July-August 2016

INDEPENDENT PRACTITIONER TODAY

The business journal for doctors in private practice

Swindler’s list

Fraudsters are finding new ways to target doctors. So how do you fight back? P14

Personality goes a long way Medical training can stifle good marketing methods. Here’s some ideas to enliven your website P16

By Robin Stride

Private doctors in London stand to lose thousands of pounds in the wake of Brexit, accountants fear.

Financial projections for Independent Practitioner Today, based on independent practitioners’ earnings from the City, predict a 2-3% average drop in private practice gross incomes in the centre of the capital for every 10,000 job losses.

That represents a drop of £3,500£4,500, although the figures could be nearer £35,000-£45,000 for some if forecasts by pessimistic commentators are realised.

But the analysis, by Stanbridge Associates, highlighted that a profits fall could be offset by more international patients coming to be treated in London as a centre of world medical excellence.

Specialist medical accountant Ray Stanbridge added: ‘Optimists are saying there could be 10,000 City job losses. Pessimists have said 100,000, which I don’t believe. But whoever leaves, they take their private medical insurance-covered (PMI) families with them too.

‘I’d advise consultants to increase their prices and level of service to self-pay patients.

‘Outer-London consultants are likely to see some fall off in the business as the economy slows

down, but this again may be offset by more self-pay.

‘Around the country, the promised £350m per week to the NHS following Brexit seems to have disappeared in a haze – if it ever was a reality. Things are likely to continue as they were before.’

Private practice marketing consultant Malcolm McCoskery said: ‘There is much uncertainty at the moment, but if Sterling continues to fall, this could attract more international patients, especially those from outside Europe.

‘If the Eurozone continues to disband, then the international markets will fluctuate even more and if the Euro currency collapses, then more opportunities could arise.

‘In the longer term, the ability of European doctors to work here could be restricted. But, there again, it may become easier for Commonwealth doctors to work here, so this could be a neutral situation.

‘As for the UK market, if there is a significant downturn, then personal PMI may suffer as subscribers – especially the elderly if their savings hit zero per cent interest –feel the pinch.’

Gary Nials, managing director at Medical Billing and Collection, said overseas self-pay might

www.independent-practitioner-today.co.uk

An accident but still your fault

Private doctors with employees need to be aware of the risks of vicarious liability P28

could well cost you thousands

increase if the pound continued to fall against other currencies.

But he foresaw little impact on embassy work, as they would continue to use the UK-based medical expertise.

He thought the UK self-pay market would continue to grow as it has done recently unless there was significant NHS investment.

NHS private patient units (PPU) expert Philip Housden said: ‘This will take years to work through and life and business needs to go on.

‘Therefore, the outlook for private healthcare provision contin-

ues to be cautiously optimistic, including for NHS PPUs.

‘Despite general market uncertainty, international and domestic trade will continue largely unaffected – although some investment decisions may be postponed.

‘So, in that climate, will individuals and companies renew PMI and will we see a hit to self-pay growth? Personally, I doubt it, as the PMI market has pretty much reduced to a core already following the recession, and self-pay is more likely to respond to NHS pressures than macro-economic ones.’

➱ continued on page 6

RETAINING THE CROWN: HCA Healthcare UK was named Private Hospital Group of the Year at the HealthInvestor Awards 2016, repeating its success of 2015.

(left), and the company’s chief operating officer Andrew Gore, collected the gong at a ceremony at London’s Grosvenor House Hotel. See page 3

John Reay, London Bridge Hospital chief executive

In this issue

July-August 2016

10 things you’re not doing right ur resident accountant outlines the ten business clangers you should avoid P12

Personality goes a long way deas to overcome your stifling training and inject some life into your website P16

Beware the black hole for money private doctors continue to lose money, so an expert shows how to stop the rot P21

You can get the staff our series looking at private patient units shows how to improve staffing P32

What to do before you exit our regular financial advisers demonstrate the importance of making a will P36

Freedoms of incorporation

accountant Vanessa sanders outlines the benefits of becoming a company P38

PlUS oUr regUlar colUmnS

Doctor on the Road: VW tiguan P40 starting a private practice: setting up a payroll P42

Profits Focus: general surgeons P44

editorial comment

What EU opt-out means

The private healthcare sector was as shocked as everyone else at the Brexit referendum result.

Feedback at Private Healthcare UK’s Private Healthcare Summit 2016 two days earlier indicated a big majority in the industry were voting to stay in – and expected we would.

Since the vote, the nation has been whisked through this foul summer into the great unknown on a daily rollercoaster of political upheaval and various degrees of financial optimism and pessimism.

In this issue, we’ve gone to some key figures to ask them what they think the effect

could be on private healthcare and, particularly, you as independent practitioners.

For those practising in central London, as the analysis by Stanbridge Associates for Independent Practitioner Today on our front page indicates, the impact could be greater than most.

