June 2014

THE BUSINESS MAGAZINE FOR DOCTORS WITH A PRIVATE PRACTICE

Today INDEPENDENT PRACTITIONER

In this issue

The route to business booty Some valuable lessons to avoid the pitfalls when trying to set up a new private practice P14

Publish & be damned good How becoming an author is good for a private doctor’s patients and profits P20

Bid to keep Ltd status for doctors

By Robin Stride

Consultants’ advisers are negotiating with HM Revenue and Customs (HMRC) over a tax disagreement which threatens specialists’ businesses with a potential ‘financial and legal nightmare’.

Tax inspectors operating the Government’s new anti-avoidance policy believe independent practitioners are reaping tax advantages by incorporating their businesses and, additionally, selling goodwill.

HMRC is convinced that a professional is unable to incorporate their business activity via a limited company, a vehicle used by many professionals to offer their services.

But around 2,500 consultants in private practice currently use this trading vehicle, which accountants argue they are allowed to do under the corporation taxes acts.

HMRC believes these consultants are now paying lower rates of tax at 20%, the current rate of corporation tax on a company.

But accountants say it appears HMRC has forgotten that personal

In association with

rates on investment income returns remain very high at 37.5% and any consultant shareholder withdrawing funds as profits will pay these rates because they are likely to be additional-rate taxpayers with taxable income over £150,000 a year.

Medical accountants are currently locked in talks with HMRC to address the apparent anomalies between current tax officials’ views and what statute and their own guidance appears to allow.

Tax law specialist and barrister Michael Ripley told a workshop for advisers involved that, in his opinion, professional services can be offered through the incorporation route and existing businesses with goodwill can be transferred to a limited company.

Specialist medical accountant Vanessa Sanders said: ‘If any doctors or other professionals who have incorporated were forced to revert to sole trader status, they would be thrown into a financial and legal nightmare.’

Ltd companies are traditionally used to allow profits to be rein-

Indemnity costs bite The constant rise in negligence compensation threatens the future of private practice P32

ON A HIGH: Orthopaedic surgeon Mr Peter Brownson, extreme sports lover, celebrated his 50th birthday in style when he went for a sky dive and persuaded three colleagues at Spire Liverpool Hospital’s Bone & Joint Centre to leap with him from 15,000ft for a ‘bonding experience’ at Black Knights Parachute Centre near Lancaster. Luckily, the surgical expertise of John Davidson, Andy Taylor and Matthew Smith was not required on the day

vested for future growth, highs and lows of business to be evened out over several years and risks of indemnity claims to be constrained.

Consultants selling goodwill –estimated to be 30% of those who have incorporated – would need to revise their tax returns and make large reclaims of capital gains taxes paid stretching back to 2010.

Accountants estimate the loss to HMRC on an average goodwill transfer value of £100,000 would amount to about £7.5m in repayments.

Mrs Sanders – whose firm, Stanbridge Associates, arranged the workshop to explore the knowledge and experiences of other advisers – spoke of the reasons for incorporating some consultant practices, in particular the need to move forward for the changing marketplace of private practice.

She said she felt HMRC was not yet aware of medical specialists’

needs to be able to offer their services using the protection offered by the limited company as a trading vehicle. But she hoped talks would help both sides.

Accountants at the meeting at London’s Royal Society of Medicine were surveyed by Independent Practitioner Today and all were buoyant that they would be able to successfully address both the tax and commercial issues raised by HMRC.

Twenty firms agreed to set up a new working party to strengthen their negotiating arm with HMRC on tax matters affecting doctors and to agree standards in accounting for consultants.

Successive governments have encouraged people to set up companies and have reduced corporation tax rates from 52% in 1978 to 20% in 2014. But personal tax rates paid on profit distributions have continued to rise.

In this issue

June 2014

www.independent-practitioner-today.co.uk

new unit fit for new doctors

a private unit is giving newer, younger specialists access to top-notch facilities P12

what is good management practice?

Key to running a successful private practice is treating it as you would your home P18

who wants to be an isa millionaire? How regular, disciplined saving can stand you in good stead for retirement P25

nsure safe disposal of clinical waste

We outline the rules for the efficient and safe management of clinical waste P28

moving home the easy way our legal columnist gives a list of tips for doctors buying or selling their home P36

Private work mustn’t harm nHs duties a medico-legal expert shows how doctors can avoid conflicts of work interests P40

Plus our regular columns starting a private

ediTorial commenT

Assaulted on all fronts by a tax

Benjamin Franklin’s oft quoted proverb: ‘In this world, nothing can be said to be certain except death and taxes’ is particularly poignant for doctors with a private practice right now.

It seems that issues surrounding the latter will never be far away. Doctors are being targeted by tax inspectors to ensure they are truly paying ever penny of tax possibly owed and a tax inquiry into their affairs is likely for each of them at some stage in their careers.

Then hundreds are hit by up to £20k by the ‘Samadian’ tax case ruling ( Independent Practitioner Today , February 2014)

which prevents them claiming against tax for many of the miles they cover while conducting their private work.

Now (see our front page) there are increasing HM Revenue and Customs’ questions over them selling goodwill and even incorporating their businesses. Then some who have received Clinical Excellence Awards for their NHS work may face an extra tax clobbering (see this page).

The big plus out of all this is that accountancy firms are uniting to negotiate with HMRC on private doctors’ tax matters and agree standards. All power to their collective elbows.

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

Phone: 07909 997340 @robinstride

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

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

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

Head of design: Jonathan Anstee chief sub-editor: Vincent Dawe Circulation figures verified by the Audit Bureau of Circulations

Beware the tax sting in tail of merit awards

by leslie berry

Consultants have been warned of a hefty financial sting in the tail arising from the long­awaited but delayed announcement of the 2013 round of clinical excellence awards (CEAs).

Seniors’ awards, which will now be backdated to April 2013, had been delayed following a report from the Doctors and Dentists Review Body recommending extensive changes ‘so that they better recognise current excellence’.

The amount of awards has fallen considerably in recent years, with the number of national awards halved to around 300 since 2010.

Consultants are currently eligible to receive national or local CEAs ranging up to £75,000 a year.

But Simon Bruce, managing director of specialist financial advisers Cavendish Medical, warned senior doctors to be aware of the consequences receiving an award can have on their pension.

He told Independent Practitioner Today : ‘Consultants who gain a CEA can discover their achieve ­

ment proves to be a substantial tax burden.

‘Those receiving significant annual increases such as a CEA could be a target for the much reduced Annual Allowance rate, resulting in a large tax bill. And doctors need to remember that the onus is on the individual to tell HM Revenue and Customs if they are liable for a tax charge.’

The Annual Allowance limit was cut to just £40,000 in April this year.

Mr Bruce added: ‘The increase in pensionable pay from a CEA could also negate the strict rules of Fixed Protection 2012, leaving your benefits subject to the lower lifetime allowance.’

Originally the ‘Fixed Protection’ scheme was created to allow pension savers to restore their previous Lifetime Allowance limit to £1.8m after the rate was cut to £1.5m in 2012.

The future of the awards has been questioned after the review body report was published in December 2012. But its recommendation have yet to be adopted.

BMI boss looks for new role

BMI group chief executive

Stephen Collier, who is to step down from the UK’s largest hospital group after three years in the post, has confirmed a ‘top priority’ will be to continue in healthcare in some capacity.

He told Independent Practitioner Today : ‘Deciding when to step down is always difficult – even more so when BMI continues to grow and strengthen. But beginning the search for a successor now is the right thing to do, as it will ensure a planned succession and an orderly handover.’

Mr Collier said being asked to stay

on as a non­executive director was ‘a real positive’. It is hoped to have a replacement by the year­end.

A company spokesman said the board thanked Mr Collier for the stable platform he had created during very challenging times for the company and the industry as a whole, setting it up for the next phase of the company’s growth as market conditions began to turn.

Mr Collier will work closely with Netcare to identify the right person to drive the company forward. The board said more growth was achievable as the economic recovery continued.

Data codes made simple

by a staff reporter

Help is at hand for independent healthcare providers to meet the Competition and Markets Authority’s (CMA) demand for highquality performance data to guide patients and their doctors.

The latest Clinical Coding Toolkit from online solutions firm Healthcode supports the use of ICD ­ 10 and OPCS ­ 4 coding systems to ensure quality and outcomes data is comparable with the NHS and without compromising the billing process for insured patients.

Managing director Peter Connor said: ‘The private healthcare sector has reached a watershed moment. The CMA’s call for providers to assist effective patient choice by publishing robust quality and outcomes information means we risk undermining the excellent care available if we do not record the necessary clinical data.’

Healthcode’s two recent white papers1 on the subject pointed out that clinical coding has historically only been seen by independent providers as part of the billing process and the sector has been held back by an antiquated set of diagnosis codes known as ICD­9.

This started to change as privatesector hospitals began treating NHS patients and so treatment had to be coded in line with NHS systems. But now there is an even more pressing reason to adopt recognised coding standards.

Mr Connor said the toolkit supports the implementation of effective coding, even for providers with limited in ­ house coding resources.

He said: ‘Users can quickly zero in on the relevant codes for recording a patient’s diagnosis or treatment, making the whole process faster, more intuitive and avoiding the need to send clinical records to coding teams, which

can delay the billing process for insured patients.’

Providers can look up the different diagnosis and procedure codes used in the NHS and independent sector using an intuitive plain language terminology search, a body map or clinical description.

For example, users can search for the common term ‘glue ear’, rather than the clinical code description ‘otitis media with effusion (OME)’.

HCA starts legal challenge against order to sell units

HCA has launched the first phase of its fight to prevent forced sales of some of its leading hospitals in London.

The hospital group has now formally lodged its appeal against the Competition and Markets Authority (CMA) ruling on divestment.

As reported in Independent Practitioner Today (April), the competition watchdog’s inquiry into private healthcare issued the company with a ‘ Sophie’s Choice’ ultimatum.

It ruled that HCA bosses should choose between sacrificing the London Bridge and Princess Grace hospitals or selling off the UK’s largest private hospital – The Wellington – and its nearby flagship diagnostic and outpatient unit The Platinum Medical Centre.

HCA has vowed to fight the

decision all the way through the courts if necessary, saying it is confident it will win.

Keith Biddlestone, HCA International’s group commercial director, told Independent Practitioner Today: ‘The expert advice that we received remains that the Competition and Market Auth ority’s analysis regarding divestment of hospitals was deeply flawed, as was evidenced by the number of proposed divestments reducing over time from 20 to only one or two.’

He claimed that the CMA definition used to demonstrate market share ignored Greater London and overseas, despite these areas accounting for the majority of HCA’s patients.

Mr Biddlestone said: ‘The CMA’s logic for the divestment remedy rests on a pricing analysis that two

Keith biddlestone: Hca’s group commercial director is confident it can win

of the five members of the CMA’s panel could not stand behind in the case of BMI Hospitals.’

BMI had been expected to have to sell off seven hospitals as a result of earlier CMA plans, but in the watchdog’s final report the largest hospital group escaped having to get rid of any.

Mr Biddlestone added: ‘Furthermore, the self­pay pricing analysis omitted over half of the invoices for care delivered in London during the period studied.’  See AXA PPP challenge, page 4

The toolkit also features crossclassification code mappings between OPCS ­ 4 and CCSD or ICD­10 and ICD­9 and vice versa. This eliminates the need to maintain and use multiple coding systems for recording clinical activity and billing purposes.

Healthcode’s code mapping technology is being used by the Private Hospital Information Network (PHIN) to convert hospital episodes recorded using the CCSD codes into OPCS, so its published quality indicators are comparable with the NHS.

The toolkit is available on subscription and includes Healthcode advice and support.

1. ‘A comparison of CCSD and OPCS procedure classifications and an assessment of mapping challenges’, Healthcode, April 2014 and ‘The path to the adoption of ICD-10 diagnosis coding for the independent sector’, Healthcode, May 2014, published as inserts in Independent Practitioner Today (May and June issues) and on the Healthcode website

BMA wants all products that doctors use to be ethical

The BMA in conjunction with the RCGP is spearheading a drive to ensure goods bought by doctors’ practices are procured ethically.

New guidance aims to ensure the rights of workers in medical supply chains are protected.

Dr Simon Poole, chairman of the BMA’s GP commissioning and service development committee, said there was significant support for ethical procurement from the medical profession with a recent BMA survey of doctors showing that 88% favoured the NHS pursuing an ethical procurement strategy.

RCGP vice ­ chairman Dr Tim Ballard added: ‘It is important that the high quality care that we deliver in the UK is not at the expense of the wellbeing of others.’

Peter connor: his firm has produced a toolkit to unify all types of code

Competition inquiry appeal

By Robin Stride

The Federation of Independent Practitioner Organisations (FIPO) is, as expected, appealing against aspects of the Competition and Markets Authority (CMA) final report into private healthcare.

It called on the Competition Appeal Tribunal (CAT) to quash the fees information remedy and also the CMA’s decision that insurers’ substantial power to constrain consultants’ fees and insurers’ control over consumer choice does not lead to any adverse effect on competition.

FIPO claimed the fees information remedy was ineffective and could not achieve its aim, as the CMA had failed to recognise how insurers’ activities ‘often work against true competition’.

It said: ‘The CMA report suggests that the redirecting of patients to consultants whose fees were within the caps set by the insurers was reasonable because patients could still select consultants whose fees were above the caps and pay top-up fees.

‘In fact, the imposition of fixed fees on young consultants, and established consultants being required by the insurers to operate

under a fee assured system – or risk derecognition – is intended by the insurers to eradicate top-up fees. Patients are denied choice and thus these restrictions mean that the patient never sees the bill and so consultant competition over prices cannot occur.’

FIPO chairman Mr Geoffrey Glazer told an Informa Life Sciences health insurance and group risk protection conference in London that the CMA’s outlined method of giving fee estimates was confusing.

He explained later: ‘Consultants are being asked to provide two fee estimates: one before the first consultation and then another 48 hours before any procedure, coupled with extensive other information which may not be available – such as hospital package prices and the details of other specialists who may be consulted.

‘Not only can this not easily take into account any unpredicted complications that could occur during a procedure and will exclude many patients with emergencies and undiagnosed conditions, the system proposed is bureaucratic and has to be monitored by the hospitals.’

FIPO agreed with the need to

HCA Sell-off ‘not enougH’

HCA and anaesthetists are targeted by insurer AXA PPP, the third appellant against the Competition and Market Authority’s final report. the insurer argued to Independent Practitioner today that if it was successful, then private healthcare market competition would be improved for patients’ better interests.

It alleged the CMA’s conclusions about HCA hospitals in central london and about consultant groups were flawed.

even after any divestiture, AXA PPP said HCA would still retain a relatively high market share in oncology, ‘a key component of the bundle of services over which hospital operators and PMIs bargain’.

