosen not to
THE FORCES THAT DRIVE A SUCCESSFUL PPU
include it – due to internal resistance, management changes and lack of suitable sites within the trust, and private operators are inherently sceptical.
Some have done fantastically well. In 2010, The Christie was generating £10m of private patient income with profits unknown. It created a partnership with HCA, who invested all of the capital (c£25m) to create a business which in 2019 made c£13m profit on almost £50m of revenues, with The Christie receiving 49%.
There are plenty of critics, internally and externally, arguing that PPUs are immoral and take capacity from NHS patients
Hugh Risebrow is chief executive of Latchmore Healthcare Associates LLP, a specialist healthcare advisory company which has advised 16 NHS trusts and NHS England on aspects of private patient strategy. He was previously commercial director at Guy’s and St Thomas’ NHS Trust, where he initiated the strategy to partner with HCA to deliver private cancer services
Keeping staff is as vital as recruiting
It is time to act and seek solutions to the nursing shortage hitting private healthcare, says international recruitment specialist Robert Landor (below)
WITH HEALTHCARE severely impacted by the pandemic, independent practitioners in the UK have seen a surge in demand for their services, particularly from self-pay patients.
Around one-in-eight adults (13%) have paid for private medical care over the past year, according to a recent report from the Office on National Statistics. Of that number, 7% paid for treatment themselves, while 5% used private insurance.
A challenge is unfolding for independent health care providers. As findings in an Independent Healthcare Providers Network poll indicate, the growth in demand is set to continue.
One-in-five people expect to use private healthcare in the next year and nearly half the public say they
would consider private healthcare if they needed treatment.
Yet, like the NHS in its struggle with a record high of almost 50,000 nursing vacancies, the private sector is experiencing mounting recruitment and retention problems of its own.
Pandemic’s impact
The impact of Covid-related staff shortages has compounded existing challenges and this has been further exacerbated by the rising cost of living and inflationary pressures on wages, leading to intensified competition for staff.
Nurses are in such short supply that, as Independent Practitioner Today reported, a ‘poaching war’ has left independent hospital bosses scrambling to keep posts filled.
Consultant general surgeon Prof Nadey Hakim sums up the situation: ‘There is a lack of good nurses all over the country. But it isn’t just about the numbers and filling posts: the quality of staff is incredibly important. The sector desperately needs someone who is going to bring in good-quality nurses in the required numbers.’
Prof Hakim has recently joined the board of my London-based international recruitment agency Trinity Healthcare to be part of a team dedicated to sourcing the right people. ‘We need hard working and efficient nurses to deliver the service we are after,’ he says. Initiative, flexibility and positivity are all attributes he values highly. ‘A smiling face, a pleasant manner makes a big difference to both the doctor and patient.’
FIVE TIPS FOR RECRUITING INTERNATIONAL NURSES TO THE UK
1
DEVELOP A COMPREHENSIVE RECRUITMENT STRATEGY.
Identify target countries and regions, build relationships with international recruitment agencies and nursing associations.
2
KEEP ABREAST OF IMMIGRATION LAWS AND REGULATIONS.
Stay up to date on visa requirements and other regulations related to hiring nurses from overseas, including eligibility criteria for sponsorship and how to navigate the application process.
3
DEVELOP A STRONG ON-BOARDING PROGRAMME.
It is critical to help international nurses adjust to their new role and environment.
4
PROVIDE ONGOING SUPPORT AND GUIDANCE.
It is important to provide support and resources to help overseas nurses adjust to life in a new country. This can include assistance with finding housing, mentorship programmes and cultural orientation, as well as career development opportunities.
5 PARTNER WITH RECRUITMENT AGENCIES.
Partnering with reputable recruitment agencies that specialise in international nurse recruitment can help streamline the hiring process and provide access to a wider pool of candidates.
So where do we go to boost our workforce?
Like many countries, Britain looks abroad to bring in foreign-trained nurses to fill the gap. They represent 15% of the overall nursing workforce, with over 100,000 nurses coming from overseas.
Prior to Covid, they were largely recruited from EU countries. However, Brexit has significantly decreased the influx of EU nurses and prompted many to leave.
At the same time, a relaxation of immigration restrictions for nurses from outside the EU has resulted in international recruitment shifting away from Europe and towards Asia.
Countries like the Philippines and India have a long-standing tradition of nursing excellence and produce a large number of highly skilled and experienced nurses.
But there are good pools of trained nurses in other geographical regions such as the Middle East, the full potential of which has yet to be unlocked by the UK and other western countries. International connections with key healthcare partners in those places are vital.
Recruiting nurses from overseas is certainly the best short-term solution to addressing the nursing shortage. However, it must go hand in hand with efforts to increase levels of retention.
This is not as simple as offering more money and requires an understanding of the root causes of turnover.
Nurses and healthcare professionals across the board are now looking for benefits other than pay rises.
Increased opportunities for career development, training and education and improved working conditions are all important for overall job satisfaction.
Supporting nurses with adequate resources, technology, and mentorship programs will help improve retention rates. This is fundamental to achieving a sustainable solution to nurse shortages.
Source Links
1. ONS Report: https://www.ons.gov. uk/peoplepopulationandcommunity/ wellbeing/articles/ theimpactofwinterpressuresonadults ingreatbritain/december2022#nhswaiting-lists
3. Poaching war article: www. independent-practitioner-today. co.uk/2022/04/poaching-war-for-staffharming-private-care/
4. Prof. Nadey Hakim: www.trinityhc. co.uk/the-team/
Robert Landor is director of Trinity Healthcare
Increased opportunities for career development, training and education and improved working conditions are all important for overall job satisfaction
ETHICS OF RECRUITING FROM OVERSEAS
With many countries facing their own critical shortages, the ethics of recruiting overseas must also be considered. It is inevitable that the question of migration of skilled individuals will arise.
This is a multi-faceted problem not to be answered by simple binary responses to deny individuals the right to improve their living standards or to ignore the problems exacerbated in the country that they leave.
The World Health Organization has addressed the matter and published a Health Workforce Support and Safeguards List in 2020. The UK Government followed up with a Code of Practice for the international recruitment of health and social care personnel in 2021, updated in 2022.
This code defined ‘red’, ‘amber’ and ‘green’ lists of countries and the terms under which each classification would be subject to recruitment rules. The code also covers the expected and required support and induction of potential health and care employees and represents the reference under which my company operates.
Trinity Healthcare was established by a group of professionals with mixed backgrounds and expertise in the healthcare sector to address the UK’s severe nursing shortage.
Specialising in the recruitment of overseas healthcare professionals for public and private sector organisations across a wide range of specialties, the company has access to a large and diverse pool of international nurses. We recruit nurses primarily from the Middle East, Asia and Africa, the majority of whom are bilingual or trilingual.
Recruiting international nurses can be a challenging process and working with an agency like us helps employers overcome the hurdles involved.
We assist with sourcing candidates, verifying credentials, registration with UK bodies such as the Nursing and Midwifery Council and facilitating the visa application process, which can be complex and time-consuming.
Our knowledge of local laws and regulations can be helpful when it comes to navigating the visa application process and ensuring that all professional and legal requirements are met. We provide support for candidates throughout the recruitment process and can help with relocation, cultural orientation and other aspects of deployment in the UK.
Trinity Healthcare connects qualified healthcare professionals from the Middle East, Asia, Africa and Europe to jobs with public and private healthcare organisations in the UK, including hospitals, clinics, nursing homes and domiciliary care providers. As an ethical recruiter, we adhere to the Department of Health and Social Care Code of Practice for International Recruitment.
Prof Nadey Hakim
DOCTORS DIRECTORY
How a database of doctors was born
An
online directory of more than 100,000 UK consultants and GPs has become an invaluable resource for those working in and allied to the healthcare industry. SpecialistInfo’s chief executive and consultant ENT surgeon Ms Olivia Whiteside (right) tells its story
SPECIALISTINFO ORIGINALLY came about from a conversation over dinner between my parents and their good friend and GP, Mike Scatchard in 1998.
He had no way of knowing the right specialist with the right interest to whom he should send his patients. With my parents’ background in editorial work, databases and IT and a daughter newly qualified as a doctor, they were well placed to gather and provide this information.
Thus SpecialistInfo was born. My parents put together a highly skilled team of editors and staff and 25 years later, the business continues to evolve and thrive.
As a family, we always discussed ideas and projects for developing the company over the years to which I could give a medical perspective.