But for everyone, Brexit and its possible implications provide an opportunity to look again at their practice and perhaps reflect on the words of the Independent Doctors Federation’s Dr Brian O’Connor on page 6: ‘Mediocre and poorquality care providers will disappear from the market’.

tell US YoUr neWS Editorial director Robin Stride at robin@ip-today.co.uk

What action to take after result

By leslie Berry

Independent Practitioner Today readers have been urged to ensure their finances are fit for purpose following the results of the EU referendum.

But Simon Bruce, managing director of specialist financial planners Caven dish Med ical, warned senior doctors against knee ­ jerk reactions.

He said there was much media speculation about what will happen to the economy now the UK has voted for Brexit.

outcome of the vote because of the non­UK assets held.

This was a good example of diversification in practice.

‘One key issue is not to make knee ­ jerk reactions because of media reports or well ­ meaning advice from friends or family.

Simon Bruce

‘While we do not know what will happen to taxes, interest rates or inflation – and those in positions of power appear to know little more than the rest of us – we can ensure that our investments are suitably battle­ready.’

Mr Bruce said doctor investors should see that their portfolios were able to withstand whatever eventuality was presented.

And he advised that they should ensure their portfolio was ‘sufficiently globally diversified to mitigate any falls to the UK market’.

He told Independent Practitioner Today that many of his firm’s doctor clients’ portfolios rose in value in the days directly following the

‘The emotional investor who attempts to outsmart the market will often cause more harm to their finances than the markets.’ Cash savers have been warned that inertia is one of their biggest risks. Anna Bowes, director at independent savings adviser Savingschampion.co.uk, said according to a Financial Conduct Authority cash market study, 80% of easy access accounts have not been switched in the last three years.

She warned: ‘The longer you hold your account, the more likely you are to see the rate reduce and, as a result, some savers will be sitting in accounts paying as little as 0.01%.

‘By not managing your cash properly, you are playing into the hands of the banks or building societies. You have to think of cash as not just a place to hold money and keep it safe, but to keep it active; to earn as much interest as possible.’

FIPO launches earnings poll

any changes to patient welfare and choice’.

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

Consultants are being asked by the Federation of Independent Practitioner Organisations (FIPO) to take part in an earnings survey looking at their practice’s profits over the last three years.

Doctors can access it at www. surveymonkey.co.uk/r/FIPO2016.

The group said it wanted to update an earlier analysis of the economics of private practice ‘and

Consultants, who have been promised confidentiality, are being asked to reveal their annual pre­tax private practice earnings broken down, where applicable, into private clinical work, NHS referred work, medico­legal work and private managerial healthcare work.

New London clinic offers salary jobs

By robin Stride

Private consultants are being offered a salaried option by a German hospital group which is opening its first overseas facility at 66 Wigmore Street, London, in the second half of 2017.

Family ­ owned Schoen Clinic London told Independent Practitioner Today that specialists could opt between full­time salaried employment or work independently.

A spokesman said: ‘Throughout our conversations, we see there is a demand for salaried positions and are optimistic to employ a substantial amount of consultants directly after a period of adjustment to the central London market.’

The move by some operators to directly employ private consultants has been viewed as a threat to their independence by some senior doctors within the Independent Doctors Federation.

But bosses at the German group argue the salaried model ‘enhances work conditions for consultants by providing stability in their daily work, which will eventually result in better patient outcomes’.

And they say the option provides a chance for younger consultants to enter the private healthcare market in central London.

The new building, costs undisclosed, will have 35 inpatient and ten day­care beds, three operating theatres and deluxe rooms with attached roof­top terraces.

Schön Klinik, a pioneer in the use of outcome measurements in medicine, operates 17 hospitals in Germany with 9,200 employees and focuses on neurology, orthopaedics and mental health.

It said it would offer an integrated and multidisciplinary approach for treating back pain patients, pre­

servative and surgical treatments, post­operative outpatient rehabilitation, follow­up care and a range of orthopaedic procedures including joint replacements.

The operator said a ‘comprehensive quality measurement system with a wide range of different quality indicators’ would be used to ensure a high level of patient outcome and satisfaction.

 So would you like a salaried private consultant job? Email robin@ip-today.co.uk

HCA retains top hospital accolade

HCA Healthcare UK was named Private Hospital Group of the Year at the HealthInvestor Awards 2016.

Fighting off stiff competition from seven others, the world’s largest private hospital group was recognised for its commitment to enhancing quality of care for patients and driving continuous innovation.

Judges were impressed by the group’s £50m investment in specialist equipment as well as new facility openings:

 The Shard in London, which offers the latest medical technology, a personalised approach and an extensive range of outpatient specialties;

 The Manchester Institute of Health & Performance (MIHP), which is a world­class centre for treatment, diagnosis and research in health, delivering programmes for the local community as well as supporting elite athletes.