It also complained that the private patient unit (PPu) remedy for future arrangements excluded HCA’s existing contract for a PPu at guy’s and St thomas’ Hospital, due in 2016.

turning to anaesthetists, it submitted that the CMA was wrong in its decision on anaesthetists’ group prices. It claimed: ‘A collective agreement to set common prices, between anaesthetists who would otherwise be setting prices individually and who collectively have a persistently high (in several cases, near-monopoly) market share, prima facie “prevents, restricts or distorts competition” within the meaning of section 134 of the Act.’

Keith Biddlestone, group commercial director at HCA International, said: ‘While we shall not comment in detail, as appeal proceedings are underway, nothing changes our view that the analysis being used is deeply flawed and that any divestment of HCA hospitals is not in the best interests of patients, many of whom choose to fly in from around the world and who benefit from HCA’s network of hospitals.’

provide fee estimates, but felt the imposed methodology was topheavy. It also wants CAT to reconsider a finding that fee caps

Tributes for retiring chief of UK’s largest private hospital

A consultants’ leader has paid tribute to the Wellington Hospital’s ‘visionary’ chief executive Keith Hague, who has retired from his post after 11 years at the UK’s largest private hospital.

Hospital medical director Mr Geoffrey Glazer described him as ‘an innovative and visionary CEO who enjoyed excellent relationships with consultants and merited their utmost respect’. He is succeeded by Neil Buckley, who for the past seven years has overseen the reconfiguration and expansion as chief executive at The Harley Street Clinic.

Mr Hague was responsible for increasing Wellington Hospital’s turnover during an economic downturn. He also led an entire hospital refurbishment and introduced new services such as the Acute Admissions Unit.

Under his management came the expansion of an outpatient treatment centre at Golders Green in 2008 and the Platinum Medical Centre in 2011, the largest private outpatient centre in the UK.

Mr Buckley said Mr Hague had also built a great team, was a tremendous colleague and friend, and would be missed by all.

‘It is a huge privilege to lead a hospital where teamwork and an absolute focus on providing the highest standards of patient care is the day-to-day reality. The specialist medical teams we have here are world-class.’

The hospital, in its 40th year, was now moving forward with major developments enabling it to offer more new tertiary services for patients and opportunities ‘for more of the UK’s leading doctors to develop their private practices here’.

Aida Yousefi is The Harley Street Clinic’s acting chief executive.

benefit patients by resulting in lower insurance premiums. The BMA decided against pursuing an appeal.

Keith Hague: retiring after 11 years

neil Buckley: new boss of Wellington

WHAt tHe ClInIC offeRS

Complex cases can be reviewed by teams in a stateof-the-art conference room with a multi-screen lCD wall where scans, X-rays and other test results can all be displayed at the same time, making diagnosis and planning discussions faster and more efficient. Diagnostics include two MRIs, one of which is a 3t MRI, the latest 64-slice Ct scanner, the full range of ultrasound and X-ray gear, cardiology diagnostics, bone densitometry, an orthopantomogram, the latest mammography equipment in the breast care unit and london’s newest lung function laboratory.

Specialists can carry out a number of minor procedures including, vacuum-assisted core biopsies, minor urological investigations and treatments. Dermatologists can carry out the Mohs procedure to remove skin cancers in a special laboratory and use photodynamic therapy to remove port wine stains.

£12m diagnosis centre opens

By Charles King

The capital’s newest and ‘most prestigious’ medical facility, The Harley Street Clinic Diagnostic Centre, has opened in Devonshire Street, central London.

Built on six floors, it covers 25,000 square feet over six historic buildings and is one of the largest private diagnostic and outpatient centres in the UK.

The £12m centre has 43 consult-

ing rooms and a comprehensive range of the very latest diagnostic technology together with its own dedicated pharmacy.

More than 100 consultants base their private practices there and cover most areas of acute and complex medicine.

The Harley Street Diagnostic Centre was the brainchild of former chief executive Neil Buckley. He said: ‘We tried to create a new kind of facility where everyone

BMI card offers 0% op loans for patients

A ‘BMI Card’ is allowing patients to spread the cost of treatment with 12 months’ interest-free credit when treated at the group’s hospitals.

Spokesman Sam Phillips said it helped make healthcare more affordable by allowing patients to spread the costs, and with 12 months interest-free credit, made private healthcare accessible to more than those with private medical insurance. She said the payment option was attractive to many patients. The card is available for purchases within any of BMI Healthcare’s 63 hospitals and healthcare facilities

for a period of two years from the date the account is created.

There is no annual charge or membership fee, and applications of up to £7,000 can be approved within 48 hours of receipt of the signed agreement.

Repayments of outstanding balances can be spread beyond the two-year period; however, the card would need to be renewed for new payments.

Representative example: 0% interest for 12 months, then 0.79% per month, representative 9.9% APR variable. Up to £20,000 available (subject to status). Monthly repayment 5% of balance or £25, whichever is greater or balance if lower than £25.

had space, calm and welcoming surroundings – yet also could enjoy benefits of the latest diagnostic technology.

‘Most people are anxious when they visit a hospital, so we designed a centre that had the look and the feel of a relaxing hotel and we have tried to put the needs and comfort of patients first at every stage.’

Acting chief executive Aida Yousefi, who oversaw the project

GMC looks into doctors’ claims that it’s unfair

The GMC is commissioning research to look at the consistency and fairness of its investigations into doctors and the outcomes.

It ordered the work after stark differences emerged between the perceptions of white and of black and minority ethnic (BME) doctors about the way complaints are handled.

According to a poll, most white doctors believe if they faced an investigation or a public hearing, they would be treated fairly and in an equivalent way to others.

But BME doctors and those who qualified outside of the UK were

from the drawing board, said: ‘Patients and their doctors tell us they are impressed by the wide range of specialties offered, the quality, range and accessibility of the diagnostics, together with fast access to some of London’s leading specialists.

‘They are pleasantly surprised by the calmness. They think it is more like coming to a luxury hotel – and the feedback is very positive.’

more doubtful. Of those who did not believe they would be treated fairly, 27% said this was because of their ethnicity.

GMC chief executive Niall Dickson agreed that while progress had been made to ensure the council’s processes were fair and transparent, there was more to do.

Nearly nine in ten doctors thought outcomes of fitness-topractise investigations were fair, but the research showed concern among BME and non-UK qualified doctors that outcomes for them or those from similar backgrounds might be more severe than for their white colleagues.

The GMC must not only be fair, it must be seen to be so, according to independent researchers NatCen Social Research, which polled 3,500 medics about how the GMC registers and investigates doctors.

one of the three latest-spec scanners at the Harley Street Clinic Diagnostic Centre

Official aid to beef up your IT security

By Leslie Berry

Private doctors can get help to beef up their IT security using a new report from the Information Commissioner’s Office (ICO).

Security vulnerabilities have resulted in organisations failing to keep people’s information secure, resulting in monetary penalties totaling nearly £1m.

But the ICO said breaches could have been avoided if standard industry practices highlighted in the report were adopted.

It said they included the £200,000 penalty issued to the British Pregnancy Advisory Service after the details of service users were compromised due to the insecure collection and storage of the information on its website.

ICO technology expert Simon Rice said: ‘In just the past couple of months, we have already seen widespread concern over the expiry of support for Microsoft XP and the uncovering of the security flaw known as Heartbleed.

‘While these security issues may

Top compuTer securiTy vuLneraBiLiTies

LisTed in The ico’s reporT

 Failure to keep software security up to date

 Lack of protection from malicious injection of data

 poor decommissioning of old software and services

 insecure storage of passwords

 Failure to encrypt online communications

 poorly designed networks processing data in inappropriate areas

 continued use of default credentials including passwords

 use of unnecessary services

seem complex, it is important that organisations of all sizes have a basic understanding of these types of threats and know what action they need to take to make sure their computer systems are keeping customers’ information secure.

‘Our experiences investigating data breaches on a daily basis shows that while some organisations are taking IT security seriously, too many are failing at the basics.

‘If you’re responsible for the

NHS GPs reject plan to make them semi-private doctors

A bid to turn nHS GPs into semiprivate practitioners has been thrown out by their national policy-making body.

GPs from across the UK resoundingly rejected calls to introduce a charge for access to general practice at their Local Medical Committees’ conference in York.

doctors at the meeting expressed concern about the extreme funding pressures facing general practice, but agreed patients should not be penalised because of a funding shortfall from Government.

BMA GP Committee chairman

dr Chaand nagpaul warned that introducing a charge for services would be a tax on illness, hit the most vulnerable the hardest and threaten to undermine the principle of an nHS free at the point of delivery.

He claimed: ‘Introducing a financial transaction would undermine the trust between doctor and patient. If patients are deterred from seeing their GP due to an additional cost, this could result in their illness deteriorating and costing the nHS even more.

‘GPs have today sent a resound-

ing message that charging patients is not the solution to the financial crisis facing the nHS. The BMA is committed to a health service that is free at the point of need and accessible to all and we should be proud to have an nHS GP service where no one has to pay to get the treatment they need.’

He said many GPs were frustrated and concerned about the future as they were struggling from a combination of rising patient demand, falling funding and more work being moved from hospitals into the community.

Nuffield vows to protect whistle-blowers

security of your organisation’s information and you think salt is just something you put on your chips, rather than a method for protecting your passwords, then our report is for you.’

The report provides an introduction into established industry practices that could save practices the financial and reputational costs associated with a serious data breach.

 ‘Protecting personal data in online services: learning from the mistakes of others’. Available at www.ico.org.uk

RSM to use £2m gift for eduction

A £2m donation to the Royal Society of Medicine (RSM) by philanthropist naim dangoor will be used to support postgraduate medical education.

The RSM said the gift, its largest in its 200-year history, would allow more work in support of young people from disadvantaged backgrounds who wish to work in medicine and healthcare.

Top radiotherapy at Spire Bristol

Single-dose intra-operative radiotherapy (Sd-IORT) is now available for breast cancer patients at Spire The Glen Hospital, Clifton.

It said it hoped all independent providers of hospital services would follow suit.

nuffield Health has signed up to the Speak Out Safely Campaign, an initiative to encourage n HS and independent healthcare providers to actively encourage frontline staff to raise an alarm if they believe they have witnessed poor practice, and to protect them if they do.

The campaign calls on the Government to introduce a statutory duty of candour forcing health professionals and managers to be open about care failings, and to protect staff who feel they need to take their concerns outside of the organisation, should they believe it to be the right course of action.

Mr Simon Cawthorn, consultant breast cancer surgeon at Spire Bristol, said: ‘This new form of radiotherapy is very exciting. not only does it cause less disruption for the patient, as in most cases there is no need to travel to future radiotherapy appointments, but recovery times are also shorter as healthy tissue is preserved and not exposed to the radiotherapy.’

Roping in the cowboys

The cosmetic surgery and non-surgical industry has again been weighing up the Government’s response to the review into the sector by Sir Bruce Keogh. sally Taber (right) gives her reaction

A SeCOnd private sector conference has been held to discuss the Government’s response to n HS Medical director Sir Bruce Keogh’s review of the cosmetic surgery and non-surgical market, published four months ago.

The Government had worked with others on formulating its response, and accepts the principles of the review. And it agrees with the majority of the recommendations.

It is pleasing that Junior Health Minister dr dan Poulter has taken a special interest in the review. He has been instrumental in taking forward the 40 recommendations, together with the department of Health ( d oH) work, across the four UK countries.

But despite some excellent outcomes for the industry, such as the proposal for dermal fillers to become prescription-only devices, there was still much negativity at the meeting about the recommendations.

noel Griffin, of the doH Implementation team, asserted at the meeting – organised by Westminster Briefing – that the Government’s priority is putting the patient/consumer first.

But my view is in line with the sector’s response: with no recommendation for a register of appropriate practitioners/organisations to undertake cosmetic interventions, just how can the patient be put first?

But Mr Griffin did announce that a programme of work has been put in place by the doH with oversight by an advisory board and various resulting project leaders reporting to a delivery board. So we in the sector are being encouraged to be patient.

The audience was also made aware of the new excellent european Standard on Aesthetic Surgery. After five years of work by

e uropean countries’ standards institutes – the UK’s one led by Mr nigel Mercer, former president of the British Association of Aesthetic and Plastic Surgeons – this has been completed to set the standard throughout the eU.

However, this work is now being challenged by cosmetic doctors in e urope who have not had background specialist training in cosmetic surgery. n ot because of patient safety issues, but because of their own vested interests. It will be a huge shame if the standard is not implemented in the UK.

Data-free zone

The previous conference organised by Westminster Briefing was given an insight into what is being done to challenge Sir Bruce’s statement that the industry is a datafree zone. Progress is certainly being made now with the Private Healthcare Information network (PHIn), together with the Breast Implant Register pilot.

Carol Jollie, programme and delivery manager for cosmetic non-surgical procedures at Health education england, shared news about the work to date, which is very positive and has made an impressive start.

Training requirements will apply on a date to be fixed to all practitioners and every one of them will have the opportunity to attain necessary skills and expertise, again at a date to be agreed.

The foundation qualification will include modality-specific elements. On completion, these will enable practitioners to deliver specific treatments to a specified standard in defined areas. All modules will include common themes, namely:

 Area 1: including psychology and patient support;

 Area 2: including risk assessment and diagnostic skills;

 Area 3: including values, behaviours, attitudes.

There will be a range of entry points to training for different groups and Accreditation of Prior Learning (APeL) including competence-based training – not timebased – supervised practice and theory and assessment.

The framework builds on a curriculum strategy which reflects the depth and level of learning and teaching required to achieve the outcomes prescribed for each modality at each level of progress.

There will be a development of more advanced skills as the practitioner moves up through framework levels.

Christine Braithwaite, director of standards and policy at the Professional Standards Authority, shared the importance of an Accredited Voluntary Register that would be able to identify and choose practitioners trained to high standards who can demonstrate accountability and protection when things go wrong.

unregulated practitioners

Her group has accredited 11 registers so far; for instance, for counsellors. The idea of this move to registers is that they will create improved supervision of unregulated practitioners that is underpinned by standards set by professional bodies, with the registrants using safe products and used safely with good, honest information available.

So where are we with the Keogh review’s Recommendation 34, namely: ‘The remit of the Public Health Services Ombudsman should be extended to cover the whole private healthcare sector, including cosmetic procedures and ophthalmology’?

It adds: ‘Providers should offer advice on their complaints procedures to patients, and where

appropriate, this advice should be available on their websites.’

Health Minister dr Poulter has now chaired four meetings to discuss this recommendation 34 –this has contributed to raising the profile of the Independent Sector Complaints Adjudication Service (ISCAS). The Parliamentary and Health Service Ombudsman has declared that her service is ready to take on the recommendation.

The sector has been represented at the meetings by myself, Stephen Collier of BMI – who was instrumental in creating ISCAS – and Andrew Wilby of the ISCAS secretariat.

ISCAS has presented detailed reports about the ISCAS service and its members. Throughout meetings with the minister, we asked members of the meeting exactly what the definition of private healthcare providers was.