At the same time, I continued with a busy NHS schedule and, having being appointed as a con-
sultant ENT surgeon, also started in private practice.
2020 brought its challenges worldwide, but particularly for SpecialistInfo and me, as both my parents, who were both still heavily involved in running the company, died unexpectedly that year.
The pandemic was certainly an unprecedented, unpredictable time to take the lead, especially while continuing to work on the wards.
Fortunately, the team at SpecialistInfo are very dedicated, innovative and experienced and adapted seamlessly to the new era of online working and information provision through our courses and conferences.
As a medic, I have worked in many teams, but this one is particularly efficient and collaborative and I feel immensely proud to be a part of it. Emma Taylor, in par-
CARRYING ON DESPITE SETBACKS
Many doctors’ businesses suffered during the pandemic and SpecialistInfo was not without its challenges.
Emma Taylor (pictured right), the company’s managing director for 20 years, reflects: ‘It hasn’t been without its difficult times; the sudden passing of our beloved founder Hugh Whiteside in January 2020 followed by the pandemic saw us face a plethora of obstacles.
‘But thanks to our fantastic team here who work tirelessly on the accuracy of the directory and the information and services that we provide to the healthcare industry we worked through things.
‘I’m very proud to be the MD of an all-female company and extremely grateful to Olivia for picking up her father’s baton and taking the helm.’
ticular, has worked for the company for 20 years and is a truly remarkable individual. She took over as managing director and has brought fresh ideas and vigour to the company.
SpecialistInfo provides an online directory of UK and Ireland hospital consultants, UK GPs, practice managers and clinical commissioning groups.
We have information on more than 100,000 UK consultants and GPs and our directory has become an invaluable resource for those working in and allied to the healthcare industry.
The directory is updated continuously by our editorial team who liaise with the doctors, the
GMC, secretaries, hospitals, NHS trusts, clinical commissioning groups and GP surgeries to keep abreast of new appointments, movers and leavers.
Though it was originally intended as a service for GPs to aid their referral process to consultants, the NHS has evolved and the database has developed much wider uses. Although it is still used for this process, it also helps:
Doctors who undertake medicolegal work to promote themselves to law firms;
Doctors interested in clinical trials and research to communicate their interest, expertise and experience to pharmaceutical, medical device and research organisations;
The media to find experts and key opinion leaders for comments on topical issues and charities.
A key part of our business is allied to the medico-legal industry. We have the most comprehensive database of over 7,000 consultants and over 2,000 GPs with a medico-legal practice.
Doctors with a profile on our directory can provide their medico-legal CV free of charge. These can then be viewed by subscribing medico-legal agencies, solicitors and insurance companies who are looking for doctors to instruct as expert witnesses.
With the aim of promoting high-quality medico-legal experts to law firms, in 2011 we introduced the Faculty of Expert Witnesses. Membership is free to doctors who can become associates, members or fellows of the faculty.
Fellows agree to undertake refresher training every three years, agree and adhere to a code of good practice and must have satisfied SpecialistInfo’s lawyers that their reports are of a high standard and comply with Civil Procedure Rules through submission of an anonymised sample report reviewed with feedback.
Over the past 15 years, alongside barristers and personal injury solicitors, we have trained over 2,500 doctors on our training courses accredited for continuing profession development and covering topics such as medico-legal essentials, clinical negligence and courtroom skills. We also provide mediation courses through the Society of Mediators.
Currently, we are gearing up for our annual medico-legal conference to be held on 20 June at The Congress Centre in London.
We have information on more than 100,000 UK consultants and GPs and our directory has become an invaluable resource for those working in and allied to the healthcare industry
Our first one took place in 2019 and, despite the challenges of the pandemic, we held well attended and reviewed events online throughout.
High-profile speakers are keen to attend and it brings together medico-legal professionals, industry experts, the press and government officials from the UK and beyond. We have always received fantastic feedback for this event, which is increasingly popular.
It is completely free for doctors to register. If you charge people, you don’t get a comprehensive list of people and services, hence making it free means it is accurate and complete.
We make our money by providing medico-legal and other courses and we run paid-for conferences too.
For the future, we look forward to our continued collaboration with the medical and legal professions.
Doctor entrepreneurs
why not share the story of your business or company with Independent Practitioner Today? Contact robin@ip-today.co.uk
Reasons doctors seek ethical help
In the first of a two-part series, Dr Kathryn Leask reveals the reasons why consultants contact the Medical Defence Union for advice
MEDICAL INDEMNITY is important at any stage of a medical student’s or doctor’s career, but particularly so for consultants who work privately, instead of or in addition to their NHS work.
For consultants working in the private sector, indemnity is essential and a requirement of the GMC.
So why do consultants contact the Medical Defence Union (MDU) and what are the most common reasons for them to request assistance or advice?
A review of recent cases opened
for consultant members revealed some interesting results.
Seeking advice
Twenty-one per cent of consultants making contact were seeking advice from one of our expert team. Remember, you don’t need to wait until a problem has arisen or an investigation started before contacting your medical defence organisation.
Here are some of the main areas of concern for consultants.
Confidentiality and subject
access requests in both the NHS and private sector are a common reason for consultants to get in touch after having been approached for information about a patient, living or deceased.
The Data Protection Act 2018 applies to living patients and the Access to Health Records Act 1990 to deceased patients. Both allow disclosure of information under certain circumstances, but consultants also need to take into account their ethical duty of confidentiality as set out by the GMC.
Even where the hospital’s data protection officer is involved in the decision to disclose information, as the senior person involved in a patient’s care, you may be asked to assist in the process so that the decision to disclose or withhold information can be justified.
There were several cases where consultants had contacted us for advice about requests from the police, solicitors, the Driver and Vehicle Licensing Agency and immigration services. There are often a lot of factors to consider, and it is better, therefore, to seek advice before any decision is made whether or not to disclose.
Records management
Records management is particularly important for those working in the private sector who may be the Data Controller and, as a result, need to be registered with the Information Commissioner’s Office.
Questions particularly arise at the time of retirement from clinical practice.
This is a time of life when queries about the storage and disposal of private clinical records or medico-legal and expert witness documents often arise. Some requests for advice about what to do with private records were from the spouse or partner of a recently deceased doctor.
So it is important to think ahead and have provisions in place to ensure any records you still hold are dealt with properly and don’t become a burden for your loved ones.
Working in the NHS is particularly challenging at the moment and this has inevitably resulted in the MDU receiving more contact from doctors who have concerns about patient safety.
The GMC has specific guidance on raising concerns about patient safety and every doctor, regardless of their grade, has a responsibility to raise concerns if they think patients may be put at risk.
In 2020, the GMC brought out its updated guidance on consent and this is another area where consultants proactively seek advice.
This can be in relation to the process itself, and what should be discussed with the patient, con -
cerns about who should be obtaining consent and about patients who refuse treatment which is thought to be in their best interests.
Coroners’ inquests
Twenty per cent of the contacts from MDU consultant members were with regards to coroners’ inquests. Whether you provided NHS care for the deceased or saw them privately, it is always helpful to get advice and, if necessary, assistance from your defence body.
While hospital legal services departments deal with inquests and liaise with staff, their responsibility is to the hospital and not to individual employees.
Even where you have no concerns about the care you provided and don’t feel likely to be criticised, it is a good idea to discuss the case with a medico-legal adviser, who can assist you in writing a report and preparing yourself to give oral evidence if you are called as a witness to the inquest hearing.
The coroner can give you ‘interested person’ status if they believe you have particular relevance to the coronial process, at which point you are entitled to legal representation.
Your defence organisation can discuss the pros and cons of instructing a solicitor and barrister, and whether it is necessary in order to protect your interests.
Where a doctor has been criticised by the coroner, in line with GMC guidance they should refer themselves to the GMC.
Again, your medico-legal adviser can discuss this with you as to whether comments made by the coroner in their summing up and conclusion do amount to criticism that requires self-referral.
Complaints
Fourteen per cent of consultants contacting the MDU did so about a complaint.
While complaints are sadly a fact of life for doctors due to rising patient expectations and limitations on what doctors can do for them, it doesn’t make them any less upsetting.
Even a simple complaint based on a misunderstanding that is easily resolved can cause a lot of stress and can be time-consuming to
Even a simple complaint based on a misunderstanding that is easily resolved can cause a lot of stress and can be time-consuming to deal with deal with. Doctors have an obligation to deal with patients’ concerns, provide an explanation and, if appropriate, an apology.