The group said new investments reflected the move towards providing access to the best consultants, care and services in an outpatient setting, as people increasingly opted for wide­ranging treatments and flexible ways to pay, including self­pay.

The award follows HCA being named International Cancer Centre of the Year by the International Medical Tourism Journal

‘will aid cosmetic surgery’

Brexit could help safeguard patients from cosmetic cowboys, according to a British Association of Aesthetic Plastic Surgeons (BAAPS) council member.

But he believed being free to set our own regulation and training standards would force businesses to employ surgeons who were trained to a UK­defined standard and abided by codes of practice stipulated by their UK­based associations and indemnity schemes.

‘These surgeons will force the clinics to up their game with respect to standards of care, which

Consultant plastic surgeon Mr Paul Harris said ‘fly in, fly out’ mainland Europe surgeons undercut UK ­ trained specialists and were not usually the most reputable in their resident country. They were often forced to work to time constraints and standards set to achieve maximum profit rather than high­quality patient care.

will not only benefit patients but also all the professionals that work within the sector.’

BAAPS president Mr Michael Cadier said the economy and financial implications were impossible to call. ‘A drop in sterling will make surgery overseas less attractive and if we have a decline in our economy, there may be price drops in the UK. But then the Eurozone may fail and costs overseas will fall,’ he said.

BAAPS member Mr Naveen Cavale said his main concern was for the future generation of aesthetic surgeons in the UK. They would have to live with the Brexit vote consequences.

‘As a specialty association, we must therefore ensure that Brexit does not ignore the views and desires of the next generation of aesthetic surgeons. We must protect and serve them, first and foremost.’

artist views of the new Schön clinic in london’s Wigmore Street, due to open next year

The private sector aims to help NHS

By Robin Stride

Private hospitals are stepping up their challenge to get NHS bosses to make greater use of the independent sector’s expertise through more collaborative ventures.

The Association of Independent Healthcare Organisations (AIHO) has announced private healthcare is ready and able to take on an increasingly more active role in easing pressure on NHS front-line services and investing in the health service’s infrastructure.

Chief executive Fiona Booth said, given the right conditions, the independent sector could play

a huge part in being the ‘saviour of the NHS’.

She told delegates at The Private Healthcare Summit 2016 in London that the UK independent hospital sector had significant additional capacity which could help cut waiting times and provide more patient choice.

Ms Booth said: ‘Although the independent sector often works alongside the public sector, there is so much more that can be done.

‘This is why AIHO is consistently taking this message to Government and MPs and outlining the benefits of a partnership beyond just providing services in peak times.

‘Policy-makers and local decision-makers should develop a strategic vision which effectively utilises the capacity and capability of the independent hospitals.’

She highlighted the sector’s ‘hugely innovative’ characteristics, not just in developing treatments but in finding new and efficient ways of working that made best use of resources.

Addressing an audience that included consultants, NHS private patient unit managers, hospital operators and insurers, Ms Booth said the independent sector had much experience and expertise to share.

She also drew their attention to comments last month from George Freeman, the Life Sciences Minister, who had called for an end to the ‘apartheid’ between the NHS and the private sector – both in the funding and the provision of health and care services. He argued for a ‘deep partnership between the private and public sector’.

How sector will show value

AIHO aims to fly the flag for private healthcare by developing a hub of case studies and practical examples of innovation which will include:

 Clinical research and development;

 Direct improvements to patient care;

 Increasing customer satisfaction;

 Increasing productivity;

 Improving environments;

 Raising employee motivation/ satisfaction;

 Technological advancements;

 Developing systems to improve organisational culture.

Ms Booth said: ‘We plan for this to be accessible both to internal and external audiences. For our members, these case studies will showcase the innovative work we undertake, stimulating discussion and best practice across the entire healthcare sector.

‘It will also be used in our work with stakeholders across Government, as well as with regulators such as the Care Quality Commission (CQC) and NHS Improvement.’

AIHO has also been actively involved in work to create ‘a reformed and incentivised insurance market’.

She added: ‘Personally, I have been really heartened by the collegiate nature of the discussions so far. Providers, insurers and consultants must be co-ordinated in setting out a clear, accessible and affordable health and well-being offer to individuals and employers.

‘Though there is still some way to go, I am confident that, by working together in this way, we will, in time, be able to present a recognised alternative route to healthcare in the UK.

‘I know that the high-quality,

personalised service provided by our industry can help improve significantly more people’s health than it does currently. In turn, this will help more businesses boost productivity.’

She told the summit, organised by Private Healthcare UK, that AIHO’s work over the last year with the CQC was an excellent example of what could be achieved by working together.

‘Through regular meetings, seminars and information-sharing, our relationship with the CQC has been vital in enabling independent healthcare inspectors to better understand acute independent hospitals and how they differ from NHS trusts.

‘Equally, the CQC has been able to explain to our members, big and small, what hospitals must do to provide excellent patient care and how we can demonstrate this to them.’