But this has not been clearly defined. One option was to define this by the scope of registration that the Care Quality Commission (CQC) has. However, this would leave out many services the public would reasonably expect to be within a definition. For example, the CQC does not register private chiropodists and chiropractors.

The CQC gave support at the meetings, acknowledging the positive contribution and success of ISCAS in raising standards and an effective complaints resolution process for complainants in independent healthcare.

The matter of the Health Service Ombudsman taking independent healthcare sector complaints might be an aspiration for the far distant future, but certainly not until the Ombudsman and the nHS get their own house in order and implement good complaints management. 

Sally Taber is director of ISCAS

Clinic computerisation is critical

Let me be blunt: any consultant running a private practice with annual revenues of more than £50,000 should be using some form of practice management software.

Of course, I would say that, wouldn’t I. But most of the consultants I know would be the first to admit that they are not business people; they’re too busy being doctors.

t here’s nothing wrong with that, of course – I’m sure that’s exactly how their patients would want them to be – but it still surprises me how many consultants have never even heard of integrated practice management software, let alone considered using it.

t he benefits are numerous, obvious and immediate – and yet I still meet consultants who rely on ancient physical filing systems and ledgers.

Practice management software will save you money, paying for itself in months. It will improve the quality of care you give your patients.

It will make your practice administration much more efficient. It will reduce stress and aggravation. And it will free up your time and your practice manager or secretary’s time to focus on what really matters: looking after your patients and generating more business.

Once consultants take the plunge and implement practice management software, the two most common reactions I hear are: ‘I wish I’d done this years ago!’ and ‘You’ve revolutionised my practice’.

Reasons for hesitation

And yet some still hesitate. So let’s look at the most common reasons why.

❏ Cost – this is the easiest concern of all to dispel. Practice management software will pay for itself within six months to two years, depending on how much you already use computers.

Your invoicing and credit control will become much more efficient, with improved cash flow

Practice management software streamlines the crucial processes that underpin any working practice

properly – if back-up is built into the system you choose, so much the better.

If you’d prefer to pay for someone else to worry about the security of your data, hosted solutions are also available – and they’ll save you money on computer hardware and maintenance.

Why change what works?

You may be thinking ‘my noncomputerised system works per fectly well. Why would I want to change it?’

I still meet consultants who rely on ancient physical filing systems and ledgers

and fewer bad debts. And the time it takes to prepare your year-end accounts will fall from many hours to just a few minutes.

❏ IT literacy – You might be worried that your computer skills aren’t up to scratch, but you really needn’t be. In my experience, the vast majority of practices are completely self-sufficient with just three hours of training and a couple of support calls.

❏ Security – It’s only natural to be concerned about the safety of confidential patient information and your practice’s financial details. You should ensure that the package you choose protects your data with multiple passwords and encryption.

Of course, you should also ensure that you back up your data

a Second oPInIon

tony Bernstein is a practice manager at 78 harley Street, a multidisciplinary practice with ten consultants working from two locations as well as some home-working.

he says: ‘We started using practice management software around 2000 and we’ve been very impressed with it.

‘It was easy to set up and it’s moved with the times, keeping pace with developments in technology, with changes in medical practice and with the requirements of medical insurers.

‘It makes patient information easily accessible, which frees up our time to focus on our patients and building the practice. one of our doctors alone has added 6,000 patients since 2005 and the system has coped easily.’

It’s true; the experience and effi ciency of secretaries or practice managers keeps many practices ticking over perfectly well. But it’s a delicate balance that depends too much on that one person being on top of every thing. If they become over whelmed or they decide to leave, the whole practice can suffer. And one person spinning many plates isn’t the most reassuring foundation on which to build an expanding practice. If you have growth plans, you need a man agement system that can grow with you.

there are practice management software solutions for any sized practice, from smaller practices using just one computer to larger ones with their own local PC net work. For multi-site practices in particular, hosted services enable you to access the system any where at any time, provided you have an internet connection. Practice management software streamlines the crucial processes that underpin any working practice. the information needed to keep on top of patient care and practice finances and administration is securely stored and available within a couple of mouse clicks. t here’s no need to go hunting through complex filing systems, no more call-backs, no piles of Post-it notes.

And once your administrative functions have been streamlined, you can expand your practice with confidence, secure in the knowledge that the systems you’ve set up can handle anything you can throw at them. n

By tom hunt managing director of PPm Software Ltd, providers of ‘PPm’ – Private Practice manager

Make sure nobody is left behind

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

ABRIDGED PRESCRIBING INFORMATION

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

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

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

Sanofi Pasteur MSD SNC, 8 Rue Jonas Salk, F-69007 Lyon, France

Marketing authorisation number: EU/1/06/341/011

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

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

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

Make hay financially while the sun shines

The crucial business months of September-December should ideally be prepared for in the summer months – if you can squeeze it in, says Susan Hutter

During the summer months, many medical practices used to see a slight decline in patients coming through the door. i always advised them to make the most of any quieter times to ensure that their business administrative procedures are up to speed. this way, the business could hit the ground running between now and the end of the year when the seasonal holidays begin.

Of course, many practices are so busy now that they might find it hard to make room for these chores at the moment, but they will need doing sooner or later and it is still important to try and get ahead.

t he crucial areas to consider are:

☞ For consultants and gPs who are self-employed, the 2013-14 tax returns will have to be filed by 31 January 2015 and the tax paid on that date. i f income has increased compared to the previous year, there is likely to be a balance of tax to pay for 2013-14.

Additionally, the first payment on account is due on that day. this is initially based on 50% of the total tax for 2013-14. So it is important to ensure that there is the cash flow to cover this.

Also it is advisable to provide the information to the practice accountants on a timely basis so that they can prepare the personal tax return and practice accounts in time and also advise you of the tax liability well before the due date.

☞ For doctors who trade as limited companies, the corporation

Make the most of any quieter times to ensure that business administrative procedures are up to speed

tax is due nine months after the end of the financial year.

Many consultants have 31 December or 31 March as the financial year-end. in these cases, the corporation tax for the year to 31 December 2013 and 31 March 2014 is due for payment by 1 October 2014 and 1 January 2015 respectively.

Once again, it is important to make sure that there is sufficient cash to cover the liability.

☞ Limited company accounts have to be filed at Comp anies house within nine months of the year-end. So check that the practice accountants have everything that they need in order to get going.

☞ Support staff may also have been on holiday on or around the

same time. Often this means that debts have not been chased and the books and records are behind. it is therefore sensible to ensure on everyone’s return to work that the books are written up to date so that all outstanding debts can be recovered without delay.

☞ Another area to start considering are pension contributions. take advice from a financial adviser and bear in mind that there are deadline dates that should be considered.

Limited companies to be tax-deductible in the current financial year, a company must make a pension contribution before the end of the financial year. Consultants with a year-end coming up should bear this in mind.

Self-employed consultants

Self-employed doctors have until 5 April 2015 to make a pension contribution for the current tax year.

i n view of the momentous changes to pension rules coming into play on 6 April 2015, this is an important year to look at pension contributions.

this applies to limited companies and the sooner one starts planning the more flexibility is available.

remember, in general, most tax planning cannot be retrospective and therefore time is of the essence. n

Susan Hutter, a specialist accountant for the medical sector, at Shelley Stock Hutter LLP

Celebrating our 22nd year in Business

www.medbc.co.uk

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

• Bad debts of less than 0.5%

• Increase in net income by up to 25%

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

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

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

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

Special offer:

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

Further information:

MBC – More than just a billing company

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

*Terms and conditions apply

Most private facilities have traditionally been supporting the longer-established consultant practices. Until now.

Sarah Fisher (below) outlines developments that should give the newer, younger consultant body better access to world-class facilities and exposure to a wider referrer base

New unit fit for

Within a short time of setting up h C a’s first enterprise in Manchester, the Christie Clinic –our very successful joint venture private patient cancer unit with t he Christie nhs trust – one thing was clear.

the demand for private healthcare services, beyond cancer care, was considerable. and growing.

it was equally clear that to even begin to meet this demand, we needed to develop a patient-centric service, the like of which has proved so successful elsewhere in the UK.

to achieve this and to develop a streamlined diagnostic and treatment service for patients, we needed to join forces with likeminded doctors and recruit forward-thinking staff. and we had to find the right location for our first non-cancer facility.

the location had to be near, or in, an area of strong patient demand. so we believe the opening of our new diagnostic and treatment centre, 52 a lderley r oad in Manchester, is a milestone in the development of a new kind of private healthcare model in the north-west.

We think that the accessible, streamlined experience we have created together with our independent practitioner partners is unique in the region.

this new £10m unit has the latest diagnostic technology. as well as a 3 t M ri scanner, it has two laminar flow operating theatres, eight recovery bays and 13 consulting rooms. We plan to make this very accessible and so it will be open seven days a week.

Until now, most private facilities have traditionally been supporting the longer-established consultant practices. this has resulted in the newer, younger consultant body not being given the same access to world-class facilities or exposure to the wider referrer base.

opening 52 alderley road has given us the opportunity of being able to offer a level playing field for all consultants and we will promote their practices equally.

We know that private healthcare has changed significantly over the past five years.

Fast access

We have found, for example, that joint venturing with doctors is a very effective way of making the patient experience as good as it can be because all parties have a vested interest in making that happen.

For our part, we wanted to be able to offer patients fast access to leading specialists in a world-class facility equipped with the very latest diagnostic technology our doctor partners and all of us share the same vision and we have now created one of the larg-

est partnerships with consultants in the country – it is certainly the largest partnership of its kind hCa has in the UK.

t he n orth-west has its own special character. i t is different from ‘down south’.

Being born and brought up in Greater Manchester, i feel a close affiliation with the north in general and the n orth-west in particular.

But i believe the expectations of most patients in the n orthwest has not been as high as it is in the south.

i want to offer people of Manchester area a new experience – the best healthcare you will find anywhere.

52 alderley road is part of the future for us. For we have already begun setting up our regional headquarters in the same block as the new centre.

The new unit in Alderley Road is a milestone in HCA’s plans for Manchester

new doctors

indeed, the development of this northern hQ is an acknowledgement of the steps we now have to take in the investment and in the development of support services including hr, marketing, consultant liaison and GP liaison and governance, to name but a few.

Future plans

a t the same time, we are in advanced discussions to develop a diagnostic and treatment centre in east Manchester and a larger facility in the south of the city. t here we plan to concentrate

on adult tertiary care – alongside more routine healthcare – and we hope in time to be able to offer a complete paediatric service too.

Construction work is scheduled

The diagnostic and treatment centre at 52 Alderley Road boasts two laminar flow operating theatres

to begin later this year with the new units opening in 2015 and 2016. all this time, we will be encouraging the next generation of distinguished specialists who want

to develop their private practice. a lready we have taken more space at alderley road. 52 and 54 comprise the diagnostic and treatment centre and our new hQ, and we have now leased 56 alderley r oad to provide more clinical space and so our expansion is already in hand.

t here has never been a better opportunity to develop a truly outstanding network of private medical facilities in the n orthwest. there has never been a better time for new independent practitioners to ‘raise the bar’ in private medicine.

of course, it won’t all be plain sailing, but all of us at h C a Ventures in the n orth-west are committed to providing the highest standards of patient care and helping our partners to achieve their goals too. 

Sarah Fisher is chief executive of HCA Ventures

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Route map to uncovering

business booty

Plenty of pitfalls can await the unwary when they try to set up their own private business. Entrepreneur Karen Espley gives some valuable lessons as she sets out her experience of navigating the ups and downs of trying to form a medical company

I WAS WA lk IN g up a stormstrewn path to enjoy a solitary hot-springs bath in the back end of a New Zealand tropical forest –not a spot I would normally expect to get a business opportunity.

But that’s where I was, on a sixmonth sabbatical, when I received an email from an old friend and work colleague saying he’d had a brilliant idea and wanted me to join him as his business partner to get it up and running.

It was a very simple idea: the NHS and private sector are increasingly reluctant to treat a particular condition, so there seemed to be a great opportunity to set up a chain of affordable clinics offering walk-in, walk-out local anaesthetic surgery.

So I cut the next leg of the trip to Australia to six weeks and then hightailed it back to the Uk

While the idea was simple, the execution proved to be somewhat more challenging.

There’s the straightforward stuff – setting up a limited company

delightful rooms for medical professionals at a surprising low cost ad hoc booking and mail handling available

Website: www.londonconsultingroom.co.uk

Email: admin@hstcentre.co.uk

Phone: 0759 004 6606

and getting a bank account open.

Except even these weren’t necessarily straightforward. Firstly, we had to come up with a name and this took weeks of to-ing and fro-ing via email from my various stop-off points in Australia before we finally got one we both liked and felt encapsulated what we were trying to do.

g etting the limited company set up should be easy enough to do, but it was originally set up with one director and part of a holding group.

So this then had to be changed before we could then open the bank account. Banks do a lot more ‘due diligence’ these days and it took weeks to get the company structure and shares right before they would allow us to open the account.

Avoiding disputes

It’s really important to get this right before you start and to establish what the shareholding should be.

Having been a minority shareholder before, it was really important to me that both parties had an equal share to avoid any later disputes due to the majority shareholder pushing their weight around and making decisions the minority shareholder has little control over.

But having a 50:50 split is not without its issues either. What do you do if there is conflict when you each own half the business?

Which is why it is so important to have a shareholder agreement outlining exactly how the shares will be split, what happens if one of you wants to leave, what happens if you want to sell the busi-

Hills of Hopelessness

Forest of Fear

Grove of Gripes

ness and a myriad of other points that can trip you up unless you’ve thought it all through beforehand.

You definitely need to get legal advice on this. It costs about £600, but is absolutely worth it in the long run. I had been bitten once before.

very big bet

The next big challenge was to work out how much money each of us would put in. This is so important. You are essentially placing a very big bet on something working.

How much money are you prepared to lose if it all goes wrong? You have to be prepared to put up a sum of money that you might lose – can you afford it?

Also, you need to decide why you are setting up the business. Is

You are essentially placing a very big bet on something working. How much money are you prepared to lose if it all goes wrong?

it a lifestyle choice; for example, just doing private work out of a private hospital and getting paid for each consultation and procedure you do?

Or are you looking at developing a business to grow your income, or even possibly looking at selling it at some stage in the future – a five- to ten-year horizon? This will affect your strategy and business model.

We decided the plan was to set up a chain of clinics which we would sell – hopefully – in five to ten years.

So having got the basics in place, the next stage was to work out the business case. Can your business idea make money? The premise of ours was affordable, high-quality surgery. Therefore, I had to work out a model that allowed us to undercut the com-

You need to decide why you are setting up the business. Is it a lifestyle choice ... or are you looking at developing a business to grow your income?

petition, but which was ultimately profitable.

There are a number of challenges working within the medical profession. Doctors are by and large not business people, so our model was built on offering the business support to consultants.

So, we would offer the appointment setting, invoicing, sales, marketing, finding clinics, getting them up and running – allowing the consultants to get on with what they are good at without the headache of having to run their own practice.