How a complaint is dealt with can make a big difference to the outcome and a good complaint response can reduce the risk of escalation, for example to the Ombudsman or GMC.
While complaint managers should ensure an appropriate response is received by the complainant, clinical staff involved in the patient’s care or named in the complaint are likely to be asked for their comments and to address any concerns relevant to them.
Even where a complaint appears to be relatively straightforward and you feel you are being well supported by your employer or complaints manager, it is still worth contacting your defence organisation for advice.
As well as our guidance on how to set out your complaint response, we can advise on the tone and style and ensure that you have addressed the relevant points.
Adverse incident report
Ten per cent of consultants contacting us did so about an adverse incident report.
The purpose of an adverse or serious untoward incident investigation is to consider whether there have been any systems failures and to establish what went wrong, rather than to identify individuals at fault or apportion blame.
Being involved in an adverse incident and being asked to attend an investigatory meeting or provide a report can be a daunting experience.
Much like complaints, these are an opportunity to review and reflect on the care the patient received, not only from you but the whole team, and consider
what went well and what could be improved upon.
Again, doctors have a professional obligation to co-operate with such inquiries and use them as an opportunity to develop professionally.
Dealing with claims
Another 10% of consultants who contacted us did so about a claim.
For private consultants with the appropriate indemnity, their defence organisation will deal with the claims process and liaise with the claimant’s solicitor.
It is important to let your defence organisation know as soon you are made aware of a claim – for example, if you receive a letter from a patient’s solicitor –because deadlines may need adhering to.
Claims made by patients treated in the NHS are dealt with by NHS Resolution. If you are involved, then it is likely you will need to write a report which may relate to care provided some years ago, including before you became a consultant or from a previous post.
We can help prepare your report, which should be based on the relevant clinical records, but, where appropriate, can also be based on your recollection of events and what your normal practice would have been at the time.
Your comments will assist the trust’s legal representative in deciding whether to settle the claim, with or without admitting liability, or defend the claim. If the claim is defended, it could result in a trial which you may be asked to attend.
As a professional witness, your role is to provide a factual account and not opinion, which would be the role of an expert, but you may be asked some questions based on the claimant’s allegations.
Again, it is helpful to have your defence organisation supporting you through the process, as you may find the trust’s solicitor contacts you multiple times as more information becomes available.
Dr Kathryn Leask (right) is a medico-legal adviser at the MDU
BILLING AND COLLECTION
Let the experts fit the bill
Outsourcing private practice medical billing and collection is increasingly the simplest and most effective route for consultants in private practice. Simon Brignall (below) examines the reasons why
WHEN MOST people need a specific service, they seek experts to help – just like a patient with a knee problem searches for a knee surgeon with years of experience to ensure they get the best care.
Consultants in private practice should be the first to appreciate that a similar rule applies to their business.
The medical billing side of private practice can prove challenging to new and established practices. Even for the most successful, a full review of their finances often brings to light issues that need sorting.
Outsourcing this vital function is increasingly common. With over 30 years in the sector, Civica Medical Billing and Collection has been well positioned to see this growing trend and the changes in the sector. We now partner with over 1,800 consultants, groups, clinics and hospitals across the UK.
New consultants especially
Outsourcing . . . frees your medical secretary to focus on the patient’s clinical journey without having to worry about the business side of the practice
favour outsourcing because it allows them to focus on growing their practice rather than having to worry about administrative issues. Practices of all specialties and sizes find benefits.
Free to focus on the patient
The most important, and generally overlooked, benefit from outsourcing is that it frees your medical secretary to focus on the patient’s clinical journey without having to worry about the business side of the practice.
Outsourcing allows this key relationship with the patient to be warm and convivial, leaving the billing company to focus on the financial side of the practice and those difficult discussions about money.
This provides many benefits to the practice such as:
Improves the patient experience;
Engenders better patient reviews; Frees the secretary to be able to respond to new patient inquiries.
All of this translates to a valuable increase in practice revenue.
Expertise is key
Consultants spend years in education and training to become experts in their specialty, but when they start out in private practice, they find running a business often presents challenges they are unprepared for.
Even busy practices running for
➱ continued on page 28
many years can still find this difficult. Procedures are often not as robust as they should be or, even more importantly, are seldom routinely followed.
I still come across consultants who do their own billing. It is not a valuable use of their time or experience. I would argue that if you are going to spend time billing, then it is surely better to spend those hours more productively by focusing on seeing patients and leaving the billing to experts.
Most billing companies’ fees are calculated against received income, so their business model means they are incentivised to ensure they always bill the optimal amount on your behalf and that these invoices are settled as soon as possible.
Improved cash flow and reduced bad debts
One of the main reasons practices contact us is that they are facing problems with their cash flow arising from their outstanding debt.
These challenges can be the result of a variety of reasons, including:
Invoicing delays;
Problems with payment reconciliation;
Lack of a robust chase process;
Poor practice financial data;
Lack of visibility;
Limited patient payment options.
We often meet with practices where they have been writing off 5% in bad debts every year and sometimes this can be as much as 10% if they have found it hard to stay on top of things.
Our robust procedures manage these issues and can often provide a range of payment pathways that better meet consultants’ needs. Our bad debt level is under 0.5% across our clients.
Medical billing is complex
Medical billing is complex and requires experience and training. Some countries require a medical billing qualification to carry out this task.
There are over 2,000 Clinical Coding and Schedule Development (CCSD) procedure codes as well as diagnostic codes to choose from and each insurance company has its own price list and rules about how these codes can be
billed. There are even formulas that are applied when billing multiple codes, and these can vary between insurance companies.
The CCSD schedule is updated monthly, so keeping on top of it can be challenging. Failure to do so can mean the practice loses income or, worse, results in issues with the insurers from incorrect billing that can lead to derecognition if not adequately addressed.
We still see practices losing out on income due to billing errors.
Chasing outstanding debt requires a specific skill set which not every medical secretary has, and this is often the reason invoices are not pursued.
Functionality for a modern practice
Outsourcing can be the easiest way for practices to offer a range of new functionality to meet modern patients’ needs.
These new payment pathways
I have found the billing, and especially the chasing side of private practice, is not something medical secretaries enjoy. That’s why they are often happy to relinquish responsibility for it
24/7 and see reports detailing the amount invoiced, payments received, patient activity and aged debt.
These can be viewed based on a range of criteria as well as at a summary or granular level.
Consultants’ concerns
not only improve the patient journey but improve practice finances.
Our clients are offered:
E billing of private medical insurers and patients;
24/7 payment collection;
Text message chasing;
Invoicing and collection of selfpay patients in advance;
Sameday invoicing and collection via our Client Self pay Module;
Settlement of multiple outstanding invoices with one payment;
Payments links for your website.
Staffing problems
Staffing issues can be one of the most challenging things to manage in a private practice. Many inquiries we receive are from consultants who are finding billing difficult to manage due to a secretary’s retirement or absence.
Outsourcing often provides a simple yet effective solution and benefits doctors’ practices where binary decisions about staffing are needed due to fluctuations in patient activity or group size. It means consultants always have the capacity of the billing company available to meet specific needs.
Lack of visibility
Consultants commonly complain they do not have easy access to upto date accurate financial data about their practice. Yet all practices rely on this information as the first step in the chase process. Difficulties getting this data also means consultants are unable to make informed decisions about their practice.
Our clients can access a full array of reporting tools to review their practice data via our software. They can get their information
Most billing companies work on a cost structure calculated against received income not on what you invoice. It is always good business practice to have a cost structure correlated to money received, as both the pandemic and recent spike in inflation has highlighted.
I have examined why outsourcing has proved to be a popular choice for many practices, but it is only fair to discuss some of the concerns consultants raise.
Some comes from a perception that the practice is giving up control, and I fully appreciate that worry. It is best addressed through transparency. You should know what the billing company is doing for you.
And that’s where access to practice data is key, because this allows you to review a company’s performance and establish trust to allow the partnership to flourish.
Other consultants worry about upsetting their secretary. Often that is more in the mind of the doctor than in that of their PA.
I have found the billing, and especially the chasing side of private practice, is not something medical secretaries enjoy. That’s why they are often happy to relinquish responsibility for this task. It is important to make sure you know how the billing company operates, its workflow and who will be responsible for your practice. This ensures a smooth transition.
A strong foundation is the base of any partnership and our onboarding process, called ‘intensive care’, is managed by a senior personal account manager to establishes a good working relationship with doctors’ teams to ensure this this happens.