JOINT ENTERPRISE

AIHO has commissioned a health economics firm to explore the benefits of the independent sector delivering hip and knee surgery in the UK.

The report, due for publication later this year, estimates the annual economic value of this to be between £540m-£692m, AIHO chief executive Fiona Booth told the meeting.

She said: ‘This is achieved through the reduction of sick days and the knock-on impact of business productivity. I am really encouraged by these findings.

‘I believe they will help to give the sector greater confidence to talk openly about the patient care we provide on a daily basis. This care supports the nation’s health, the nation’s economy and the NHS.’

Fiona Booth, chief executive of AIHO

Health insurance taxes predicted to increase again

Recent rises in insurance premium tax, which have made it more expensive for patients and employers to buy private medical cover, may not be the last.

According to James Parker, the chief executive of mutual friendly society CS Healthcare, only a brave person would bet against the tax going up yet again.

The tax increased by 58% to 9.5% following last November’s Budget and will go up to 10% later this year.

Talking on why the private medical insurance sector needs to change, he said it should stop ‘obsessing about price’ and to focus on the benefits that cover brought to people. And it should not be shy about what it offered.

Four ‘pluses’ it should promote were speed, access, quality and choice – advantages that patients did not get in the NHS.

He told the audience their goal should be to bring more young people into the market and get people thinking about their health and how they make provision for it in the same way as long-term saving.

Mr Parker claimed: ‘As an industry, we are almost apologetic about what we can offer.’ This was in complete contrast to the US where they talked ‘loud and proud’ about what they could do.

It needed to show how private care could transform people’s lives and it was time to be more bullish, because private healthcare had an increasing role to play, he added.

Responding to an audience question, he agreed there was an opportunity for a broader range of products in the private medical insurance market.

Currently, there was a lack of innovation, he said.

AIHO’s new chairman plans to expand body

The new chairman of the Association of Independent Healthcare Organisations (AIHO) aims to see the body showcasing the sector’s ‘impressive and essential contribution to the UK’s health economy, to the NHS and to patients’.

Des Shiels, chief executive of Aspen Healthcare, said his hospital group had benefited considerably from AIHO membership and he hoped the growing number of smaller specialist centres could too.

He said: ‘With an increasingly diverse membership of large hospital providers to smaller specialist centres of excellence, it is really important that the wider sector is

strongly represented to external audiences.’

Mr Shiels takes over after a three-year stint from former Spire Healthcare boss Rob Roger.

AIHO chief executive Fiona Booth said: ‘I am really looking forward to continuing to work with Des in his new role as chairman. As the trade association for independent hospitals, AIHO plays an important role in representing the sector to regulators, policymakers and in the media.

‘The wealth and breadth of his expertise in independent healthcare will be hugely beneficial for AIHO’s continued growth and success as the voice of the sector.’

Business is ‘set to boom’

The boss of the UK’s largest hospital group has painted an upbeat picture for the future of private healthcare and doctors working in it.

Jill Watts, chief executive of BMI Healthcare, predicted that private hospitals ten years from now would be busier, more efficient and delivering a wider range of services.

And she expected the sector would enjoy significant investment the like of which had not been seen for many years.

Ms Watts told the Private Healthcare Summit 2016, held two days before the Brexit referendum: ‘The key is all the players working together and taking responsibility to shape the service.’

She observed it was interesting to see the mixed model that had been emerging, with the main driver of growth across the private hospital sector coming from NHS outsourcing.

This growing demand had been driven by capacity and financial pressures within the NHS and the service was clearly failing.

But, unfortunately, the debate over the benefits of opening up the NHS to a greater diversity of providers had become riddled with scaremongering and confusion, she said.

Even in the unlikely case that private provision of NHS doubled over the next five years it would still only equate to 10% of the budget.

Ms Watts believed the time was rapidly approaching when the Government needed to determine what was essential care, and part of core NHS services, and what was not.

The private sector had much to offer and needed to present solutions that took away pressure

from the NHS. And it needed to better position itself to governments as being complementary to the NHS, not in competition with it.

Turning to private medical insurance, she forecasted it would become more popular and more patients would be able to top up their cover.

The hospital group boss said insurers believed it was all about price, but while this might be a part of the solution, the real issue was the scope of the product on offer. The scope was too narrow, becoming narrower, and did not meet people’s needs.

She said the private healthcare sector should work with insurers to widen and broaden the range of products. There had never been a better time for insurers, hospitals and consultants to come together to actively shape the future.

Ms Watts warned that the independent sector was seeing demand for a rapid move into the digital world and the care delivery model needed to embrace new technology available through mobile devices and apps. ‘It is emerging – but we are still a long way behind.’

The market was changing with new entrants coming in, but she saw competition as healthy ‘because it is going to make us all lift our game’.

Jill Watts, boss of BMI Healthcare

What will mean What could cost

By Dr Brian

The fall-out of Britain leaving the EU is difficult to predict in the context of private healthcare provision and delivery of independent medical practice.