I was lucky that I had access to a huge amount of data from an existing clinic and I used this to start working out what the model looked like. You have to start off small.

You see so many people on Dragons’ Den spouting tremendously large revenue figures by the end of year two. Well, yes, wouldn’t we all like to have businesses like that?

The reality is, you need to test what you’re doing first and if your plans are to roll out a chain of clinics, you absolutely need to get one running first of all to test your model.

Test

it out

Does it work? If not, would it work if you tried something different? And if not, that is your second point at which you walk away. Your first point being when you’ve calculated your model and the figures don’t work.

The model was very conservative and based on consultants working two days a week. Even that is probably a big ask, as many consultants are understandably reluctant to give up NHS work unless they know their private practice more than compensates for the steady income.

It showed that it wouldn’t work based on only one consultant day a week, unless you could get multiple consultants working out of one location. Equally, we were set to make a fortune based on a fiveday-a-week model. Only that wasn’t realistic.

We settled on two days a week with a very slow build-up, taking up to ten months for a consultant to reach near full capacity.

Then – get it checked by an

accountant. Explain the model, what your assumptions are and how you’ve come up with the figures you’ve come up with and then leave them to pick holes in it.

You really need them to do this – this is not the time to be precious. You may have missed something vital that you can’t see when you’re up to your eyes in multiple-paged spreadsheets.

Work out your profit and loss and, almost more importantly, you need to work out your cash flow. How much money is it going to cost to get you up and running and until you reach the breakeven point. Are you going to have enough?

If not, how are you going to fund it? If you need to go to the bank for a loan, you will need to have a very robust plan and financial model before they will look at you.

We looked at ‘angel’ investors, too, and crowd-funding platforms. Angels would only really be interested once you have your business running, so they can see whether or not there really is potential –you will have to give up equity.

But, hopefully, in return you get investment and, more importantly, good business advice as long as you choose your ‘angel’ wisely. Crowd-funders only invest once you have several years’ worth of accounts and all you’re getting is money at a good rate.

There are lots of free and cheap software applications that you can look at to help keep costs down, such as online booking systems or outsourcing your payroll, when you get to that stage.

Website essential

All businesses these days need a website and you could do worse than get a free template from Wordpress. It’s relatively straightforward to use. However, I recommend documenting what you want your website to do first. What look are you going for, what image are you trying to convey, what information do you want to share, what functionality do you want it to have and so on. Having spent a fortune on websites in a previous life, my big lesson was to start simple.You can add more complex functionality at a later stage. The beauty of something like Wordpress is that,

Having spent a fortune on websites in a previous life, my big lesson was to start simple. You can add more complex functionality at a later stage

for less than £200, you can get a more functionality-rich site, which will allow you to plug in external applications, such as online booking or payment.

When writing copy for your site, remember that it is your shop front. You want to give people the information they need for them to decide whether your company/ clinic is the one they want to use. Use plain English.

If you’re going to use medical terms, explain them in non-medical ways. Telling someone that a risk of a procedure is thrombophlebitis, for example, may make perfect sense to you, but to the layman this means nothing. Don’t baffle them with science.

Keep it simple

Also, don’t overload them with information – unless it’s useful. k eep it simple and to the point and make it easy for them to contact you. I’m a big advocate of having contact details (phone, email, ‘book now’ links) on every page – top right-hand corner is a good place and where most people look.

Continually let them know they can contact you if they want more information – encourage the ‘sales’ process as much as you can. Make sure you proof-read it. There is nothing worse – especially for me, a grammar pedant, and lots of others too – than incorrect spelling or apostrophe abuse. If you can’t get that right, what does it say about your service? Check all the links work, on every page. give the link to friends/colleagues/family to read to make sure it makes sense. Ideally, get a non-medical person to read it and ask if it makes sense.

Is the information readable, can they navigate around the site easily, could they work out how to contact you, does the contact form send you an email notification and so on.

The more people you can test this on, the better. Only set it live once you are happy it’s all working properly. If you have a phone number and contact details on there, you must be able to respond quickly. Have you got someone who can do that, if it’s not you? Do you want to use social media such as Twitter, Facebook and have a blog? If you do, these are

Search engine optimisation firms will very convincingly sell you the dream of ‘page one’ rankings. the reality is you will spend a lot of money for very little return

very time-consuming activities to keep up with.

You have to constantly use them and refer them to your website and have links to them from your website. If you can add new content regularly to your site, it helps move it up the google rankings.

Don’t forget that you also need to submit your website to the main search engines – g oogle, Bing, Ask, Yahoo and so on – for them to start indexing your site, otherwise you won’t be found. Be warned, it can take up to three months before you start creeping up the ratings. Search engine optimisation (SEO) is an extremely complex beast, but I don’t recommend using SEO firms. They will very convincingly sell you the dream of ‘page one’ rankings. The reality is you will spend a lot of money for very little return. Far better to make sure you have all the key words that you want people to find you with peppered throughout your content and if you want to, use google Ads to bring you on to the first page of a search.

Again, this can eat up your money, so I set a daily amount and limit – once the money has run out for the day, it’s gone –rather than racking up massive advertising costs.

google

Analytics

getting to grips with google analytics is a ‘must do’. It will show you what search terms people are using to find your site, what pages they visit most and where they are based. All this is useful information to help you tweak your site. Having established the model made sense and that there was a potential business, the big challenge really began. g etting the business up and running.

This involved a whole range of activities, from sourcing equipment, to finance deals, to finding clinics to operate out of and consultants who wanted to work with us.

The first bits were easy: getting all the building blocks in place takes time, but having contacts really helps and the internet is your friend. The real challenge has been trying to find the clinics and consultants.

We talked to three main sup -

plier companies and presented the model, believing that they may wish to partner us to help grow their own business by helping us with finding clinics and consultants.

Unfortunately, as they were much larger organisations, getting decisions made took a very long time. We are, in fact, still waiting for one company to come back to us despite having had multiple meetings with them and given them a detailed commercial plan.

The other only really wanted a commercial arrangement with us to sell their kit and consumables and weren’t interested in developing the business with us.

A third one was interested and as a one-man band was much more able to pick up the model. He opened a couple of doors at clinics for us, but as our model was based on using spare capacity in minor surgical facilities, it didn’t work for them, as these are their most profitable rooms.

stumbling block

As it was a low-cost model, we couldn’t use the main hospital groups, as they were far too expensive to use for what we wanted to achieve. And we didn’t need to pay the overheads of a highly equipped hospital for walk-in, walk-out surgery. We only needed access to minor surgical facilities with Care Quality Commission (CQC) accreditation.

This proved to be a major stumbling block. Trying to find private or NHS gP surgeries with minor surgical facilities was hard enough, but then trying to get to speak to the practice managers proved almost impossible. They get so bombarded with medical reps and other people wanting their time that you can’t get past the receptionist. It seems a shame that a receptionist can make a decision to say no without allowing you to talk to the practice manager about a real opportunity to help generate extra income for the practice.

Trying to contact relevant consultants also proved incredibly difficult even with the backing of my business partner, who is a highly respected doctor. He contacted a lot of consultants via linkedIn, giving a brief outline

of the proposition. While we got some responses to that, it was impossible to then get to talk to the consultants who emailed us.

A couple did, but all they wanted to know was how much money they could earn. Not unreasonable, I suppose, but given that we wanted to offer a customer-centric, high-quality service, I was hoping to speak to consultants who were excited by that opportunity as much as by the money.

valuable insight

I did speak to one delightful consultant in Ireland who gave me a lot of very valuable insight, even though we both agreed early on that the opportunity wasn’t right for him, based where he was.

He did say that, had he been on the mainland, he would have jumped at the opportunity. But it was really useful to run the model past him and to get his feedback on how he thought the model would work for him as a consultant.

Which brings me to my next top tip. You need to talk your model through with all the types of people who may be involved to get their perspective on whether it would work for them. As a consequence of my conversation with him, I tweaked the model.

I also spoke to insurance firms; very important if you are hoping to get your patients’ treatment paid for by health insurance.

Interestingly, one insurer was not taking on new facilities and no longer covered this particular condition. You have to jump through many more hoops these days with the provider teams at insurance companies – lots of forms to fill in before they will consider you as a business – as opposed to a consultant wanting practising privileges.

The other minefield I had to navigate was understanding the complex requirements of the CQC.

By the time I’d downloaded two PDF documents, both in excess of 200 pages, my brain had already started going into meltdown.

It was incredibly difficult to find out what we needed to do and then there was a bewildering array of evidence we needed to supply to ensure CQC requirements were met.

There are companies out there who can help supply ready-made

documentation with the up-todate requirements – useful if you’re going to have multiple clinics, for example. But don’t underestimate the impact of CQC accreditation – not just in getting it, but maintaining it and all the evidence you need to support your business.

If I knew at the beginning what I know now, I’m not sure I would have started on the endeavour.

The business idea may have been a simple one, but the reality is that what we were trying to build was more complex than I had realised at the outset.

Thinking that one person fulltime – part-time, actually, as I was doing some contract work to keep the money coming in – and another with only a very limited amount of time to devote could get this particular business off the ground was naïve.

impossible task

Starting a new business such as this one with limited resources was madness. Unless you have all the requisite skills and knowledge of setting up a clinic/multiple clinics, it is a near impossible ask. Ideally, three people full-time would have been a far better idea and with a lot more money than we put in. This would have allowed one person to be out there finding the clinics and talking to consultants, another putting all the operational processes, backend procedures, sourcing equipment and so on in place, and the third pushing the training and regulatory/clinical aspects.

At a push, we could have done it with two people and added a third later. As it was, I was largely working by myself with very limited contact with my business partner.

This can be demoralising and you don’t benefit from bouncing ideas off someone else. You have to have very strong motivation for what you are doing if you are going to do it by yourself.

Eight months down the line with all the building blocks in place but still no clinic to trial the model at or a consultant willing to take the risk, we’ve had to face the unfortunate fact that either the model is wrong, the time isn’t right or that we weren’t the right people to do this.

I don’t think it’s the latter. We

certainly had the right skill set between us. Having other people on board sooner would have made a difference.

It has really underlined for me that you can’t do this sort of thing half-heartedly; there needs to be commitment, time and energy from all the business partners.

Maybe the model is wrong –perhaps there isn’t any way of offering the treatment except through private hospitals. In which case, we would just become another competitor in the field with nothing unique to offer.

The upshot is that, reluctantly, we have decided to put the whole thing on ice due to the reasons above and because one business partner now has even less available time than before and for me.

I can’t afford to keep going without earning any money, as I’ve not taken anything from the business in eight months and now need to look at ways of generating income. 

Karen Espley (below) is a medical business consultant who helps doctors in developing start-up ventures and websites

Best practices are

close to home

Good practice management has been described as the key to your commercial success. So we asked Maitland Cook (left) to spell out what this means in practice

Your practice is your living. Now, it may be many other things as well, of course. But the overriding factor is ‘your practice is your living’.

So it is important to never forget this, because all the keys to the commercial success of your practice are locked into this phrase.

Naturally, there are a myriad of different types of practice, but however large or small, complex or simple, they need management. a nd the practice will always be defined by the efficiency of this management.

We are in the service industry, and must offer the clients – your patients – a personal, caring service to minimise their natural stress when utilising your services, and to make the patient journey as smooth and painless as possible.

clients’ choice

all patients, including the elderly and children, must be treated respectfully. in this time of great change in the medical services industry, i believe it is essential to remember that clients have choice.

a nd, more than ever before, they question the values and service they receive from all their suppliers.

it is essential to treat all patients

with the respect they deserve and to give them a high degree of both personal attention and professional expertise.

But this standard of personal service requires a great deal of attention to detail and a ‘handson’ management structure. the practice manager must personally manage and oversee every aspect of the operation as though it is their own home. this is the easiest way to run any business. Make it personal and run it as though it is home.

at home, cups are put away. at home, the washing-up is done. at home, the paintwork is cleaned. t here is always loo paper. Your floors and windows are clean. Home looks cared for. i t is vital that the practice is cared for at all times and in every respect. this starts with the building or the rooms themselves. a re they kept clean, tidy and well maintained?

the first contact with the practice is making an appointment, and then coming to see the doctor. Make sure the appointment process is simple and efficient. confirm the appointment by text 24 hours before the scheduled time.

Make the patient feel wanted. o nce confirmed, be sure all the medical notes and other relevant information are attached to the clinic list.

All ready on the day check the appointment subject is fully covered in the information prepared. Be sure all is ready when the patient walks through the door, including any medical insurance pre-authorisations or data that is relevant.

a big, warm smile and a cheery ‘Good Morning, Mr’ or ‘Mrs’ starts the experience on the right foot. t he offer of a beverage and newspaper while waiting is always

appreciated, as is accurate information on any potential delays. patients understand delays can happen, but much prefer to know rather than sit waiting until long past the appointment time.

t he receptionists are the best support of the practice management. they are the ears and eyes and set the drumbeat.

Make sure, therefore, that they are fully trained in all the people skills and have the appropriate personality to handle people in volume.

if they are on top of their game, they will ensure the practice does not lose patients. But if they do not care, then the complaints will start before the patient has arrived in the consulting room, and once the complaints have started, the patient is looking for fault throughout the journey.

o nce the patient is with you, then the practice management team can have no direct effect –

If the receptionists do not care, then the complaints will start before the patient has arrived in the consulting room

positive or negative. t he next phase is entirely in your hands. Your commitment must be to support the good work they have done to date or to get things back on track if they have not performed to the high standards set.  next month: What you should do before the patient leaves you

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

ATTRAcTIng pATIEnTs

Publish and be damned good

Surgeon and marketing guru Mr Dev Lall shows how becoming an author is good for patients and profits

There are two broad ways to grow your private practice:

1 Go out there and put yourself in front of people who have need of your skills and expertise;

2 have people with problems you treat actively seek you out.

Clearly, we would all rather the latter. after all, it implies far less work on our part, as we just kick back and lap up all the private cases we want.

and, certainly, most consultants behave in that manner – metaphorically sitting back and waiting for patients to knock on their doors.

The reality, of course, is that, in the vast majority of cases, it just does not work out that way. You really need to actively seek out potential patients or face a pretty shallow growth curve for your practice.

Yet it is perfectly possible to create a situation whereby patients

seek you out as the ‘go-to’ guy in your specialty. The way to do this is by harnessing the twin powers of celebrity and authority.

The power of celebrity TV and the media are full of news and gossip about celebrities. There are numerous TV shows where Joe and Julie Public strive to become celebrities – and faded celebrities attempt to re-boot their careers and return to the limelight. There are celebrity chefs, home

makeover artists, gardeners. and there are also celebrity doctors. and although some are experts – think Lord Winston in the field of infertility, for example – the amazing thing is that most of them are not experts at all. Look at the TV GPs, for example. By the nature of their specialty, they are generalists, not experts. Yet they have two things in common:

 They are looked upon as experts, even if they are not experts at all;

You really need to actively seek out potential patients or face a pretty shallow growth curve for your practice

 There is no shortage of people wanting to consult with them –purely because of their celebrity status.

everyone loves an expert. From having your car fixed by the main dealer to getting home decorating done to consulting with a doctor, each of us would far rather deal with someone who was recognised as having relevant expertise to the situation in hand.