Outsourcing is a well established and growing trend. If you feel it might benefit you, then do contact a medical billing and collection company.
Simon Brignall is head of sales at Civica Medical Billing and Collection
EMPLOYMENT ADVICE
Lee-Anne Crossman (right) considers what neurodiversity means within the workplace, how to create a more inclusive workforce and encourage a celebration of different minds
Neurodiversity can be an asset at work
‘Neurodiversity refers to the natural range of difference in human brain function, but in a workplace context, it’s an area of diversity and inclusion that refers to alternative thinking styles, such as dyslexia, autism, ADHD and dyspraxia.’
The Chartered Institute of Personnel and Development (CIPD), the professional body for human resources and people development
IT IS estimated that around 15% of the population are neurodivergent, which translates into onein seven employees. Many people with a neurodivergent condition will not consider that they are disabled.
As neurodivergence exists on a spectrum, it will be important –just as it is with any other condition – to consider the effect on an individual employee on a casebycase basis.
The question of whether an individual is disabled will be answered with reference to the allimportant statutory definition in section 6(1), Equality Act 2010 (EqA): ‘A person (P) has a disability if P has a physical or mental impairment, and the impairment has a substantial and long term adverse effect on his ability to carry out normal daytoday activities.’
Therefore, it is important for employers to understand that the definition in the EqA will encompass many of those who are neurodivergent and this may have the effect of requiring the employer to
put appropriate adjustments in place.
Individuals with neurodivergent conditions might be considered to have ‘invisible disabilities’ – subject to meeting the statutory test above – because they are not selfevident and may only impact or become evident in particular situations or in relation to certain duties.
Substantial disadvantage
An employer’s obligation to consider and implement reasonable adjustments arises only in circumstances where they know or reasonably ought to know of the employee’s disability and that they are likely to be placed at a substantial disadvantage.
While neurodivergent conditions might potentially amount to
a ‘disability’ under the EqA, one must also consider that the concept of ‘neurodiversity’ is used to provide an understanding that cognitive differences bring positives to be celebrated rather than presenting a deficiency.
Designing a truly inclusive workplace for all ‘neurotypes’ can produce real benefits for business.
Like other forms of diversity in the workplace, neurodiversity has proved to be a business asset and competitive advantage by ensuring diversity of thought and spurring innovation and creativity.
In an effort to create a more neurodiverse workplace, organisations may need to:
Revisit their hiring process by casting a wider net, reassess their interview process and expand the
roles available – thereby avoiding stereotypical assumptions that might be associated with a diagnosis.
Create a more conducive work environment, which might mean tweaking communication and adapting to an individual’s style of working.
Provide tailored career journeys which enable both the employee and organisation to grow.
Make existing policies accessible to neurodivergent professionals and consider implementing a specific policy for neurodiversity, otherwise known as a ‘neurominority policy’ to cover:
1
Hiring targets for neurodiverse talent;
2 Extensions and exceptions of your organisation’s flexible working policy;
3 Workplace environment adaptations;
4 A framework for internal support;
5 Performance management adaptations.
Overall, employers should embrace the challenge of rethinking their workforce strategies and policies, as it will undoubtedly unleash the potential of the neurodivergent workforce, thereby opening up opportunities and inevitably making the workplace a better, safer and more inclusive place for everyone.
Solicitor Lee-Anne Crossman is a senior associate at Hill Dickinson LLP
A magic bullet for everyone?
Greater access to health data, high-tech diagnostics and innovative treatments have led to the emergence of personalised medicine. Dr Tim Woodman (right), medical director for policy and cancer services at Bupa UK Insurance, explores its benefits, particularly for cancer patients, and the challenges we will need to overcome to make it a sustainable future option
PERSONALISED MEDICINE is a term that is bandied about a lot, and it means different things to different people.
To me, it’s more than just matching the treatment to the disease. It’s about going a step beyond and making sure the treatment will work in, and with, your body to deliver the outcome you want.
Bringing a treatment into your body is a bit like hiring a new employee. The CV may perfectly match the role description, but performance will suffer if the work environment is toxic.
At one level, this is the function of pharmacogenomics: the rapidly evolving science of looking at how well your body will potentially respond to treatments for a range of diseases.
Pharmacogenomics can maximise the beneficial effects of drugs and reduce the risk of adverse effects.
It is being heavily marketed for many conditions such as hypertension and depression, where the target population is massive, but
the cost of the tests (high) versus the cost of the treatments (low) should really see them reserved for those who have failed multiple lines of treatment or who have severe, life-threatening levels of disease.
One Canadian company offers testing against over 200 medications in 19 different treatment areas at a cost of more than £400.
When dealing with cancer, personalised medicine can become highly complex. Again, there are three parties to the treatment – the cancer, the therapeutic agent and the patient.
Targeted therapies
Cancer, even of the same primary site such as bowel, is not identical across all patients. Each cancer must be looked at individually and we have certainly become adept at developing tests that identify mutations in cancer cells so we can hopefully match these to ‘targeted therapies’.
In that case, if the treatments are that targeted, how come only 30-50% of patients respond well?
Even if you identify multiple mutations and pick them off one at a time with different treatments – and ignore the cumulative toxicity – the cancer will probably still progress. Why is this?
When tumours resist treatment and metastasise, this may well be because new mutations have developed that do not respond to the ‘targeted’ agent.
Fortunately, we can now routinely look for circulating tumour DNA (ctDNA) in the blood which picks up mutations from anywhere in the body, including metastases. We may not find the tumour, but we can find its fingerprints.
More accurate tests
‘Treatment failure’ may also be because some of the ‘actionable’ mutations identified were present long before the cancer developed and are part of the ‘background noise’.
There are now more accurate tests that can filter this background noise out – a bit like eliminating the homeowner’s finger prints at a burglary. This can prevent patients being given ineffective, or even dangerous, treatments.
A significant element in treat -
None of what I have written here is science fiction – it’s either already here or coming to a clinic near you in the next year or so
ment resistance is that many treatments rely on the immune system to finish the job, and some tumours are very good at hiding from the body’s defenders: T-cells. Immunotherapies, such as immune checkpoint inhibitors, were developed to ‘light up’ these tumours and attract the T-cells. Even then, fewer than half the patients treated will have a significant response.
Unique immune systems
The problem is that there is no ‘one size fits all’ immune system. We’re back to fingerprints again, and immune systems are just as unique and are constantly evolving with subtly changing networks of epigenetic proteins that can enhance or obstruct the ability of immunotherapy to ‘find and fix’ tumour cells for T-cells to destroy.
Your immune system can also be affected by the microbiome of your gut – a healthy microbiome can stimulate a healthy immune system.
Fortunately, it is now becoming possible to test the proposed immunotherapy against both the tumour and the immune system to assess in advance of starting treatment the likelihood that a patient will respond.
This is important for several reasons. These are toxic biological agents that cause significant sideeffects in 60% or more patients. It also takes time to decide whether a patient is responding, and these treatments are often used in latestage disease where time is of the essence.
If you know in advance that a patient is highly likely to respond, you can persevere with treatment in the face of apparent nonresponse. On the other hand, if the test suggested response would be unlikely, as a clinician you can
start the discussion about changing treatment while there is still time to do so.
Suppose you respond brilliantly to treatment, but you will need to stay on it ‘until progression’. This could be for years, with a continuing risk of adverse events and at a massive cost – often £100,000 per year.
Using ctDNA personalised to your cancer, it may be possible to provide re-assurance that the disease really has been eliminated and allow treatment to be paused, while repeating the test at intervals can detect relapse long before it is clinically apparent and enable rapid resumption of treatment.
Everyday practice
This new paradigm presents two main challenges – to insurers in particular.
First, many of these tests were developed to support clinical trials, as they represent more objective ways of assessing treatment response. How do we translate this into everyday practice?
Insurers need to work in partnership with genomics providers, clinicians and hospitals to develop real-world evidence to support the wider uptake of genomics.
Second, how do we ensure we get best value in terms of clinical outcomes and cost-effectiveness? There are many genomics providers out there, with very variable histories.
Again, the answer lies in partnerships between the genomics providers, the insurers and the hospitals to ensure that there are good governance processes in place covering both the adoption of tests and the criteria for their use.
It is also vital that there is clear agreement about the place of these tests in clinical pathways.
None of what I have written here is science fiction – it’s either already here or coming to a clinic near you in the next year or so. None of these challenges is insurmountable and, at Bupa, we are working with our partners to deliver solutions.