The last economic crisis in 2008 did not hugely impact on the private healthcare market within London. Market conditions were different then, however.

There was not any major pressure from the private medical insurance companies to cost contain; from recollection, their customer base was higher than currently.

tals have evolved to provide centres of excellence across various specialties not often available to the overseas patient.

Equally, the Harley Street area has gone through a period of regeneration and many different consultant-led groups and clinics have been established across London to provide world-class facilities for leading-edge care.

be sustainable, but only for those private healthcare stakeholders providing quality care.

The impact of Brexit on private care and privately contracted NHS work outside of the capital is more problematic. If we are to believe the gloomy predictions of reduction in tax income and a fall in economic growth to near recessionary levels, then PMI subscribers will reduce. Funding for the NHS is bound to diminish.

➱ Continued from front page

Market commentator Keith Pollard, chief executive at Intuition Communication Ltd, said the referendum results brought more uncertainty to what was already a time of change in the private healthcare sector.

Equally, the self-pay market had not yet developed and represented less of a percentage of the total market when compared to 2016.

Indeed, since 2006, the London private hospital market has grown by more than 7%. A lot of the growth in revenue can be accounted for by the overseas markets, particularly patients from the Middle-East.

London retains its position as one of the leading major cities in the world to deliver complex care. In the last decade, private hospi-

Therefore, within London, my view is that the impact of Brexit will be minimal for those specialists, clinics and providers who continue to deliver top-class verifiable and transparent complex care.

It is difficult to predict the impact of this new situation on PMI subscribers. If there is a ‘flight of capital’ out of London, some of the major City banks and institutions may reduce their workforce and this will lead to an inevitable reduction in the PMI market.

Nonetheless, London continues to be home to some of the wealthiest individuals on the planet and I suspect the self-pay market will

The private healthcare market in London will not only survive but will thrive and those who provide excellent self-care will flourish regardless of Brexit.

A fall in the value of sterling will encourage more overseas visitors, which will offset any possible PMI leakage. Patients and health users are already more savvy than ever before. Somewhat harsher economic conditions will accelerate the inevitable disappearance of poor-quality health provision.

Outside of London, after a period of turbulence, I suspect the market will equilibrate, but may fall in parallel with changing economic circumstances.

Scrips via practice’s system

Private consultants are testing a new facility this summer enabling them to send out private prescriptions from their practice management system.

A four-week pilot will be followed in September by a roll-out of the enhancement to the 6,000 claimed users of the DGL Practice Manager system.

The facility has been launched following a new partnership between technology and services company Clanwilliam Group and ‘everyone’s local pharmacy’ Pharmacierge .

Prescriptions from consultants and GPs are received by Pharmacierge and it then provides free delivery of the medication to patients ‘within two to four hours’ to all London postcodes.

Outside London, it offers a free overnight delivery service to patients and also international delivery options.

Clanwilliam said the partnership would enable private consultants and GPs who use its DGL Practice Manager product to access the delivery service directly

through their existing system.

Kingsley Hollis, its head of practice management (UK), said the development would help independent practitioners offer ‘a superb service to their patients’.

‘With discreet, confidential and secure delivery – medication is only released upon signed authority –Pharmacierge offers a reliable service which we are pleased to bring to our existing customer base.’

Leon Ungar, pharmacist director of Pharmacierge, added: ‘This is a logical partnership which will make it simple for private consultants to access our service.

‘Patients appreciate the care and convenience we offer through our next generation service, which takes account of the busy lives people are increasingly leading.’

‘Private hospitals will be concerned that the resulting economic chaos will put further pressure on the NHS and threaten their NHS-funded business. And consultants will be worrying about their pension funds.

‘Would it be likely we get more patients from abroad? The pound’s decline will deliver some price advantages for the UK, but I don’t see any significant stimulus for inbound patient flows.’

Fiona Booth, chief executive at the Association of Independent Healthcare Organisations, said the NHS’s funding settlement for the remainder of the Parliament, based on continued economic growth, could be called into question.

‘The financial pressure the NHS has faced over the past few years could well intensify.

‘This means we must continue to partner with the NHS, providing high-quality care that helps to reduce waiting times and alleviate pressure on front-line services.

‘Over the coming months, AIHO will be carefully monitoring negotiations between Britain and the EU, particularly in relation to freedom of movement. Like the NHS, independent hospitals rely on motivated staff from EU nations to provide fantastic care to patients and we hope Britain’s role outside of the union will still enable this.’

Matt James, chief executive at the Private Healthcare Information Network, said: ‘There are areas of medium-term uncertainty; for example, whether and how the General Data Protection Regulations will now be brought into force, and even whether Scotland and Northern Ireland will still be part of the UK. But we will be in a good position to monitor the impact on the private healthcare market.’