Moreover, people will pay a premium for the privilege of doing so. and so they should.

Author and authority

One of the best ways of becoming the go-to guy – the consultant who is sought out by patients rather than vice-versa – is by combining the powers of celebrity and authority. and one of the fastest and easiest ways to do that is by writing a book.

It is no coincidence that the word ‘authority’ contains the word ‘author’ within it. We all naturally look upon anyone who has written a book with a certain sense of awe. a fter all, the guy who wrote the book surely must know what he’s talking about and be a leader in that field?

But what do I write about?

You should write about a topic that has relevance to your patients. You should aim to create, in effect, a glorified patient information leaflet – but think of it as containing within it everything which a patient with, say, asthma, needs to know.

This extends from what it is, symptoms, diagnosis, treatment, living with the condition, when to seek routine help and when to seek urgent help – everything. ask yourself: if I was not medically qualified, what would I want to know about condition XYZ?

You can inform your own answer by considering the questions you are asked by patients. r emember, there are no stupid questions, only stupid answers.

Your aim is not to make vast sums of money through sales of the book – that really is quite unlikely. Your goal is to cement your authority as an expert in the mind of the public – not among your peers,which is quite a different matter entirely.

➱ p22

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Three ways to write a book OK, so we can see why it’s a good idea to write a book and what it should be about. But how to go about it?

1

The obvious way

This is the way we assume all authors write: they have a plan/table of contents then simply start writing to that plan. There is a lot to recommend this approach.

For a start, it’s quite easy – as, of course, we all have an extremely good grasp of the clinical conditions we treat. No referencing of the literature or detailed discussion is required apart from in exceptional circumstances.

In fact, if you find yourself going down this route, I can guarantee that what you have written is totally inappropriate for the target readership – patients.

Jargon, too, is an absolute no-no. r emember: the average reading age of the UK population is nine years old. Which means, of course, that by definition 50% are lower still. Scary stuff.

2

The interview technique

This is a neat approach that can work very well. here you get yourself interviewed at length about a given topic. The trick is to treat the interview as an informal chat in and around the topic – the more wide-ranging the better, while also remaining relevant. afterwards, you send the audio to a transcription company who will compile and edit it for you. The folks at www.theadminsource.com are very good. Tell them you intend to use it as the basis of a book and they will take extra care. at the end of this process you’ll have a small amount of editing to do, but they will have done the majority of the work for you.

3 The Q&A approach

One excellent approach is to pick the five or ten aspects of a given condition that are really important and write down the top ten questions you get asked on each and answer them. Next, write down the top ten questions patients ShOULD ask –but most often don’t – about that element and answer those ‘unasked’ questions.

nothing makes more of a statement of expertise than a physical book with you as the author

So you might talk about wound care postoperatively, stopping the oral contraceptive Pill pre-operatively, exercise, travelling, postop nausea and vomiting, surgical complications and very many other topics in this way around the main topic of, say, hernia repair.

gETTIng IT pUBlIshEd

There are three ways to get a book published and I suggest you employ all three:

AThe eBook

The eBook is simply a digital mock-up of a book in PDF format. The advantage of this is that it can be sent by email or automatically downloaded from your website. eBooks can be created easily using a home computer or outsourced to someone to do for you.

BThe Kindle book

You can get a book self-published on the Kindle platform (and others) very easily from home in a couple of hours. This gives you the advantage of the might of a mazon in marketing the book for you.

cThe physical book

Nothing makes more of a statement of expertise than a physical book with you as the author. The magic of the information age means that anyone can very easily and cheaply publish their book from the comfort of their own home. Simply Google ‘publishing on demand’ or ‘selfpublishing’ and you’ll be away. My own book was published precisely this way. It took a week from receipt of the manuscript (in MS Word format) by the publisher to get 500 copies printed and delivered to my door – and this is of a 240-page a5-sized book with a full colour cover.

Using your book to grow your private practice

So you’ve finally written your book, now what? how do you use it to grow your private practice? What it all boils down to now is public awareness. Your aim is simply to get as much public awareness as possible, thus raising your profile in the treatment of that condition. There are various ways of doing this:

it is my firm conviction that every consultant should write a book – a glorified patient information leaflet at the very least – to give away to their patients

1

Start by putting references to the book all over your website and in all your communication, both NhS and private.

2 have a stack of them available in your private practice for people to pick up.

3

Write to GPs in your region and tell them you have written a patient self-help book on XYZ which they can have for free to give to their patients. This will also bolster GPs’ awareness of you and your practice.

4

Invite visitors to your website to phone/email for a copy of your book.

5 Give visitors to your website access to an electronic version: a freely downloadable eBook.

6 Contact relevant self-help groups, charities and so on and offer them copies of your book to give away to patients.

7

Get some P r in the local press publicising your book and how it can help patients.

8

Give a stack to fellow clinicians, physios, nurses and so on – depending upon the nature of the conditions you treat – to freely distribute to patients.

Writing a book is neither difficult nor expensive, and it is my firm conviction that every consultant should write a book – a glorified patient information leaflet at the very least – to give away to their patients.

With proper publicity to promote it, not only will you gain celebrity and expert status, you’ll also get many more private patients. 

Dev Lall (left) is an upper-GI surgeon and runs a specialist private practice consultancy. His latest book, Succeeding in Priv ate Practice: The Quick ‘n’ Dirty Secrets to Doubling your Income in Six Months or Less , can be found at www. PrivatePractice Expert.co.uk/book

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ThE powER oF REgUlAR sAving

Who wants to be an ISA

You can be an ISA millionaire if you are disciplined. Patrick Convey examines why regular saving really is one of the best habits you can adopt

John Lee , now Lord Lee of Trafford, is credited as being the country’s first ISA millionaire. A former minister in the 1980s’ Thatcher Government, and now a Liberal Democrat life peer, Lord Lee has recently written a book on how he made his ISA fortune.

he cites his ‘low-risk, conservative approach designed to avoid losses’ as the key to his overall investment success.

‘As a poor 28-handicap golfer, I draw a parallel between golf and the stock market: it is the shot in the woods or in the river that ruins one’s round, and so it is with the stock market; it’s the losses that drag down overall performance.’

he is not alone in his success. Many savers are now contribut-

ing to their ISAs with the same diligence as their pension plans. new isA

Thanks to the new, more generous ISA rules surprisingly announced by the Chancellor in his ‘Big Bang Budget’ that come into force later this year, it should be possible for far more people to achieve a substantial ISA savings pot.

From July, the limit individuals can save tax-free every year will rise from £11,880 to £15,000. These changes could enable doctors to build large, tax-proof retirement pots which can be used to top-up their nh S Pension fund.

As we discussed in last month’s

➱ p26

article, if a doctor and his/her spouse invested the maximum deposit of £30,000 a year every year for the next 15 years and achieved a 3% real return after charges and inflation, the final fund will be worth £668,222.

At these same rates, it would take just under 20 years for the fund to reach £1m.

As senior doctors may not be able to maximise pension savings without triggering harsh tax penalties for breaching the reduced annual and lifetime allowance rates, the popularity of ISAs is continuing to grow.

Many of our clients have already achieved ISA pots of around the £100k-£200k mark in a relatively short space of time as a result of disciplined, regular savings.

Setting up direct debits means the money is transferred into the investment before you get used to it in your current account.

Avoiding the noise

Indeed, it is the discipline here which achieves the results. Your money is drip-feeding into your ISA portfolio no matter what peak or trough the market is experiencing, forcing you to ignore the ‘market noise’ that can often lead to emotionally-led, poor decisionmaking.

While it is important to understand and work within your own attitude to investment risk, a regular investor is not being heldback by any notion of when a ‘bad’ time to invest is.

Many would-be investors were deterred by the financial crisis, but the FTSE All-Share has produced a return of more than 90% since April 2009. Those who invested on a monthly basis throughout this period benefited from the resulting rebound – this is commonly known as ‘pound cost averaging’.

And should circumstances alter, the ISA fund is accessible tax-free – normally without penalty – and can also be augmented with sporadic lump-sum payments.

other funding routes

For doctors who have surplus income once their ISA allowances have been maximised, another investment vehicle is a General Investment Account (GIA). A well-diversified portfolio can pro-

duce gains that are not subject to capital gains tax when disposals do not exceed your annual CGT exempt allowance.

When portfolios are well managed, this allows gains to be ‘harvested’ annually to make maximum use of the allowance – which is also available to your partner.

You can roll the proceeds into your ISA or withdraw the gains tax-free as additional retirement income. Losses from previous years can also be brought forwards to offset gains in the current year.

Investment portfolios that are not managed suffer from ‘style drift’ and ‘concentration risk’. This can be seen where certain investments are purchased and then left to accumulate substantial gains over the years, becoming disproportionately large as part of your overall portfolio or investment capital.

Drift results in a portfolio with a level of risk very different to that agreed at outset and leaves you open to bigger losses in a market decline or higher taxes when making disposals.

Proper and effective tax management of your investment accounts not only reduces this risk, it can also save a substantial amount of tax over the medium term.

Although interest/dividends accrued within the account are taxable each year, the rate of capital gains tax for higher-rate tax-

your money is drip-feeding into your iSa portfolio no matter what peak or trough the market is experiencing, forcing you to ignore the ‘market noise’ that can often lead to poor decisionmaking

payers is still 28%, which reflects well when compared with income tax rates of 40% and 45% or dividends.

Although less tax-efficient than ISAs, there are no restrictions to the amount that can be invested and you can accumulate substantial balances before capital gains tax becomes an issue.

Decumulation

There is a tendency to focus solely on the ‘accumulation’ aspect of long-term savings, as this seems to attract the most attention in the press.

The ‘decumulation’ process –converting hard-earned savings into a retirement income – should not be overlooked. The decisions taken at this stage of life can often be one-off and irreversible. It is a complex area, shaped by the same forces as when you accumulated the funds: risk, return, inflation and taxes. However, one also has to consider what level of withdrawal to adopt to maintain a comfortable standard of living without depleting the overall pot. While the Government’s radical pension changes offer a welcome freedom for savers, the relative protection from ‘running out of cash’ which annuities offer could be lost.

Indeed, critics were quick to assume those who have saved responsibly throughout their career may have a complete change of attitude to their

finances upon accessing their pension fund.

The Institute for Fiscal Studies warned ‘…without wanting to be seen as patronising, it is important to point out that increased choice could lead to more mistakes.

‘People at 60 or 65 are known to underestimate their own life expectancy, and especially the likelihood of living to extreme old age. They may over spend early in retirement.’

Fears of the pension blow-out on fast cars – pensions minister Steve Webb famously commented that he was happy if people bought a Lamborghini with their pension pot – are, of course, largely unfounded, but life expectancy should be considered.

Figures from the Office for National Statistics suggest that average life expectancy for people in this age range is now 86 for men and 89 for women.

ensuring you do not exhaust your money and can maintain your chosen lifestyle for 30 years depends on creating an adequate retirement fund through orderly saving

how long will you live?

Mr Webb has proposed providing savers with an estimate of life expectancy based on health factors and place of residence in order to help with financial planning.

But these are only averages, which, as actuaries tell us, are notoriously unreliable in the later stages of life where new forms of treatment can prolong life by many years.

Expenditure at this time is rarely even. There is a spike in expenditure immediately after retirement as people start to enjoy their free time.

This expenditure can continue for many years before reducing as mobility decreases before increasing again to pay for care or medical expenses.

Ensuring you do not exhaust your money and can maintain your chosen lifestyle for 30 years depends on creating an adequate retirement fund through orderly

saving and a good plan on how you will eventually spend it. Detailed cash flow planning should take into account not only pensions, savings and investments for you and your loved ones – adjusted for inflation – but also your general health and your position relevant to tax, inheritance tax and what happens to your private practice. 

Patrick Convey (left) is technical director of Cavendish Medical, specialist financial planners helping senior 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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disposing oF clinic wAsTE

Making safe

waste

The efficient management of clinical waste by private GPs and consultants is vital. Rebecca Allen (right) outlines the rules

As A privAte medical practitioner working from your own rooms or other non-hospital premises, you are likely to be a relatively small producer of clinical waste in comparison to hospitals and NHs clinics.

But you still need to ensure your practice or clinic organises the disposal of its clinical waste and adheres to all current legislation.

Due to the potential risks associated with the improper handling of clinical waste, its proper management and disposal is vital and there are strict regulations to prevent harm to the environment and to human health.

clinical waste regulations

t he controls to ensure clinical waste is managed and disposed of safely are listed under the environment protection Act 1990, where it states that it is ‘unlawful to deposit, recover or dispose of controlled (including clinical) waste without a waste management licence, or in a way that causes pollution of the environment or harm to human health’.

All clinical waste handling and disposal procedures must comply with the following regulations:

 the environmental protection Act 1990 (including the Duty of Care regulations);

 t he Controlled Waste r egulations 2012;

 the Hazardous Waste Directive 2011;

 t he Carriage of Dangerous Goods regulations, statutory duty of care regulations state it is the responsibility of the producer of any controlled waste to ensure the correct and proper management of the controlled waste their business produces.

the main principles of duty of care cover documenting the transfer of waste and ensuring it is handled correctly by waste carriers. Do you use a registered carrier of waste? Are they taking waste to suitably licensed/permitted sites?.

what is clinical waste?

Clinical waste is defined as ‘any waste which consists wholly or partly of human or animal tissue,

blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles or other sharp instruments’.

t his type of waste may prove hazardous to any person coming into contact with it unless it is rendered safe. Waste is defined as ‘hazardous’ when the waste itself or the material or substances it contains are harmful to humans or the environment.

Offensive waste is the other main waste stream and is primarily waste that is considered unpleasant due to its appearance and smell, such as incontinence waste.

waste transfer paperwork

For all transfers of waste, there must be appropriate documentation. For non-hazardous waste, this is usually in the form of a Waste transfer Note. You will be provided with an annual waste transfer note covering all transfers of non-hazardous waste for a 12-month period.

When you receive the documen-

tation, you must check it for accuracy purposes and the return slip must be returned to your waste contractor for full traceability.