Genomics is the biggest thing to hit medicine in my lifetime and it falls to us all to work together to ensure that our patients can reap the benefits in a sustainable, affordable way.
Can you now afford retirement?
What now for pensions? Dr Benjamin Holdsworth (right) gives you the detail behind the recent big announcements
retirement?
IT HAS been an interesting few months for those doctors with NHS interests.
As specialist financial advisers, we have become all too accustomed to regulatory reform to your pay, pensions and tax rules over the last two decades, but the majority of the recent changes – reported by Independent Practitioner Today last month – have been positive.
The news that the Chancellor had finally acted to stem the exodus of senior clinicians leaving the NHS or reducing hours because of punitive pension taxes brought relief for many.
Jeremy Hunt announced he would end the tax charges on the lifetime allowance and would increase the annual allowance, reducing substantial tax bills on pensions growth in the process.
These key measures followed the conclusion of the NHS pension consultation which confirmed more flexible retirement opportunities in future.
So what do these developments mean and what are the important issues you should consider now?
Lifetime allowance
The lifetime allowance has not yet been ‘abolished’, but, instead, the tax charge has been removed until April 2024 when a Finance Bill should eliminate it completely.
This means there is no limit on pensions savings, but it should be noted that the pension commencement lump sum, or ‘tax-free cash’ as it is more commonly known, will be capped at its 202223 level of £268,275 – unless you have ‘protected’ a previous allowance limit.
This means you will be paying tax on the rest of the savings when benefits are drawn.
While a largely positive step, it does sadly raise questions for those who have taken pension benefits recently under the former lifetime allowance regime and who almost certainly would have deferred
doing so if given notice. There has been no formal announcement of recompense for anyone in this situation.
Post-Budget, the Labour party announced that it would re-instate the lifetime allowance if it were elected at the next general election, due to be called by January 2025, but that medics could be made exempt from the limits, in a similar way to judges.
Pension ‘protection schemes’
At the end of March, the official Finance Bill was passed, which sets out how the new lifetime allowance rules will operate.
Specific regulations relate to pension ‘protection’ policies, which were introduced in various guises when the Government made cuts to the lifetime allowance. They safeguard a person’s former lifetime allowance figure provided set criteria are met.
In a significant change to former rules, individuals with enhanced protection and fixed protection registered before 15 March 2023 can now pay in new contributions to their pensions and retain their existing protected tax-free cash entitlement.
However, the maximum amount of tax-free cash those who hold enhanced protection can take will be restricted to the amount they could take on 5 April 2023.
Annual allowance
The annual allowance has proved particularly problematic in recent years and has often been cited as a main reason senior doctors consider early retirement.
By increasing the limit of yearly tax-free pensions savings by 50% to £60,000, the Chancellor has removed the problem for most clinicians for the time being.
In addition, the tapered annual allowance, which reduces the standard savings limit further on a sliding scale, will now revert to its ➱ continued on page 34
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previous minimum level of £10,000 from £4,000.
You will also be able to earn more before the tapered annual allowance applies. In April, the ‘adjusted income’ threshold rose from £240,000 to £260,000. This figure includes not only workplace earnings, dividends from investments and property income but also NHS pensions growth and any personal pensions.
With these changes in place, it may prove beneficial to consider whether potential tax benefits exist for restarting private pension contributions or buying additional pension.
The Spring Budget publication also confirmed that public sector pension schemes will be considered ‘linked’ for the purposes of annual allowance calculations. This effectively means that negative pension growth in the 1995 section can be offset against positive growth in the 2015 scheme.
NHS retirement
The outcome of the Department of Health and Social Care’s consultation into NHS retirement flexibilities, published in March, now offers further opportunities for those thinking about the future.
A new ‘retire and rejoin’ scheme has been active since April and means doctors can now retire, draw their NHS pension benefits and rejoin the 2015 scheme to accrue further benefits.
This strategy allows members of the 1995 section to enjoy the same
By increasing the limit of yearly tax-free pensions savings by 50% to £60,000, the Chancellor has removed the problem for most clinicians for the time being
facility as those in the 2008 section and 2015 scheme.
There is no set limit to the pension benefits which can be accrued, so long as the member is under 75. Previously, individuals returning were limited to 16 hours of work for the first month after ‘retirement’ but this condition has now been removed.
Partial retirement
In order to delay the full retirement of key staff and the loss of senior skills and experience, doctors will be able to access partial retirement from October 2023 while retaining their current job role, terms and conditions.
Individuals aged 55 and above, can choose to take up to 100% of their pension benefits, but must reduce their pensionable pay by at least 10% to qualify.
The Department of Health and Social Care has promised new guidance on how this might work in practice, but it is possible that an agreement could be forged between the employer and consultant to make some programmed
activities non-pensionable, for example.
Valuations and inflation
From now on, the date that the 2015 pension scheme is revalued each year will be 6 April rather than 1 April.
Each year, the 2015 pension is revalued to keep in line with the cost of living, using the Consumer Price Index rate from the previous year plus an additional 1.5%. The new date gives a fairer and more accurate view of pension growth.
McCloud Remedy
A further 12-week consultation was launched in March to discern how the Government plans to implement the McCloud Remedy from October this year.
To recap, this is the plan to alleviate the deemed age discrimination caused by moving some members to the 2015 scheme.
It has also been confirmed that doctors who moved their accrued 1995 section benefits into the 2008 section as part of the previous ‘Choice 2’ election will be offered the chance to change their decision as part of the McCloud Remedy.
This is because some members may have moved to the new section because of the lack of flexibility in the 1995 scheme at the time.
This does create an extra layer of complexity for calculations, even before we begin to unravel the figures generated for the seven years of the McCloud remedy period.
There can be hidden pitfalls to some of the new measures which could prove costly in the long run
Seek expert advice
The recent Budget and NHS developments present opportunities, but as with all financial decisions, must be considered in relation to your particular situation and as part of your overall plan.
There can be hidden pitfalls to some of the new measures which could prove costly in the long run. Always seek expert help before making bold choices.
Dr Benjamin Holdsworth is a director of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS
The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.
Levels, bases of and reliefs from taxation may be subject to change and their value depends on the individual circumstances of the investor. The value of investments and the income from them can fluctuate and investors may get back less than the amount invested.
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KEEP IT LEGAL
What can we learn from GMC cases?
We
can learn a lot from the big GMC cases
but there’s much to be usefully gleaned from the ‘run of the mill’ hearings. Dr Tania Francis reports
NONE OF us can help reading news of GMC cases and decisions of the Medical Practitioners Tribunal Service (MPTS). They have a sort of horrid fascination, perhaps because we can’t help but worry that we will one day be on the receiving end of a GMC complaint.
However, this does actually serve a useful purpose, because we can learn a lot from GMC cases and MPTS decisions.
GMC cases fall into a number of broad categories:
Clinical cases. These range from one-off clinical errors to cases of deficient professional performance. There is invariably an allegation of poor record-keeping thrown in;
Conduct cases. These include behavioural issues, poor communication with colleagues or patients, personal relationships with patients or allegations of sexual misconduct and dishonesty;
Criminal convictions;
Health cases including cases of alcohol or drug addiction.
From time to time, a high-profile GMC case will grab the headlines, at least in the medical press. We will all have heard of Mr David Sellu, Dr Hadiza Bawa-Garba and Dr Manjula Arora, for example. But we can learn from more runof-the-mill cases too.
Chaperones
Did you know that it’s not enough to have a chaperone in the room?
If you are examining a patient behind a curtain or screen, the chaperone needs to be with you and the patient behind that curtain, so that they can see you both.
In one case, a Medical Practitioners Tribunal found that a failure to do so amounted to serious misconduct, in circumstances
where the examination was inti mate and the patient had not been expecting it to take place in that consultation.
Indemnity cover /insurance
Don’t forget to renew your professional indemnity cover.
A doctor was erased from the medical register when they failed to renew their insurance, knowingly practised without it, and gave misleading statements to staff at the private hospital where they worked about providing the certificate of insurance.
Adding to or amending medical notes after the event can be found to be dishonest, particularly if the changes are inaccurate or self-serving
Amending medical records
Adding to or amending medical notes after the event can be found to be dishonest, particularly if the changes are inaccurate or selfserving.
If you need to amend or add to medical records, you should
ensure that the changes are accurate, mark the changes as retrospective and provide an explanation for them.