Leon Ungar of Pharmacierge and Kingsley Hollis of Clanwilliam Group

O’Connor, chairman of the Independent Doctors Federation’s specialists committee

More ill doctors referred

By Edie Bourne

Growing number of doctors are subject to complaints or fitness-topractise proceedings relating to mistakes or actions as a result of their health problems, a defence body has revealed.

The Medical and Dental Defence Union of Scotland (MDDUS) said it welcomed GMC proposals to make the fitness-to-practise process more sensitive to the needs of vulnerable doctors.

The union is backing a Royal Medical Benevolent Fund’s (RMBF) campaign to raise awareness and help doctors with physical and mental health problems.

NHS unit moves into Harley Street

MDDUS medical division joint head Dr John Holden said doctors were renowned for being resilient and a rise in the volume and complexity of workload meant their job had never been more demanding.

‘While doctors are caring for patients, they can sometimes neglect to care for themselves. From our experience, seeking help early can make all the difference for those who face these problems.

‘Mental health issues can come in many guises – from anxiety, irritability and fatigue to depression, emotional exhaustion and withdrawal. Burnout or stress can affect a doctor’s judgement, concentration and productivity – all

Royal Brompton and Harefield Hospital Specialist Care Outpatients and Diagnostics is due to open this month at 77 Wimpole Street pending inspection from the Care Quality Commission. The service will support the NHS trust’s growing private care offering for heart and lung patients. Featuring eight consulting rooms and extensive diagnostic services, the new facility will bring the world-renowned expertise of Royal Brompton and Harefield Hospitals into the Harley Street medical area – the first NHS specialist trust to open a private facility there. The unit hosts the only PET scanner providing Rubidium imaging in London (faster imaging protocol and less radiation burden to patients undertaking cardiac assessment) and is only the second for the UK.

of which can lead to mistakes in dealing with patient care.’

He said doctors speaking to a colleague or their GP about these issues should not be seen as a sign of weakness.

‘Doctors who are concerned about a colleague’s well-being are advised to be sensitive and encourage them to seek help.’

A recent survey by the RMBF found over 80% of doctors know of others experiencing mental health issues such as depression and anxiety.

The survey also revealed 84% cent of doctors are unlikely to reach out for fear of discrimination or stigma from colleagues.

As part of its campaign ‘What’s Up Doc?’, the RMBF has developed a free online guide for doctors called The Vital Signs, which highlights common stressful trigger points for doctors, as well as signposting help and advice.

RMBF chief executive Steve Crone said: ‘I would urge any doctor in difficulty to reach out – no one should feel too proud or ashamed to ask for help.

‘Every year, the RMBF supports hundreds of doctors and their families who are struggling with financial concerns, ill health or addiction. We would like even more people to know we are here to offer confidential help.’

‘GP at Home’ upgraded

Harley Street GPs Dr Justine Setchell and Dr Fiona Payne have moved their virtual consultation service, GP at Home, to nearby King Edward VII’s Hospital.

The hospital said the service differs from recent trials of similar services involving Skype because of the built-in security and additional features which allow for file sharing and for prescriptions to be sent by courier.

The service also allows for unlimited consultations 365 days a year, from 7am to 7pm.

Drs Setchell and Payne developed the service to allow their

patients greater flexibility and convenience while ensuring that they would always be seen by their familiar GP.

This has been useful for patients who are full-time professionals or living outside of London. For those patients able to visit King Edward VII’s Hospital, they also have access to screening, vaccinations, imaging and diagnostic tests.

Dr Setchell said: ‘This service allows us to see our patients anywhere in the world at their convenience while maintaining the personal touch that is central to our practice.’

Proton centres aim to be UK network

Proton Partners International will deliver a cancer network for the UK to improve treatment, care, survival and research, according to its chief executive Mike Moran.

Speaking at the International Festival for Business 2016 in Liverpool, he discussed the company’s progress in bringing three proton beam therapy centres to the UK and the importance of making the treatment more available for patients.

There are currently no operational high-energy proton beam therapy facilities in the UK. However, Proton Partners are building new centres in Newport, Wales, Northumberland and London.

Mr Moran said the demand for proton beam therapy was rising and at least 10% of patients who receive traditional radiotherapy would be treated more effectively with protons. He added: ‘Our centres will provide an all-encompass-

ing cancer service for patients, offering proton beam therapy, as well as chemotherapy, traditional radiotherapy and imaging.

‘We’re confident that our three centres will deliver world-class treatment, but the key for us is to network all of our centres together.

‘Building on the UK’s reputation for clinical excellence, our aim is to create an eco-system, drawing on the data we gather from each centre, to deliver greater outcomes

for patients and advance proton beam therapy technology. We think it’s important that this should be done from a patient’s perspective, rather than a manufacturer’s perspective.’

John Pettingell, the company’s head of physics, said: ‘The very latest technology in radiation therapy means that the likelihood of damaging or long-term sideeffects for patients is hugely decreased.’