Hazardous (England and wales) or special (scotland) waste consignment note All consignments of hazardous (special) waste must be accompanied by a hazardous or special waste consignment note. this will include:

 All site addresses and personnel involved with the waste transfer;

 A full description of waste type, including required shipping terms;  Correct e uropean Waste Catalogue (eWC) code for each waste stream;

 A required copy for you to store on your premises.

t he e nvironment Agency has imposed a legal requirement in e nvironmental p ermits for disposal sites to ensure producers carry out audits of their waste before it can be legally accepted and disposed of. these are known

as ‘ p re-acceptance Audits’. producers will also be required to periodically re-audit sites in the future.

to ensure your waste is suitable for any chosen method of disposal, all your waste streams must be audited, documented and this information relayed to your final disposal site. Failure to do this may leave you in breach of your duty of care responsibilities, which can lead to prosecution and unlimited fines.

segregating clinical waste

it is imperative that clinical waste is separated out at the point of production, following the ‘ s afe Management of Healthcare Waste’ guidance issued by the Department of Health.

the mixing of waste streams is prohibited by law in england and Wales, and best practice in scotland and Northern ireland. it also helps support waste minimi-

sation and reduces the risk of exposure and injury to your staff.

All containers used for the disposal of clinical waste must be labelled in accordance with the details of the legal requirements for transporting and packaging waste.

Container labels should also clearly identify the waste types present within, and should be signed by the producer ready for onward disposal.

proper segregation of different types of waste using the national colour coding system detailed below is critical to its safe management:

Yellow i nfectious waste for disposal by incineration

orange infectious waste for disposal by treatment or incineration

Yellow/Black (Tiger)

Offensive/hygiene waste for disposal by deep landfill

Blue

Medicinal waste for disposal by incineration

purple containing cytotoxic or cytostatic waste for disposal by incineration

Red Anatomical waste for disposal by incineration

disposing of sharps and medicines

it is essential that sharps are segregated and disposed of on the basis of their medicinal contamination.

the lid colour relates to how the waste should be disposed of:

Yellow lidded: s harps that are contaminated with medicines (excluding cytotoxic or cytostatic medicines) for disposal by incineration.

orange lidded: sharps that are not contaminated with medicines for disposal by treatment or incineration.

purple lidded: s harps that are contaminated with cytotoxic or cytostatic medicines for disposal by incineration.

Blue lidded:

Waste medicines for disposal by incineration.

The types of contract available to private doctors

Most waste management companies offer a flexible service to suit the business need of different customers including daily, weekly, fortnightly or monthly servicing visits.

it is important your practice has a waste collection and disposal service that meets your bespoke requirements and level of waste production. Overflowing waste bins and uncollected containers are hazardous if they are not addressed.

Check you are using a registered waste carrier; you can do this by asking to see a copy of their licences. Other points you should look for or questions you should ask include:

 is the waste carrier licensed

to take away the types of waste you are producing?

 Are the service technicians that will be collecting your waste ADr licensed? this is essential when transporting dangerous goods such as clinical waste

 Will you receive all the compulsory waste documentation to cover your waste transfers?

 Will your waste be fully traceable from point of product through to end disposal?

 Do all the products supplied to you meet legal requirements, such as UN approval for your sharps containers?

 Will the supply of products be free of charge or are they an additional cost?

 Will your waste be fully segregated on site and during transportation, to meet the current regulations?

from January 2014, you have to register as a waste carrier if you regularly transport waste as part of your business. If you only transport waste that is generated by your own business, such as sharps and clinical waste, you will need to register as a low-tier carrier. You can be fined up to £5,000 if you do not register.

Registration is quick, easy and, most importantly, free if you’re just transporting your own waste. once registered, you do not have to renew your registration. however, it is advisable to keep a record of your registration number and any other related information.

to register, go to www.wastecarriersregistration. service.gov.uk

 Can the contractor guarantee your service delivery will happen on time, every time?

 Has the service been tailored to your specific requirements?

 Are there any hidden charges?

Rebecca Allen is category manager at Initial Medical, healthcare waste management experts

Indemnity costs bite private practice hard

At a recent Independent Doctors Federation meeting, MDU chief executive Dr Christine Tomkins (right) explained why all doctors should be concerned about the alarming rise in the cost of clinical negligence compensation payments. Here she explains why legal reform is needed

When the MDU paid the first £1m compensation award in 1988, it caused a sharp intake of breath among the profession.

now, some 26 years later, multimillion pound damages payments in clinical negligence claims are common.

Some of the largest compensation payments we have made have been on behalf of members in independent practice. For example, our highest payment was £9.2m plus legal costs to compensate a patient rendered tetraplegic following spinal surgery.

Another example was £6.2m in damages with £3m in legal costs to a female patient for nerve damage after plastic surgery.

In the first claim, the damages were so high because of the cost of providing future care and accommodation for a young person with a long life expectancy. In the second, the claimant’s loss of earnings made up most of the award.

While no one would deny that patients harmed as a result of medical negligence should be properly and fairly compensated, this needs to be balanced against society’s ability to pay. Damages payments of this size are no longer unusual and claims inflation is rising at an alarming rate, way above wage, house and price inflation (see graph opposite).

In fact, clinical negligence claims inflation is doubling every seven years. A claim that would cost £9m if settled today is likely to cost at least £18m in seven years’ time.

Organisations indemnifying doctors in the independent sector have no option but to reflect the costs of these ever-rising awards in their subscriptions.

It is possible that if awards were to continue to rise unchecked, practice in the independent sector might become unaffordable. not only is this unsustainable

for doctors, but more widely it affects all taxpayers who are funding public liabilities such as the nhS Litigation Authority’s, which were estimated to be £22.7bn in April 2013. however, we believe there is a solution to this runaway claims inflation and on behalf of our members the MDU is campaigning to change the law.

What can be done?

the MDU is advocating a package of legal reforms that should provide a fairer and more sustainable system for all. We urge:

1

Repeal of the law Reform (Personal injury) Act 1948

Under the current law, the cost of future care must be calculated on the basis that it will only be provided privately, rather than through the nhS. So we are calling for repeal of this anachronistic law – S2(4) of the Law Reform (Personal Injuries) Act 1948.

Calculating compensation on the basis that future care could be provided by the nhS and not the private sector could save billions in nh S money that is currently paid to the private sector.

Also, organisations like the MDU and personal injury defendants, such as employers and insurers of road traffic accidents, would be able to buy nhS care packages, boosting nhS funds for the benefit of all patients, including those who cannot prove negligence.

2 Cap on earnings costs

If people who are negligently harmed are high earners and can prove they are not able to work as a result of the injury, they can receive millions of pounds in compensation for loss of future earnings. But it is possible to award financial compensation on a more equitable basis.

For example, in Australia, the maximum amount a person can claim for loss of earnings is three times the national average salary. We believe that is fairer and suggest such a system is adopted here.

3

Cap on future care compensation

We are also advocating a cap on the sums that can be paid for care packages. It should be possible for an independent body to define a care pathway for a particular injury that would apply to all patients who have such injury, irrespective of the cause.

Defendants such as the MDU should be required to fund the agreed level of care up to an agreed reasonable limit. Claimants who want additional care would have to prove they had exceptional needs that could not be met by the care package.

Repeal of S2(4) and the other legal reforms will not be easy and we don’t expect anything to happen quickly, especially with a May 2015 election coming up.

even if the reforms were implemented, it would be unrealistic to expect the nhS and local authorities to provide appropriate care packages throughout the country in a consistent way immediately. But it is very clear that the current compensation system cannot continue because society cannot afford to foot the bill for liabilities that are increasing in an uncontrolled way. t here must be change.

1. s pinal surgery – damage to spine leaving patient tetraplegic: £9.2m damages, plus legal costs.

2. general practice – failure to diagnose meningitis in six-month-old

infant: £6.5m damages including claim for future care, plus £300,000 costs.

3. Plastic surgery – facelift – damage to facial nerve: £6.2m damages, plus £3m legal costs.

How Damages are CurrenTly CalCulaTeD

In the uK, damages are not intended to be punitive but compensatory and should cover what is necessary to put the claimant in the position he/she would have been in had the negligence not occurred.

There are two major elements to damages awards. general damages are for pain, suffering and loss of amenity arising from the injury or illness.

The claimant is also entitled to an award of damages in respect of the financial consequences of the injury or illness which can include the cost of care, loss of earnings, loss of pension, the cost of special equipment and adaptations required in the home.

In circumstances where a claimant has suffered a serious injury or illness, such as in the case of a braindamaged child, a large proportion of any award will be to provide funds for future care needs for the patient’s projected life span. In such cases, the annual cost of care often exceeds £100,000, resulting in substantial seven-figure awards.

In addition, the loser has to pay the costs of litigation, including costs of legal advisers for both sides and the fee for both sides’ medical experts. 

mDu ClaIms examPles

Are billing firms

The £64,000 question

Mr Simon Owen-Johnstone (below), an orthopaedic upper-limb surgeon working exclusively in private practice at London Bridge and The Lister Hospitals, describes how outsourcing helped to recover money he was owed from an unpaid bills problem and helped his business grow

I B ega N P r I vaT e practice as a consultant orthopaedic surgeon in 2004. I started at a hospital near my NHS base and, initially, I only needed a little admin help.

Soon I was introduced to a secretary who looked after a number of small practices like mine. She did everything clerical for me: appoint ments, bookings, typing and billing.

a s my reputation developed, I expanded my practice to London Bridge Hospital. Business there grew more rapidly and soon outgrew the arrangements that had been sufficient only a few years earlier. I needed my own secretary.

It was only during the transition that I discovered nearly £79k owing to me that the previous system had not been robust enough to control.

as I didn’t want to burden my new secretary with the problem, I spent hours trying to sort out the mess; I sent some reminders and chasing letters myself, but it

appeared hopeless. Outsourcing was the answer.

I met g arry Chapman of Medical Billing and Collection (MBC), contracted their services and was greatly relieved to hand over a huge pile of papers.

My account was initially in MBC’s ‘intensive care’ as new managers set about reconciling my records with those from the insurance companies.

Recovering the backlog

We exchanged lots of emails, and, over about a year, they managed to recover all but £15k of the backlog, some of which was six years old.

Having taken sufficient action to chase the backlog, the true bad debt could then be written off, with my approval. The income tax I had already paid was then recovered.

Together with tackling the bad debts, MBC handled the ongoing billing. My secretary had simply

worth the cost?

– and answer

OutSOurced bIllIng IS nOt free, SO What dO I get fOr My MOney?

 I get paid for all the work I do, not just some of it

 Work is invoiced the day Mbc receives theatre and clinic lists

 aged debts are actively chased and insurance excesses are pursued

 My bad debts are almost zero, but any I do have can be legitimately written off for tax purposes

 My secretary is able to answer the phone and run my practice, because she is not bogged down with time-consuming credit control

 Outsourcing is so efficient that it is cheaper to buy credit control from them than have my secretary do it

 My secretary maintains a wholly positive relationship with patients. Someone else does the unpleasant money-chasing

 a secure website allows me to see business finances real-time, monitor my business and produce figures for my accountant

 Weekly email and texts inform me invoicing has been done and money received

 Mbc handles all cheques and electronic payment: I don’t need a card reader, nor do I have to visit my bank

 Most importantly, the headache of credit control has vanished

What I would pass on to other consultants from all this is not to let your practice outgrow your arrangements. It is important to scale your business structure as turnover grows to email clinic and theatre lists from the Practice Manager software, and my support team ensured the invoices were all paid. Having such a stable practice structure in place ensured my practice continued to grow steadily so that, in 2011, I chose to leave the NHS and work solely in private practice. The billing company has been able to advise me on all aspects of my practice billing to ensure that I am now billing efficiently.

My recommendations I think the figures speak for themselves. If your practice bad debts are greater than the MBC fees, you are already losing money.

To this figure, add the cost of

business lost because the phone was engaged as your secretary chased debts. Don’t forget that having your secretary do the billing isn’t free just because you have already paid for him/her.

Don’t worry about getting accounts straight first. I felt awkward handing over the accounts that were in a disorganised mess, so I spent hours trying to straighten them, largely out of embarrassment. I should not have bothered: it didn’t matter and I didn’t help.

Don’t worry about losing control. You remain in complete control of practice finance; someone else just does the legwork. What I would also pass on to other consultants from all this is not to let your practice outgrow your arrangements.

It is important to scale your business structure as turnover grows. a share of a secretary who does everything is fine to begin with, but the arrangements need to be reviewed to ensure they are appropriate to the practice.

e qually, if there is a deficit in billing capacity, get billing help, not more secretaries. Do it now. I think your practice, accountant and secretary will thank you.  The Association of Independent Specialist Medical Accountants is a national network of firms advising over 3,000 medical practices across the UK. For some of the best advice available on accounting, taxation and pensions, visit our website and find your nearest AISMA accountant.

Moving home the

On the move?

Robert Capper (below) offers an easy-to-read check list of top tips for doctors who are buying or selling their home

Unless yo U are planning on buying a top-of-the-range Bugatti, your home purchase will most probably be the biggest purchase you will ever make.

Moving can be extremely stressful so here are a few tips to help make the process as stress-free as possible.

sElling yoUR homE getting the price right

 Too high a price and you are at risk of never finding a buyer.

 Too low a price and you might end up putting potential buyers off by thinking there is something wrong with the property.

 Be prepared to accept a lower offer if the buyer is able to move quickly and does not require mortgage finance.

 s peak to the local agents and get their view on the market.

Disclosure

 Remember, it is your duty to disclose any issues with the property in the property information forms – your buyer will rely on the information provided.

Fittings and contents

 If you want to sell your chandelier or your Persian rug, make sure you let your solicitor know. They will add it to the contract and save you the bother of collecting payment direct from the buyer. It is surprising the number of disputes which can arise.

Exchange

 Don’t go spending the money

before your buyer has exchanged contracts. your buyer can change their mind about buying at any point before contracts are exchanged.

 Booking your removals early can be very risky as your completion date is not fixed until exchange of contracts. Make a provisional booking until exchange has taken place.

moving day

 Remember to read the meters and let your utility providers know about the move.

 Cancel your buildings and contents insurance.

 Apply for redirection of mail. If you don’t have a permanent address to move to immediately, consider redirecting to the practice.

easy way

Beware of gazumping. Your offer to buy may be rejected after acceptance if a new buyer comes in with a higher offer

BUying yoUR homE

Research the locality

 Does it have a good transport route? Test out the journey to work.

 Are there any good schools nearby? For those private medical practitioners who have children, you may want to consider being in the catchment area of a soughtafter school. For those of you who don’t, you may want to steer clear of noisy playgrounds.

 s peak to the neighbours and see whether they are happy living in the area.

 Visit the house at different times of the day and night – is the road always quiet?

 How close is the local supermarket? After a hard day at work, the last thing you want to do is drive a few miles just for a pint of milk.

is the price right?

 Compare the house price with nearby properties. Are you paying more than it’s worth?

 Try negotiating the price down. If your seller is desperate to sell, you may get lucky.

 Check the stamp duty threshold. you may end up paying thousands of pounds extra if you are on the wrong side of it.

 Beware of gazumping. your offer may be rejected after acceptance if a new buyer comes in with a higher offer.

Which firm of solicitors?

 Compare quotes online. These days, any firm worth using will have the facility to provide a quick and easy online quote which will save you time in the long run.

 Don’t be fooled by a cheap quote. Read the small print and check all associated costs before you make comparisons.