Drugs and alcohol
Perhaps an obvious one – but being under the influence of drugs or alcohol while at work is a serious issue.
Even outside of work, issues arise if the intoxication leads to behaviour which might bring the profession into disrepute or lead to a conviction – for example, drink
driving. Be careful if you are working or driving early in the morning after a big night out.
Care Quality Commission inspections
While the Care Quality Commission’s (CQC’s) remit is to regulate health service providers, rather than practitioners, if you run a service – for example, a private clinic – and a CQC inspection reveals serious failings, this could result in a referral to the GMC, either because the CQC inspection reveals issues with your own clinical practice or because you are responsible for the clinic and its failings.
Scope of practice
Make sure you are clear about your scope of practice, including to your insurer or indemnifier and to your Responsible Officer. This is particularly important if your scope of practice changes or if you do different work in the private and public sectors. As to the latter, make sure you can justify any differences between your private and public sector work.
It’s important that you do enough of any particular type of work or procedure to ensure that you are sufficiently skilled and keep up to date. This can be a problem in private practice, where some doctors may perform a wider range of procedures than they do in the NHS, in smaller numbers. Be careful to work within your scope of expertise. It may be tempting to stray outside your
expertise, for the best motivation – to try to help your patient. However, you will be criticised for doing so and your patient will be better off being referred to a more suitably qualified and experienced colleague.
Using
drugs off-licence or unusual treatments
This can be a particular issue for independent practitioners. Patients may come to you asking for specific medication which they have read about online and which they cannot obtain from their NHS doctors.
It may be that the drug is not licensed or not licensed for the use for which the patient wants it. Independent practitioners have more flexibility to specialise in less common areas of medicine, but it is important to ensure that your practice remains evidence-based.
A doctor was suspended for nine months in a case in which they were criticised for providing advice that was without biochemical, physiological or clinical evidence and prescribed medication without clinical indication.
They also provided treatment which failed to meet NICE guidance; it was not supported by any professional UK medical body or the NHS and was unproven in terms of benefits.
Prescribing outside of licence
Doctors have also been reported to the GMC for social media posts or WhatsApp messages. Be very careful to maintain patient confidentiality and ensure that your posts and messages are appropriate
sally safe, and that there were potential health risks associated with using the treatment in the manner recommended.
It’s important that you do enough of any particular type of work or procedure to ensure that you are sufficiently skilled and keep up to date
and NICE guidelines may be necessary and appropriate in some circumstances, but it must be done with great care and in accordance with the relevant GMC guidance.
Boundaries
It is vital to respect boundaries in your relationships with colleagues and with patients. Inappropriate relationships, or allegations of such, are often the subject of complaints to the GMC – or, in more serious cases, police investigations.
Internet issues
It is vital to be extremely careful in your social media and internet presence. In one case, a doctor was criticised for the information published on their website.
The tribunal took the view that the doctor should have taken measures to ensure it was clear there was no evidence, by way of studies and guidance, that the treatment they recommended would be effective.
It also determined that the doctor should have notified the public and their patients that the treatment was not licensed, not univer-
The tribunal took the view that the doctor’s actions put patients at risk and undermined public health, as there were concerns that the advice on the website could have discouraged people from following other advice, which, in turn, could put them at risk of harm. The tribunal found that the doctor’s actions amounted to serious misconduct.
Doctors have also been reported to the GMC for social media posts or WhatsApp messages. Be very careful to maintain patient confidentiality and ensure that your posts and messages are appropriate.
Even if you yourself are not posting or messaging anything inappropriate, you could be criticised for not taking action if you are aware that other doctors are doing so.
Conclusion
There is a lot of guidance out there from the GMC and from professional organisations such as the BMA and royal colleges, as well as from indemnity organisations. Read it and follow it, and if you are not sure, ask them or discuss any issues with a senior colleague. If you are the subject of a complaint, seek advice from your insurer or indemnifier or take independent legal advice.
Tania Francis (below) is a solicitor and a partner at Hempsons, a specialist healthcare law firm. She specialises in regulatory law and is also a qualified doctor, advising doctors, dentists and other healthcare practitioners and providers
Events have an effect on private care
Independent Healthcare Providers Network boss David
Hare (right) reflects on some important recent national events affecting doctors and their patients
IT HAS been very interesting to observe Chancellor of the Exchequer Jeremy Hunt’s behaviour around the NHS and social care since entering No.11 Downing Street.
I say that given how strong he was from the backbenches and as chairman of the Commons’ Health and Social Care Select Committee about the need for continued investment in the health service – and specifically the need for a fully funded, costed, long-term workforce plan for the NHS.
One thing we were particularly pleased to see when he delivered his much-anticipated Spring Budget was some acknowledgement of the important role that employers – through occupational health – can and should play in
supporting the health and well being of employees.
A £400m investment was announced to increase employ ment support for mental health and musculoskeletal (MSK) problems. This will involve turning community hubs and leisure centres into MSK hubs so more people can access treatment.
Pensions progress
The Budget also announced the expansion of funding for the upcoming small- and mediumsized enterprise subsidy pilot study for occupational health services, as well as bringing forward two new consultations seeking to improve occupational health, covering potential regulatory options and tax incentives.
We have worked hard to make this case to the Government in recent months, so it was very
One of the longest-running workforce issues facing the NHS particularly has been around pension rules, which have impacted senior doctors across the country. Their punitive impact undoubtedly has had an enormous impact and completely disincentivised senior medical colleagues particularly from continuing to work – in some cases, it literally cost them to do so.
As reported in Independent Practitioner Today last month, Mr Hunt announced there will be an increase to the annual pensions tax-free allowance from £40,000 to
Meanwhile, the pensions life time allowance, which currently sits at £1.07m, will be abolished entirely. There had been earlier briefing that the cap might just be raised.
The policy itself was pitched quite clearly and overtly to target and resolve the issue for senior doctors specifically.
In that respect, many colleagues have welcomed it, including the BMA, so a tick in that box and many Independent Pract itioner Today readers will doubtless welcome these developments. However, by avoiding some kind of ring-fencing around doctors –admittedly this would have been
very complex – it ended up taking fire for being a windfall for all top earners.
Junior doctors’ strikes
We were looking closely to see what the impact of the junior doctors’ strikes might be on services across our members and we stood up a working group with clinical leaders from across the member-
So far, as I write, the impact appears to have been relatively minor. That is thanks in many respects to the support and willingness of senior medical colleagues supporting the NHS and due to pragmatic and sensible management by private providers. Most of our members have reported only minor impacts to planned lists and activity. This in itself raises an interesting question about workforce. Some critics of the independent and private sectors have in the past used a
‘robbing Peter to pay Paul’ argument when considering the workforce.
There is no point – the argument goes – in commissioning more work to the independent sector, as the people delivering it all work in the NHS, so there is no additionality – the workforces are the same.
One could see the strikes, and the comparatively modest impact on the independent and private sector, as evidence that perhaps there’s a much greater level of ‘insulation’ after all. Perhaps there is not so much ‘fishing in the same pond’ going on? It’s something we will be considering.
Waiting list misery continues
More widely of course, the knockon impact of the strikes is almost inevitably that more patients are not being seen in planned care.
The NHS reported that 175,000 appointments were missed as a result of the first action, with a
likely 250,000 more impacted by the second.
That is a huge number of patients impacted, appointments to rearrange and procedures to re-book. With over 7.2m people still on the waiting lists, we must hope that this does not turn into a long-running issue or patients will suffer the consequences.
Patients vote with their feet
The travails of the NHS are undoubtedly having a continued impact on consumer behaviour.
We are seeing consistent evidence of this through ever-increasing market research – whether that is public polling or analysis by insurance companies and others.
We have just completed a significant body of research showing some very interesting findings and will be publishing these in due course.
It is becoming clear that members of the public are starting to vote with their feet in terms of pur-
suing private healthcare – whether that is operations, diagnostics or primary care. And it is not necessarily just in the UK either.
On the latter point, we need to remind the public that the UK remains one of the safest and best places in the world to receive medical treatment.
There have been several stories in the media recently about patients travelling abroad and receiving substandard care, which puts their lives at risk.
This is obviously a worrying trend and we need to consider how patients are making judgements and decisions and hopefully ensure people are not just taking the cheapest option.
Earlier last month, IHPN held its first Private Primary Care group meeting. It was a productive first session. We discussed its future work programme and the good work members are doing in private primary care.
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BUSINESS DILEMMAS
Does the GMC need to know?