Try changing consultation styles

The paT ien T who seeks treatment in the private sector can sometimes be very demanding and challenging.

in these situations, you might need to think about changing your consultation style. i have found using the health coaching approach in consultations is an excellent way to support decisionmaking.

The coaching methodology was first used in the post-war period in the sports industry and this has now transferred into business and performance coaching.

These concepts are now used in healthcare too, focusing on individuals to provide insight and awareness of health goals and increasing patient responsibility for managing their own health

By

• Completely open scanner that is well tolerated by claustrophobic patients

• Weight-bearing scans for spine and joints enable a more precise diagnosis

• Patients who are large or cannot lie down can be accommodated

rather than to find solutions directly.

it is a skill that involves:

n active listening; n appropriate questioning techniques;

n Support for decision-making without direct guidance other than trying to find solutions.

patient-centred approach

h ealth coaching moves us to a more patient-centred approach, empowering patients to take responsibility for their care through exploring their goals, looking at the options available to them and reflecting on the consequences of their options.

The three elements that a doctor can offer to support health improvements using a coaching style is through:

n health expertise/knowledge; n h ealth advice/recommendation;

n Behavioural change interventions.

a good health coaching conversation hinges on the belief that the patient has the potential to solve their own problems contrary to the traditional approach where the doctor is the problemsolving expert.

The health coaching style encompasses a continuum approach and uses tools to raise a

a good health coaching conversation hinges on the belief that the patient has the potential to solve their own problems contrary to the traditional approach where the doctor is the problem-solving expert

patient’s awareness of their health issues and increase their personal responsibility for solving them. There are a number of health coaching models and tools developed to support health professionals.

The iGROW model, developed and promoted by Sir John Whitmore, is the most widely known and validated. This model can be used in a ten-minute consultation with appropriate training and practice by being clear, concise and positive as you introduce the coaching conversation.

The iGRoW coaching model

I – What is the issue?

G oal – What do you want to change/achieve from this consultation?

Reality – What is happening now? Tell me about the current situation;

Options – What could you do differently? What might get in the way?

W ay forward – h ow committed are you?

i ndependent practitioners of today have to be versatile and adaptable to different consultation styles and the coaching style consultation is one to embrace. if you have not done so already, i recommend you seek out a training course or read more about it. n

ms Beryl de souza, Plastic surgeon, associate postgraduate tutor for Central North West london, and honorary secretary of the medical Women’s Federation

PRACTiCeS MAde PeRFeCT

Are you really doing the job you do best? That you enjoy most?

For 18 years we’ve helped large and small healthcare organisations across the world transform, grow, and improve the way they manage their businesses. Making your life better. And your patients.

While you concentrate on caring for your patients, our role is to help remove the yoke of management.

Not just the day-to-day logistics, but strategically, short and long term. Over the years we’ve transformed and grown countless practices and business. Planning and developing medical facilities. Marketing your healthcare services professionally, by knowing and employing the technology and media that deliver results.

Our teams are tailored to your needs. And if those needs change, so does our team. We have crisis management experts available 24 x 7. We combine clinical expertise with commercial sense and experience. We see the full picture, providing support when and where you need it most.

We work with both public and private sector healthcare providers. Our case histories in operations management, clinical advice, consultancy and development are outstanding.

To give it a thorough examination, call Peter Goddard on +44 (0)203 356 9699 or mobile +44 (0)780 314 4954

www.worldwidehealthcare.co.uk

Charles Rifkind Property

Neil Huband Communications

Peter Goddard Performance

Keith Hague CEO

Howard Ware Medical

Dr.Danny McGuigan Leadership

Scott Hague Technology

Help us form plan for private care

The Independen T d octors Federation (IdF) was established some 27 years ago by a group of like-minded doctors who worked full-time in the independent sector.

They were conscious of the need and benefits of establishing a forum to exchange ideas and have meaningful discussion about their practice in the private sector and establishing a means of support for each other.

The ‘forum’ became the ‘federation’ in 2009 to more aptly describe the evolving role of the IdF.

n ow the I d F exists as a membership organisation to promote excellence in the independent medical sector and is the voice for independent doctors, both specialists and Gps.

Its continued success and growth, as for any top organisation, is its ability to recognise and institute change to ensure it remains relevant to its membership.

The I d F has been particularly fortunate to secure a succession of conscientious chairmen who have steered it through the many changes in the development of independent medicine and the effects of the changes of regulation in the management of healthcare in the UK.

And now the IdF is again challenging itself to review its administrative organisation, its services for members and its overall role as a voice for independent doctors in healthcare.

Sue SmIth Interim chief executive, Independent Doctors Federation

This is a time for action and, as the recently appointed interim chief executive, my immediate role is to work and support the current executive in developing a strategy that will include demonstrable and tangible initiatives for the many stakeholders that we represent.

Best-kept secret

I will be ensuring that the IdF is no longer the best-kept secret in town but the organisation of choice for doctors who aspire to make a positive contribution to their future.