 Choose a firm of solicitors where the solicitors carry out the conveyancing, not unqualified ➱ p38

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MoneY MoneY MoneY

 Get your funding in place. If you do this before you make an offer, you will be better placed to proceed. Have your mortgage agreed in principle. You will be surprised how long some lenders can take, which will inevitably impact the speed of your transaction

 Prepare a budget. Your mortgage costs should be no more than 50% of your net income. Where you are buying jointly, build in a contingency in the event that one of you cannot work

 Check the conditions of your mortgage offer. You may be required to pay off any outstanding debt

 Remember, your lender will require notice to release funds. This can range from five to ten working days, although some lenders can be more flexible

 ensure your monies are easily accessible when the time comes to make the transfer to your solicitors. Some saving accounts do not allow instant electronic transfers

 Consider entering into a trust if you are contributing more than your partner. Your solicitor can draw up a declaration of trust to help protect your investment in the event that your relationship breaks down

staff. This is probably the most expensive purchase that you will make, so it is worth paying a little extra for a good-quality service that could save you thousands of pounds and heartache later.

 Work with your solicitor. Discuss any important dates or deadlines you have. Ask for regular email updates if you are not contactable at the practice during the day.

Fittings and contents

 Check the fittings and contents form completed by the seller. Does it include all of the items agreed between you and the seller?

 If there are any items not included that you are interested in buying, don’t be afraid to ask if the seller would be willing to leave them on completion or sell them to you.

 Check the form alongside the sales particulars to ensure you are not being charged for items that should be included in the sale.

survey

 Do not rely on a valuation carried out by your lender. These are very basic and tell you little about the property.

 Get the experts to give the property a once-over. Much like the human body, you never know what hidden dangers there are lurking beneath the surface.

 your survey will reveal any works that have been carried out at the property which may have required planning permission or building regulations consent.

sEARchEs

There are a number of searches which can be carried out, the main ones being:

local search

 This will reveal any applications for planning permission or building regulations specific to the property itself. It will also reveal whether the property is in a

AdveRTISe HeRe

conservation area or subject to a tree preservation order.

Water and drainage search

 This search will reveal whether the property is connected to mains water and drainage and the charging basis. It will also indicate the presence of any sewers close to the property which may impact on your ability to extend.

Environmental search

 Issues such as flooding, radon gas and contaminated land will be revealed in this search. you will also be able to check if there are any landfill sites nearby.

chancel search

 This search will reveal whether the property is within an area which could be affected by chancel repair liability – a legal obiligation to pay for repairs to the local church. Indemnity insurance is available in such cases.

inspection

 Report any issues to your solicitor, such as works carried out at the property which may have required consent.

 It would be wise to inform your solicitor of any occupiers. The last thing you want to be faced with on completion is inheriting a granny living in the annex.

selling and buying

 If you need to tie in your sale and purchase, you will be involved in a longer chain. It is prudent to remember the more people involved in the transaction, the less control you will have over the speed of the transaction and the more compromise required in reaching a completion date agreeable to all parties involved. 

Robert Capper is a partner in the Health and Social Care Team at Harrison Clark Rickerbys and heads the team acting for doctors

An independent firm offering one to one meetings anywhere in the UK giving advice and help with:

• how to start in private practice

• how to maximise private practice income

• ways to reduce tax payments

• setting up in Chambers/Groups

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• tax and financial advice re: car purchases

• pensions: NHS, personal and employee schemes

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Private work mustn’t harm

NHS duties

Conducting private work in the NHS is still a potential pitfall for some doctors. Dr Angelique Mastihi (below) goes through the rulebook

THE ClICHé of NHS consultants spending the majority of their working day at St Elsewhere while their team is left behind to look after the NHS patients may seem outdated.

But concerns about the potential or perceived conflict between NHS and private work are as real as ever.

The overriding principle remains: provision of private care should not prejudice NHS service and interests.

Salaried consultants were given the right to engage in private work at the launch of the NHS. This was to ensure that hospital consultants would work within the new NHS system, avoiding the development of a two-tier system.

There was concern that the profession would fail to engage due to a lack of enthusiasm, endangering the whole project.

Although these original con -

cerns are no longer relevant, controversy and a tension between private and public work has remained a common thread – in particular, the underlying concern that consultants’ interest in their private practice creates a lack of incentive to carry out NHS work.

In 2000, a House of Commons’ Health Committee report concluded it was impossible to measure the degree of conflict between the two.

If you intend to work in both the private and public sector, there are a number of issues to consider:

The contractual relationship with your NHS employer

During the job planning process, you should discuss with your NHS employer the type of private work you intend to undertake and a proposed timetable.

You can work together to agree how this will work alongside your

NHS commitments and in line with trust policy. It would be unusual to schedule private work within NHS time, although it may be possible to make such provisions if a prior arrangement is made.

The common theme across the jurisdictional codes of conduct is that public sector work must take priority over private. There may be the rare situation when you are called to deal with a private emergency during NHS time, but regular incidents will cause you difficulties.

Undertaking private work using NHS facilities

You should only attempt to do private work in an NHS hospital with prior agreement of the trust. It is ultimately for the organisation to determine what private care can be undertaken, and which staff or equipment can be used.

It is important to remember that private care should not prejudice NHS service provision.

Influencing patient choice

Even if you maintain the two areas of your practice in distinct locations, there are additional pitfalls to consider.

Imagine the scene: you are in your NHS outpatients clinic and the patient asks about waiting times and the conversation moves onto whether or not it would be quicker to have the procedure performed privately.

Did you raise the subject or did the patient? Were the waiting times you gave an accurate reflection of current times within the department?

The GMC’s explanatory guidance on financial and commercial arrangements and conflicts of interest (2013) states (paragraph 15): ‘You must not try to influence patients’ choice of healthcare services to benefit you, someone close to you, or your employer. If your organisation dispenses medicines, you must not allow your financial or commercial interests to affect the way you prescribe.’

Care needs to be taken to ensure you are not perceived as encouraging patients to use your private service. The guidance is very clear that you must not initiate discussion about the provision of private care or encourage others to do so.

Of course, if a patient asks, then you are able to provide factual information and if the patient can obtain care sooner within the NHS but provided by a colleague, then you must inform them of that too.

A potential criticism that may overshadow private work is a concern that a doctor’s actions benefit their private work at the detriment to their NHS; for example, purposefully lengthening NHS waiting times.

Private patients and NHS care

Patients who choose to be treated privately are still entitled to NHS care. This is another contentious area and one where guidance has changed over the years. It used to be that if a patient started their care pathway within the private

The guidance is very clear that you must not initiate discussion about the provision of private care or encourage others to do so

sector and then chose to revert to the NHS, they had to return to the beginning of the referral pathway. However, this is no longer the case and patients can opt to change. They must be treated in the same way as someone that has always been treated within the NHS, under the same criteria and join any lists at the same point they would be if there treatment to date had been as an NHS patient.

The old rules were an attempt to resolve concerns that patients could queue-jump by being seen initially as a private patient. But, on review, it was realised that duplication of care was neither in the interests of the individual patient or of the health service as a whole.

So, do we find ourselves in a situation where the NHS could be handcuffed into providing expensive treatments not usually available as free at the point of care?

The answer is no; it is not a case of ‘I have started, so I will finish’. If the initial treatment planned or commenced would not normally be funded by the NHS, then the patient will be offered the alternative treatment that would usually be available. However, a patient may apply for their case to be considered for individual funding.

You must remember that although a patient who has received private care is still entitled to use the NHS, a patient cannot be both a private and public patient for the treatment of one condition during a single visit. NHS and private care should be delivered separately; a patient cannot pick and mix.

An example provided by the NHS Commissioning Board is of a patient undergoing a cataract operation as an NHS patient and wishing to pay a fee to have a multifocal lens implanted during the surgery instead of the standard single focus one. This would not be permitted.

Co-funding treatment

Co-funding is the term used when part of an episode of care is funded by the NHS and partfunded privately by the patient.

As a general rule, co-funding is contrary to NHS policy, although there are limited forms permitted. For example, in the situation

Top Tips To follow

1 provision of private care should not prejudice NHs service and interests

2 work in partnership with your NHs trust to prevent conflict between NHs and private care

3 public facilities, staff and services can only be used for private care with prior agreement of the NHs organisation

4 Do not initiate discussion about private services during NHs care

5 Ensure that information provided is accurate

A patient cannot be both a private and public patient for the treatment of one condition during a single visit

where a patient is advised of a combination of drug treatments, of which only some are routinely available as an NHS treatment, the patient can choose to pay for the additional ones as long as there are no patient safety issues in the combination being provided at one time.

The patient can also apply to have the non-NHS treatment considered for individual funding and the fact they are willing to pay for these drugs should have no bearing on the ultimate decision as to whether the drugs will be funded.

NHS prescribing

Another area which can create tension between the NHS and private sector is if a private clinician asks an NHS GP to prescribe a medication on the NHS.

If the drug is normally publicly funded and the GP considers it is clinically indicated and is willing to accept clinical responsibility, then there is no difficulty. In my experience, problems arise when communication between the consultant and GP fails and the GP is left unclear as to the management plan and monitoring arrangements.

General practice differs from consultant-led care, in that the GP Contract does not allow an NHS GP to provide privately any care that would ordinarily be available on the NHS to patients registered on their NHS list.

Dr Angelique Mastihi is a medicolegal adviser at the Medical Protection Society

With an eye to

Dr Richenda Tisdale (below) responds to two dilemmas concerning ophthalmologists which highlight the need for sensitive and effective communication

Dilemma 1 Should I confess I made an error?

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Two weeks ago, I carried out cataract surgery on an elderly man who has worn glasses for years to correct shortsightedness.

The patient has just returned for review and told me he was delighted with how much clearer his vision has been following the procedure. However, after carrying out a pinhole test I realised he remained short-sighted and when I measured him again his vision was only 6/18.

My operating notes revealed that I had inserted a 17.5 dioptre implant instead of the 19 dioptre intraocular lens (IOL) I had originally proposed.

I remember that day was particularly busy and I had a full operating list, but, of course, that is no excuse. What should I do now?

AIf you have made an error, you have an ethical duty to tell the patient at the first opportunity.

If a patient under your care has suffered harm or distress, guidance in the GMC’s Good Medical

Practice says you should: ‘...put matters right (if that is possible); offer an apology [and] explain fully and promptly what has happened and the likely short-term and long-term effects’.

The prospect of confessing your mistake to the patient might be acutely embarrassing, but don’t be tempted to cover up what has happened, as the consequences of staying silent could be far worse for your reputation.

While the patient is currently unaware that anything is amiss, a complaint or a claim may follow if he later discovers a problem during an optician’s appointment or by comparing notes with another patient.

In that event, you will be asked to disclose your records, when it will become obvious that you have made a mistake. Any suspicion that you have tried to deceive your patient could lead to a GMC referral.

In breaking the bad news, it’s important to remain professional and communicate effectively for the patient’s sake and to avoid making matters worse. It may help to bear in mind the following advice from the Medical Defence Union (MDU):

 Try to visualise the conversation from the patient’s perspective. For example, be sensitive to the fact that he had previously seen the consultation as a routine followup to a successful operation.

 Be clear about what has gone wrong by using the patient’s language, rather than resorting to medical terminology.

 Explain his next options – for example, wearing glasses, a lens exchange procedure. Provide him with information to take away, if necessary, and give him the time to decide what to do next.

 Check he has understood and give him the opportunity to ask questions.

 Apologise for what has hap -

to being sensitive

pened and acknowledge his feelings, whether he accepts what has happened or reacts with distress, fear or anger.

 Be aware of your non-verbal communication such as making eye contact, avoiding defensive postures such as crossing your arms and using acknowledging gestures such as nodding.

 As an independent practitioner, you will also need to discuss the financial implications with the patient, especially if he is selffunded. To reduce the chance of confusion and ill-feeling later, be clear about what you are proposing – for example, waiving your fee, paying for corrective treatment.

The hospital where you carried out the procedure should have its own local procedures for investigating adverse incidents and the GMC expects you to report what has happened and contribute constructively to any subsequent inquiry.

Acknowledging that you have made a mistake is difficult, but it may be some comfort to realise that what happened is unlikely to be the result of human error alone. For example, the investigation may highlight existing problems with managing theatre time, or inadequate protocols for checking that the correct IOL has been prepared. By helping to address these issues, you could reduce the likelihood of another patient experiencing harm.

Dilemma 2

He also revealed that he and his wife had just returned from southern Africa after living there for several years.

On examination, I found severe inflammation with lesions spread ing along the retinal vessels in a pattern suggestive of cytomegalovirus retinitis and I suspect the patient is HIV positive.

However, I am concerned about broaching the need for an urgent referral in front of his wife. What should I do?

AAt this stage, your priority must be to ‘promptly provide or arrange suitable advice, investigations or treatment where necessary [and] refer a patient to another practitioner when this serves the patient’s needs’ in line with the GMC’s guidance (paragraph 15, Good Medical Practice).

As with any referral, your patient needs to know the purpose and what to expect before he can give his consent.

However, it would clearly be a mistake to discuss your suspicions in front of his wife, given the obvious sensitivities associated with HIV infection and your duty of patient confidentiality.

The patient may have implied he is happy for her to know about his eye problems, but not necessarily about a serious communicable disease.

ral which would include your suggestion of an HIV test.

Instead, consider asking the patient whether you can have a few minutes with him in private. You can then talk to him openly about your concerns, stressing that there could be other reasons for his condition, but making clear that you think he may need an HIV test.

Bear in mind that your findings are likely to come as a shock to the patient, so give him the opportunity to ask questions and come to terms with what you have said.

The patient should then be able to decide how much – if anything –he tells his wife at this stage.

As with all referrals, you should record the details in the patient’s records and have a system in place to follow up with the doctor concerned.

REFERENCE

1. Confidentiality: disclosing information about serious communicable diseases, GMC, 2009

Dr Richenda Tisdale is a MDU medico-legal adviser and former eye surgeon

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Qcould be HIV?

Do I tell him that he

A male patient attended with his wife, complaining of visual disturbances and light sensitivity. When I took a medical history, the patient said he was otherwise in good health and taking no medication.

There may be exceptional circumstances in which a doctor can disclose a patient’s infection status1 but, in this case, the diagnosis has not even been confirmed.

One option is to be deliberately vague, suggesting that there may be a problem with the patient’s immune system which requires further investigation.

However, this approach is simply likely to prompt questions. In addition, you would still need the patient’s consent to include all relevant clinical details in your refer-

Keep tabs on your

Maintaining adequate books and records is an essential part of running any business and your private practice is no exception to this.

Ian Tongue (below) gives his top tips for new independent practitioners (NIPs) and other more established doctors with a private practice who may still not have got around to doing all the financial admin they should

If th I ngs are set up correctly from the start, then it should not be an onerous task to have everything sorted for your accounting and record-keeping.