Being issued with a Community Resolution Order gets lights flashing for this consultant. Dr Kathryn Leask advises what he needs to do in response
Dilemma 1
Must I report a tiff to the GMC?
QAfter a heated dispute with a neighbour, the police have issued me with a Community Resolution Order.
As a private dermatologist, I am aware that I need to declare cautions and convictions to the GMC, but the police told me that this was neither of those things.
However, one of my colleagues has said this should be disclosed to the GMC. I don’t want to let the GMC know about this unnecessarily. Please could you advise.
ACommunity Resolution
Orders are used by the police to deal with low level offences, particularly when the offence is a momentarily lapse of judgement by someone who is normally a lawabiding citizen.
It does avoid the offender having a criminal record, but it can still show up on a Disclosure and Barring Service (DBS) check.
As they do not constitute a criminal record, from the police’s point of view, they are not recorded on the Police National Computer, but they are recorded on police information systems for intelligence purposes.
This means a previous Community Resolution Order can be taken into account if a further offence is committed.
There are different types of order, which can include a restorative jus
tice meeting with the victim, a warning and agreement, and rehabilitation.
The GMC’s more detailed guidance on reporting criminal and regulatory proceedings states that doctors are expected to report Community Resolution Orders
If an offender lacks insight into the concerns about their behaviour, they can be asked to attend a victim awareness course.
Paragraph 75 of the GMC’s Good Medical Practice says registered medical practitioners must tell the GMC without delay if they have accepted a caution from the police or been charged with or found guilty of a criminal offence.
The GMC’s more detailed guid
ance on reporting criminal and regulatory proceedings states that doctors are expected to report Community Resolution Orders, as this is, in effect, an admission of committing a crime.
It is important to comply with the GMC’s guidance. If the GMC were to find out about a conviction or other disclosable sanction from another source and the doctor hadn’t reported it themselves, the doctor could be vulnerable to criticism and allegations of being dishonest.
An end to my skeleton
Dilemma 2
How do I get rid of my skeleton?
QI am a consultant orthopaedic surgeon and am due to retire soon. I have had a human skeleton since I was in medical school and have used this for teaching purposes during my clinical career.
As I am retiring, I will no longer have a use for it and would like to know how to dispose of it appropriately. Someone has mentioned the Human Tissue Authority to me, and I don’t want to find myself in difficulty if I breach any rules.
AThe remit of the Human Tissue Authority (HTA) is defined in the Human Tissue Act 2004 and as well as postmortem examination, the HTA regulates anatomical examination, public display of tissue from the deceased and the removal and storage of human tissue for purposes such as education and training.
The disposal of bones needs to be done sensitively and the HTA recommends this can either be by incineration separate from clinical waste and, if possible, accompanied by a simple but respectful ceremony or burial.
If burial were to be considered, you should consult local burial authorities to establish what type of services they provide.
The Human Tissue Authority states in relation to the disposal of former anatomical specimens that ‘cremation may be viewed as a more dignified or respectful method of incineration’.
In England, Wales and Northern Ireland, two different sets of regulations govern the process of cremation: the Cremation (England and Wales) Regulations 2008 and the Cremation (Belfast) Regulations (Northern Ireland) 1961. Both sets of cremation regulations are outside of the remit of
the HTA but fall within that of the Ministry of Justice.
I would anticipate there being a fee for authorised burial/cremation. A local undertaker, your local council or a hospital mortuary technician might be able to give you information about the facilities nearby that would be able to help you with this. A local licensed mortuary may also be able to provide guidance.
Another alternative is to donate the skeleton to a medical school for teaching purposes.
A consultant’s retirement throws up an unusual question – how should he safely and appropriately dispose of human remains?
Dr Kathryn Leask (right) gives her view
Provided the medical school holds the appropriate HTA licence, they could accept the skeleton for a ‘scheduled purpose’, which would include education or training. Providing first class medical consulting and therapy rooms at prime locations in Central London and Liverpool
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A PRIVATE PRACTICE – Our series for doctors embarking on the independent journey
How to create a happy business
It is important that your hard work and valuable time is rewarded to build a prosperous business. Richard Norbury’s key points will help give your practice the best chance for success
CONSIDER YOUR private practice as a business and your time and expertise is what the business is selling.
Carry out a review of which areas of your business are most profitable and offer the most reward. This could be by looking at your ‘take-home pay’ or rewards from a non-financial point of view.
You will naturally strike a balance and many of you will take the view that you want or need to continue with less profitable areas of the business.
While it may be awkward, HM Revenue and Customs (HMRC) will expect you chase slow payers and review this regularly and document this to allow you to write off bad debts against profits. Not following this up means you can end up paying tax on income never received!
Understanding exactly how you are paid and how the insurers work
A thriving private practice usually has an excellent team in the background to support you
will put you in the best position to maximise your profits.
Often an excess is payable by patients and can be deducted from your fees if you are not careful.
Fee increases
fees would effectively mean you are working for less.
Fee increases for self-paying patients should be considered, but in order to remain competitive, you need to be aware of the fees your colleagues are charging.
Build the right team
A thriving private practice usually has an excellent team in the background to support you.
An experienced and efficient secretarial/practice management team will often be the first port of call for many patients and will help in many ways, including:
Managing patient expectations,
Ensuring that you are paid for the work that you perform;
Ensuring efficient time management;
Identifying billing opportunities;
Keeping accurate records.
A team should not be limited to
Raising your fees is a topical subject, but, with inflation running at over 10% in recent months, you need to consider that your costs will increase more significantly than in recent years. So not taking the opportunity to increase your ➱ continued on page 44
the people on the payroll. Consider building a network of businesses and individuals who, although perhaps not employed full time, are engaged to achieve a common goal – the success of your business.
Specialist professional advice
Often the advice that you receive from professional advisers is instrumental. A specialist medical accountant will be able to ensure you are trading in the right structure to maximise your take-home pay and offer practical advice.
An in-depth knowledge of the NHS pension is essential to be able to offer you a full package.
In addition to accountants, you should assemble a team of trusted advisers, including solicitors, independent financial advisers and other professionals to achieve your goals.
Often you will find that firms are specialist or have departments that deal with healthcare due to your specific needs as clinicians.
Choosing the right trading structure
Choosing the right trading structure should be considered on a case-by-case basis and you should take advice from a specialist medical accountant.
For companies, corporation tax for profits over £50,000 in a single company has risen recently, as has dividend tax and a review of your trading structure may be necessary.
However, using a company may still be the best option, especially for those individuals facing the ‘cliff edge’ thresholds of £100,000 for childcare benefits or £200,000 for pension annual allowance tapering considerations.
Partnerships offer an alternative way of trading and can sometimes be more efficient in certain circumstances.
Choosing the right trading structure may increase your ‘takehome’ pay or mean you have more free time for the same amount.
Software and systems
Many consultants will use software to track their fee income and also to make other areas of their business more efficient, as some software will hold clinical information.
As your private practice grows, you should be able to check to make sure that you are paid for the work that you have already performed and systems should be put in place for this.
Some of you will already be VATregistered, perhaps due to medico-legal work. Systems and software can help track and prepare the VAT returns for submission to HMRC.
From 2026, Making Tax Digital (MTD) is planned to be introduced by HMRC to businesses with income of over £50,000, so the requirements of this should be reviewed to make sure you will be compliant when the time comes.
Systems will help to ensure you save for tax as you go along and get into the habit of saving a percentage of your income every month to ensure you have enough saved to meet future tax liabilities.
Diversification
Consider the risks to your business and how Covid had an impact.
Is there anything that can be done to mitigate this risk, such as applying for admitting rights in more than one private hospital?
Considering your own premises/ clinic, could you be expanding the services you currently offer, such as medico-legal work or do some subcontracting for a particular provider?
You should bear in mind that branching out to different areas comes with its own set of issues. For example, medico-legal work usually has a very long delay between performing the work and actually being paid.
This can lead to tax liabilities on work that you have not yet been paid for. In addition, once you reach certain levels, you will need to register for VAT and this can be an additional administration burden.
While diversification may be a good way to mitigate the risk of your business losing income, you should consider your unique skill set and where your time is best placed.
Value for money
Extra fees are always welcome, but additional income often brings about additional costs necessary to fulfil the service. Examples of this could be room charges, staff costs or your time.
A specialist medical accountant will be able to ensure you are trading in the right structure to maximise your take-home pay and offer practical advice
However, reducing £100 of your expenses should equate to an extra £100 on your bottom line.
However, take care that reducing costs does not impact on the product or service you receive. A balance should be maintained so that you get value for money and this sometimes means that the cheapest option is not always the best.
Choosing the right group
Choosing the right group to belong to can be a great way to achieve common goals and offer lucrative opportunities. Often this may be working in familiar surroundings with support and logistics already arranged for you so you can concentrate on the clinical procedure.
Take care to consider the groups that you join and in what capacity and level of commitment. Joining a group where you do not share the same ethos is likely to cause friction between colleagues and
may mean that the group is less likely to flourish.
Groups have become more prominent over recent years and are likely to continue to be a poplar way for the NHS to reduce their waiting lists.
Consider how committed that you want to be in these groups from full, paid-up membership and running the show down to a level where you may subcontract for these groups and you simply invoice for your services.
It is a good idea to take specialist professional advice on the best structure or contracts that are needed from a legal perspective.
Marketing
As your private practice grows, you will be expected to have a professional website which is easily found and allows patients to book consultations without problems. Social media sites are now used widely for marketing and it may be the case that family members or support staff can help promote your business on the various different platforms that are available, possibly tailoring the sites you target to the profile of a typical patient.
Private hospitals often have inhouse teams to help with marketing that you can use to help boost your business, as they have their own vested interest in your success.
Taking specialist professional advice will help you follow sound advice to build and maintain a successful private practice and help avoid unnecessary stress and risk.
Next month’s article: Alec James looks at current VAT issues
Richard Norbury (below) is a partner at Sandison Easson & Co, specialist medical accountants
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DOCTOR ON THE ROAD: KIA NIRO EV
Niro is no emperor
The Niro comes in many guises. Will Independent Practitioner
Today’s motoring correspondent Dr Tony Rimmer give his test car the thumbs up, or the thumbs down?
AS WE know in our medical work, there is often more than one solution to any particular problem and each will have its own strengths and weaknesses.
In many cases, various combinations of surgery and medical therapy can be used to best effect for any particular patient’s individual needs.
As medic car buyers, we also have very individual needs and situations. We may want to join the increasing band of electric vehicle (EV) drivers for noble environmental reasons, but are thwarted by circumstances.
The lack of a drive or designated parking space if we live in a city will make home charging almost impossible. If we then must rely on the external public charging network, it becomes much less convenient and far more expensive.
We are then looking at selfcharging petrol hybrid models and plug-in hybrids. They are cheaper to buy than full electric EVs and allow more flexibility for refueling and recharging needs.
Mid-life update
Some manufacturers offer all variants of the same model which, although being an engineering compromise, allows the customer to fulfil their individual requirements. Such a car is the Kia Niro and it has recently been given a mid-life update by the Korean brand.
It is available as a 139bhp 1.6 litre petrol hybrid for £27,745, a 180bhp plug-in 1.6 litre petrol hybrid for £33,525 and a 201bhp full electric version for £36,245.
There are three trim levels to each model: Levels 2, 3 and 4.
I have been testing the £38,995
Level 3 EV which offers the optimum trim level and value for this all-electric Kia.
The 65kWh battery promises a range of up to 285 miles. This is about the same as is claimed by VW for the standard iD3 and MG for its MG4.
The revised styling has smartened up the exterior of the Niro with a more futuristic front end and the potential for some contrasting-coloured bodywork behind the rear doors; reminiscent of the ‘side blades’ on the Audi R8 sports car.
Good space
However, this is no sports car. It is a roomy five-seater hatchback with good space for rear seat passengers. Because it shares a platform and bodyshell with its petrol hybrid siblings, this EV version has space
The revised styling has smartened up the exterior of the Niro with a more futuristic front end
under the bonnet for extra storage – a good place to keep the recharging cables.
The updated interior uses goodquality materials and the controls are straightforward and clear. It feels more solidly built than before and better than its rivals too.
There has obviously been some real thought given to passenger convenience, with good storage pockets and individual USB sockets on the backs of the front seats.
Boot space is a generous 475litres with a flat floor for easy loading.
Excellent visibility
Out on the road, the Niro EV is as sprightly as expected. The steering is light and direct and visibility is excellent from a slightly elevated driving position.
As it shares its chassis with its hybrid siblings, the Niro is front-
I found the Niro a perfectly good companion for fulfilling all the practical functions demanded of a family car but lacking any real character wheel drive, which means that the turning circle is less than its iD3 and MG4 rear-drive competitors.
The brake regeneration can be altered through four strengths and, on the highest strength, allows almost one-pedal driving. All the usual driver safety features are standard, but the lane assist function is quite intrusive and when you turn it off in the infotainment menu, it annoyingly
KIA NIRO EV ‘3’
Body: Five-door hatchback
Engine: Single electric motor. Front-wheel drive
Power: 201bhp
Torque: 255Nm
Top speed: 103mph
Acceleration: 0-62mph in 7.8 seconds
WLTP claimed range: 285 miles
CO2 emissions: 0g/km
On-the-road price: £39,895
defaults to being on again when you restart the car for your next journey.
This is a feature common to all VW EVs too, but not the MG4 where it remains off when turned off.
Road noise
Performance is swift, perfect for the urban cut and thrust, and the ride is soft and comfortable. Although engine noise is absent, road noise is a little intrusive at motorway speeds.
Handling is fine but not dynamic enough to entertain the keen driver. As you can gather, I found the Niro a perfectly good companion for fulfilling all the practical functions demanded of a family car but lacking any real character.
Pure EVs are still only really
suited to city/urban living where home-charging is available. The real-world range of 200 miles which this Niro and its direct competitors offer is just right for this sort of use.
Kia’s solid build quality and standard seven-year warranty –only matched by MG – is also a strong selling point.
However, if you are a medic who is not yet convinced about the suitability of all-electric vehicles to your lifestyle or needs, then you could still consider the cheaper hybrid or plug-in hybrid versions.
Dr Tony Rimmer (right) is a former NHS GP practising in Guildford, Surrey
Boot space is a generous 475 litres with a flat floor for easy loading
HERE’S WHAT TO LOOK OUT FOR IN OUR JUNE ISSUE
Coming in our June issue, published on 6 June:
Cyber security – is prevention better than cure? The high-profile ransomware attack on a major IT provider to the healthcare sector, Advanced, in August 2022 highlights a fastgrowing risk to health organisations and the need for greater focus on cyber security. It is not just the NHS at risk. Don’t miss our report from Aoife Ryan, legal director at Hill Dickinson
Check out what’s happening out there in our reports from LaingBuisson’s annual private healthcare summit
So you know why you need a personal assistant and now you are asking yourself ‘What should I look for in a PA? What does a good PA look like?’ Dawn Shrives provides the answer
Business Dilemmas – storing images of a child where intimate areas of the body are showing. A paediatrician’s colleague advises it is a criminal offence to keep these kind of images. So what should he do?
Dr Kathryn Leask of the Medical Defence Union gives her response
Ten things lots of doctors wished they had known before going into private practice
It may feel counter-intuitive, but independent practitioners looking to grow their private practices should look at opportunities to secure contracts with the NHS. These are often time-limited and projectfocused to help resolve issues. Solicitor Robert McCartney of Hempsons gives a legal view on preparing for procurement opportunities
Get armed for your response! Nicola Wheater of Ridouts on responding to GMC complaints – plus . . .
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Private doctors reveal the impact of GMC investigations on their mental health
Check out some more reasons why consultants contact their defence body for advice, in the second instalment of this month’s article from a leading medico-legal adviser
Important VAT issues to be aware of in private practice
Neurodiversity can offer opportunities for different thinking and fresh ideas. To harness this potential, Bupa Global and UK medical director Dr Robin Clark says there is a need to raise awareness of the condition and how to design the workplace so that neurodiverse employees can thrive and make the most of their talents.
Don’t fall behind! Simon Brignall, of Civica Medical Billing and Collection, warns it is vital for independent practitioners to keep up to date with the increased activity many are seeing with cash flow and debt
What biases do investors face when assessing their portfolio returns?
Financial specialists Cavendish Medical on the importance of assessing the FTSE 100 against a well-diversified portfolio
Our Doctor On The Road columnist Dr Tony Rimmer takes a trip in the VW ID Buzz
Plus the latest from the Independent Healthcare Providers Network, a look back at what was making the news in Independent Practitioner Today a decade ago and all the latest news and views
ADVERTISERS: The deadline for booking adverts in our June issue is 19 May
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