But having to tidy things up at the end of a year certainly can cause problems. the following are some tips for keeping on top of things and making sure you have the information required for running the business – and to avoid falling foul of h M Revenue and Customs (hMRC).

Engage an accountant

An accountant with knowledge of your profession can be invaluable. t hey will have come across all sorts of practical situations that allow them to relate to the specifics of running a private medical practice and how this fits in with the tax system.

Meet before you start your private work, if possible, as your time will be even more restricted once you have commenced. they will deal with the formalities of commencing your business and provide not only advice on record-keeping but also the most appropriate trading structure for your practice, such as sole trader or limited company.

Maintain regular contact with your accountant to ensure that they are kept up to date on your position. t his is particularly important for tax planning at the earliest opportunity.

Understand

the tax system

With most consultants having little or no financial training, the self-assessment tax system can be a little daunting.

t he PAYE system has been a safety net for many in the past, but now having to save each month from income for the private practice can be a challenge.

s elf-assessment has key payment dates and it can be a long time between earning the money

and paying the tax and therefore it is vital that you save for tax from day one. the rate to save will depend on your circumstances and trading structure and this is a key question to discuss with your accountant.

VAt comes into play if you are performing medico-legal or purely cosmetic/aesthetic work. It is vital that your systems allow this to be kept under monthly review, as there is a compulsory requirement to register for VAt if your fee income from these ‘standard-rated’ services exceed the VA t threshold, currently £81,000 a year.

keep records from day one

Playing catch-up is never a good idea and when it comes to accounting records, it can be a very time-consuming process.

t his can also introduce error into the record-keeping system that could result in incomplete records being maintained. hMRC has powers to fine taxpayers who do not keep adequate records.

t he accounts must be able to records the basic details of the work performed, such as date of

work, patient details, amount and whether they have paid.

Don’t assume that self-paying patients can always afford the treatment or insurance companies always get things right. h aving adequate records allows you to focus attention on those where issues may exist and help prevent work being done for free. s ystems to chase outstanding debts need to be robust to ensure that payment is received.

If any debts do turn bad, there is tax relief on these amounts, as it is likely to have been declared as income in an earlier period. Ensure that all correspondence chasing these debts is kept, as hMRC could ask for this should you have a tax inquiry.

keep separate bank accounts

It is surprising how many consultants do not run their practice through a separate bank account when they are sole traders, particularly if they have not engaged an accountant early on.

But it is extremely important that you keep your business records separate from your personal finances. t his approach

accounts

Electronic record-keeping

When starting out, simple spreadsheets should be adequate and your accountant may be able to provide you with a template. however, as your practice grows and the volume increases, one of the bespoke practice management packages should be considered.

I hear positive things about such software and with the cost being tax-deductible and its likely time savings, it usually pays for itself in no time. there are a number on the market and you should request a demonstration. Discussing experiences in this area with other colleagues can be invaluable.

HMRC inquiry

makes the preparation of accounts easier, as accountants are not having to trawl through a consultant’s personal expenditure to identify business expenses.

Hire a secretary with bookkeeping experience

Most consultants engage the services of a secretary or secretarial service. Often, these individuals have been providing this service for a long time and they may have a preference for a particular method or software package if they use practice management software (see later).

One of the key themes that are evident from talks that I attend where established consultants are discussing their experiences is that a good secretary is one of the key aspects to a successful practice. Choose wisely and make sure that they are not encroaching on other commitments; for example, the nhs.

Most secretaries are selfemployed and will issue an invoice, but as your practice gets larger, you may employ someone or share an employed secretary with other colleagues.

At some point in your career, you are likely to have a tax inspection or inquiry. the first thing is not to panic. hMRC has very powerful computer systems nowadays and is often asking about targeted parts of the tax return – ‘aspect inquiry’ – although it then can open a full inquiry that is more involved and requires all records to be submitted to them.

Your accountant will deal with matters, but it can often be a slow process to conclude. Most accountants offer a fee protection insurance against the professional fees for dealing with an inquiry, but obviously not the outcome. As it is usually the more senior accountants who deal with inquiries, this can represent good value. having a robust accounting system that properly integrates with your individual circumstances is essential. Investing the time from the outset should ensure that the whole process is efficient and makes fulfilling your obligations with hMRC easier.

 Next month: The private practice ‘Top Ten’ issues

Ian Tongue is a partner with Sandison Easson & Co, specialist medical accountants

A very nice F-word

The cat is back! Thirty-five years since the last E-Type Jaguar was built, the marque has delivered a worthy and beautiful successor to the iconic 1960s’ sports car. An enthralled Dr Tony Rimmer gets his breath back to report

A FEW DE c ADES ago, before medicine became a factor in my life, I clearly remember the impact the original Jaguar E-Type had on this car-mad schoolboy.

It caused excitement when spotted on the road and earned a poster place on the bedroom wall.

This was a sports car that was to shape Jaguar’s image and reputation ever since that time.

Surprisingly, it has been over 35 years since the last E-Type rolled off the production line and Jaguar has only just returned to building a focused, two-seat convertible sports car. Enter the new F-Type.

There will be quite a few independent practitioners out there who will be taking a close look at this important new and very British car. I have been lucky enough to spend a week behind the wheel to see if reality lives up to the promise.

Well, first off, it looks stunning. Showroom presence counts for a lot in this sector and I reckon

Jaguar has got it just right. Thoroughly modern detailed lines and taut proportions with a hint of E-Type around the tail create high desirability in spades.

A signature ‘power bulge’, side ducts and the iconic Jaguar badge finish off this fantastic-looking car. In a sports car world of Porsches, the F-Type is a refreshing standout alternative.

Using the neat pop-out door handles, I slid inside and was relieved to find that the interior lives up to the smart exterior.

Sense of occasion

The cabin feels upmarket and its quality levels would not embarrass Audi. Leather trim is standard and the controls are angled towards the driver.

A clever touch that increases the sense of occasion is the central air-vents which calmly rise from the top of the dash when the car senses it is too cold or too warm; a nice touch.

Only the slightly clunky, slow sat-nav and touchscreen stops this Jaguar from having a perfect sports car interior.

The F-Type is available with three engine options and all are supercharged units. The 3.0 litre V6 in the standard car has 335bhp and the V6 S model has 375bhp. Top of the range is the hairy V8 S with a massive 488bhp and comes with wheelspin as standard! The most balanced package is said to be the V6 S and this is the model I had on test.

Transmission is a smooth and responsive eight-speed automatic box with paddle-shift controls when you are feeling in a playful mood.

With a 50:50 weight distribution and power through the rear wheels, this is a real driver’s car. Handling is sharp with very direct steering and the ride can be dialed in to the prevailing conditions using the excellent adaptive dampers.

These are standard on the S models as is a limited slip differential for better traction out of tight turns and an active exhaust that sounds absolutely brilliant on full throttle. The sound really makes you feel that you could be driving a classic racing D-Type from the 50s.

This car is not a just a raw trackday weapon. Turn the dampers to soft, use the gearbox in fully auto mode and you can cruise in comfort on the motorway for hours on end and match any grand touring (GT) rival like a Mercedes SL.

Noise is subdued with the roof raised and feels solid and secure. If you want to enjoy our British summer, just flick a switch and the roof folds away neatly in just 12 seconds – and the device works even up to 30mph.

Something special

So this is definitely a car to appeal to the successful medical professional who deserves something special as a treat for all the long hours and hard work building up a private practice.

On a pragmatic business front, although Jaguars are not usually renowned for good residual values, the experts predict the F-Type will be worth at least 50% of its original value after three years. This is equal to most rivals like Porsche, Audi and BMW. If you prefer a hardtop rather than a full convertible, the F-Type coupé goes on sale this year to broaden the appeal and may handle even better than the convertible.

Are there any negatives to this superb car? Well, the boot is tiny. Even though you don’t expect much luggage space in a twoseater sports car, there is only enough room in the boot for a couple of squashy bags; less if you opt for a space-saver wheel.

The Porsche model that sits as direct rival to the F-Type, the Boxster, has two boots front and rear and is much more practical. The Boxster also handles better and is a slightly better driver’s car all round.

However, do you want to disappear in the mass of German sports machinery or do you want something special with real soul and personality that reflects the person you are?

You can’t go wrong with the F-Type. I had a fantastic time with my test car. The desirable sporting Jaguar is back and deserves poster space on any current schoolchild’s wall. 

Dr Tony Rimmer is a GP practising in Guildford, Surrey

jAguAR

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Body: Two-seat convertible engine: 3.0 litre v6 supercharged power: 375bhp

Torque: 460Nm

Top speed: 171mph

Acceleration: 0-60mph in 4.8 secs

Claimed economy: (Combined) 31mpg

CO2 emissions: 213g/km On the road price: £67,520

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The cabin feels upmarket and its quality levels would not embarrass Audi

ProfiTs focus: anaEsThETisTs

Profits bubbling along

Anaesthetists have managed to keep their profits stable as they take on an extra workload. Our regular accountants Ray Stanbridge and Martin Murray report

Despite the recession of the past few years, anaesthetists as a group seem to have performed reasonably well.

For the year to 5 April 2012, at least, their income appears to have been fairly constant. t hey do not seem to have been particularly badly affected by the introduction of reduced price schemes, such as Bupa’s open referral.

Our headline figures show that, between 2011 and 2012, the average consultant anaesthetist’s private practice income rose by 1.4% from £70,000 to £72,000.

Costs rose by about 4.3% from £22,000 to £23,000. As a result, taxable profits, on average, rose by 2.1% from £48,000 to £49,000.

i t is important to stress that there are limitations in our data.

First, the figures are not statistically significant, but rather they represent a typical sample of anaesthetists working across the country.

second, there are – as with other groups of consultants – increasing difficulties in reconciling data to provide consistent trends.

this is because a number of con-

aveRage inCoMe anD eXPenDituRe oF a ConSuLtant anaeSthetiSt With an eStaBLiSheD PRivate PRaCtiCe

sultants have formed groups, which generally have resulted in a stimulus to income. Others have established limited liability companies, which complicate data comparisons.

Group success

And others have established new lines of business, such as pain management clinics and/or medico-legal services, which has led to new sources of income growth. so it is also important to remind readers of the criteria for establishing our sample.

i n reviewing our figures, we find gross fees have increased marginally between 2011 and 2012. We are observing that fees, on average, in groups are growing at a faster rate than for individual consultants.

We are pleased to observe that the Competition and Markets

Authority (CMA) in its April report did not rule that anaesthetic groups were anti-competitive. As a result, we now expect to see a further rate of growth. i t is clear from studying the sample of figures that a number of anaesthetists’ incomes have held up as a result of extra work they have done, for example, on Nhs waiting list initiatives or Choose and Book. Others have diversified their activities.

costs constant

Costs have been fairly constant from 2011 and 2012. We have noticed that staff costs have shown a slight increase. Again, this is probably a function of the increase in personal allowances over recent years, or where a consultant is a member of a group, an increase in salaries

our income summary is restricted to those consultant anaesthetists who are not full-time in private practice. they:

 hold either an old-style or a new-style contract with the nhS

 have been in private practice for at least five years

 are seriously interested in pursuing private practice as a business

 have generated a gross income of £5,000 for the year under review

 May or may not have incorporated the business and/or be a member of a group

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd. Additional information: Sandison Easson and Co

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paid to employed staff working for that organisation.

Car expenses seem to have fallen slightly. We would expect further falls in such expenditure over future years as anaesthetists fully recognise the effect of the decision in the Upper tax tribunal in the ‘samadian’ car mileage case, reported extensively in Independent Practitioner Today

‘Other’ costs have shown an increase. some individual consultants have invested in websites and other forms of marketing. Others

PRoFitS FoCuS iS the inDuStRy BenChMaRk

Doctors and their specialist medical accountants use the statistics published in our ‘Profits Focus’ series to look at how their earnings compare with others and see where they can cut costs and boost their income.

now all this information is available on our website and is free when you take out a subscription. either fill in the subscription form on page 24 or phone 01752 312140 or email lisa@marketingcentre.co.uk. get a discount by paying by direct debit.

www.independentpractitioner-today.co.uk

have had a contribution to marketing imposed on them by virtue of their membership of groups.

As with other sectors of the consultant body, marketing is becoming an increasingly important item of expenditure.

s o what then of the future for anaesthetists’ income?

We have seen the growth in anaesthetists’ income, on average, by about 5% a year compound since 2007 – despite adverse market situations.

Many anaesthetists are becom-

ing increasingly businesslike, and we expect to see a further small growth in incomes – at worst a situation of no growth. Costs are continuing to rise, so we would expect to see a further tightening of margins, albeit on a small scale.

 next month: general surgeons

Ray Stanbridge runs an accountancy, finance and tax advisory service specialising in the medical profession. Martin Murray is a partner at Sandison Easson & Co, specialist medical accountants

years ending 5 april

Source: Stanbridge Associates Ltd

what’S coMing in our julY/auguSt edition

Make sure you don’t miss our next issue, published on 24 July. only subscribers to the magazine are guaranteed to receive every copy and we don’t think anybody who is serious about continuing private practice in the future, when there is so much happening that will affect them, can afford to miss any issue.

Coming up next month:

 Codes for Success. healthcode’s Peter Connor explains why the private sector needs to embrace clinical coding to secure its future and looks at the most cost-effective and efficient way to achieve this. he outlines the different coding systems used and their purposes, the disadvantages of coding as currently practised in the private sector, the challenge ahead and the potential of mapping and coding tools

 use our Better Biller Quiz to find out how your practice is performing

 What to do before the patient leaves you

 Don’t leave succession planning too late. Practical advice on passing assets to the next generation

 Location, location – the changing tide and place for consultants’ practices

 end-of-life tax care for you and your company

 keep it legal – duties of good faith in partnerships

 Profits Focus looks at the earnings trends for general surgeons

Published by The Independent Practitioner Ltd. Independent Practitioner

Today is editorially independent and thanks Bupa for its assistance with distribution.

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Material is governed by copyright. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form without permission, unless for the purposes of reference and comment. Editorial layout is the copyright of the publishers. If you wish to use it for promotional purposes on websites or for reprints, we would be happy to discuss licensing the copyright to you.

© The Independent Practitioner Ltd 2014

Registered office: 7 Lindum Terrace, Lincoln LN2 5RP

Write to Independent Practitioner Today PO Box 198, Cranleigh GU6 9BB

 Recent tax investigation trouble for doctors and what to do about it. accountant Craig tully, who used to work for hM Revenue and Customs, offers some useful advice

 Doctor on the Road: columnist Dr tony Rimmer is all big smiles after his test drive in the latest Mini Cooper S (right)

 Business Dilemmas: an anaesthetist asks what to do after an anaesthetised patient claims to have heard sounds and felt pain during the procedure. and a doctor facing an appraisal with an appraiser with little experience of his specialty asks if he can refuse to co-operate

aDveRtiSeRS: the deadline for booking advertising for our July/august issue is 27 June

eDitoRiaL inQuiRieS

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Email: robin@ip-today.co.uk

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