I am very keen to hear from members and non-members alike as to suggestions for innovative and sustainable services that are value-added

members but, for many, all of the available activities play an important role.

As different barriers emerge for doctors practising in the independent sector, there are potentially other and possibly more critical services that should be available.

My review will look at this in some detail and I am very keen to hear from members and nonmembers alike as to suggestions for innovative and sustainable services that are value-added.

Younger doctors

I am particularly interested in seeing our younger doctors involving themselves in their own future and helping to shape debate and engagement.

There are currently more than 1,200 members of the I d F, with an increasing geographical spread across the UK.

This is partly driven by the appraisal and revalidation service that is provided and also by an increasing desire to have the opportunity to engage in meaningful dialogue with the regulators, the insurers and other key agencies that impact on the daily life of independent practitioners.

To shape and implement a proactive strategy, the voice and views of our current membership is critical.

I have been and continue to meet with as many grass-root members as I can to ensure that views of consultants and G p s, across specialties, younger and older doctors and those doctors who practise outside of London can all be taken into account.

The I d F offers an important opportunity to doctors to discuss the many issues that they face in the administration of their practices and that access to others facing similar issues can produce workable solutions.

The parallel activities of education and networking as well as the appraisal and revalidation service have different significance to

Regulation of healthcare delivery and changes to professional freedom will continue and it is imperative that a vibrant and committed membership of the I d F is proactive in these discussions. doctors must be at the centre of these important talks.

We also have the opportunity to work with doctors and the medical profession as a whole to strengthen trust in the profession. This is part of the bigger picture of working together and strengthening the image of independent practice and its practitioners.

As we look at current and impending issues, a collaborative approach will reap dividends not only for our members but also for our members patients.

The IdF can continue to achieve its vision of excellence in healthcare as we initiate dialogue with all stakeholders and recognise that quality is the remit of all of us.

I have had the privilege of working in healthcare delivery my entire career, both at the sharp end and also in executive positions.

I am excited about the future potential for the IdF and its ability to support doctors, enable them to be involved in decisionmaking about their careers and strengthen their identity with key stakeholders. n

10 things you’re not doing right

Most business do not get it right all the time. But doctors, generally without the business training enjoyed by many other entrepreneurs, are prone to some costly howlers.

We asked accountant Susan Hutter to help independent practitioners improve their businesses by highlighting the top ten clangers to avoid

1Fee invoices are not sent out quickly enough.

They should be raised immediately after the work is done, either to the insurance company, if applicable, or to the patient if he or patient is self-paying or to the patient’s employer, if they are paying.

Some doctors have taken this on board and now issue invoices to self-payers for consultations there and then, and ask for payment.

I know that many specialists do not like this method – however, it is becoming more common and is worth considering.

2

Raising the invoice is one thing – but collecting the debts is another.

Many consultants behave like a deer in the headlights when it comes to collecting the money in.

Getting the support staff to phone the patient is often a good

Many consultants behave like a deer in the headlights when it comes to collecting the money in

way forward. Also, when dealing with large organisations such as foreign embassies, establish at the outset who the contact will be for making payment.

If the payer is habitually late, then in future demand at least 50% of the fee up-front.

3

Carrying out further work for those who have not paid for ‘old’ work is a common error.

If self-paying patients, whether an individual, a corporate entity or embassy, have not paid the previous bill, then do not do any more work.

4

Not updating your banking records. Many consultants are now trading as limited companies. It is imperative that the insurance companies are advised immediately of the change in circumstances so that they pay the money into the correct bank account.

Sometimes this goes unnoticed for ages and the money is accruing in the old practice bank account.

5

Many consultants do not keep practice records, on a regular basis.

The result is that there is a huge rush at the year end in order to provide information to the accountants.

Missing deadlines can be expensive, so it’s worth a little investment of time each month. It will be worth it!

6

The practice records are one thing, but to keep up to date, consultants must also send their personal tax return details to their accountants in time.

Many do not. Apart from latefiling penalties, it also makes it difficult for the accountant to advise on the tax planning strategy for the business.

7

For consultants who trade as limited companies, many make the mistake of taking too much out of their firms – they withdraw over and above their income needs.

There is no point in doing this for higher-rate taxpayers, which most consultants are, as they will have to pay income tax on the money they draw, usually as a

For consultants who trade as limited companies, many make the mistake of taking too much out of their firms –they withdraw over and above their income needs

dividend, which is at a much higher rate than the corporation tax paid by a company.

8

Some consultants ‘miss out’ by not paying salaries to family members including children over the age of 16 and spouses who do legitimate work for the practice.

Many consultants have bright children who assist with the administration of the practice –for example, using their IT skills, which are often better than their parents’ – and do not get paid.

But if the children have no other income or are basic-rate taxpayers, it is sensible to pay them for the work done under a pay-asyou-earn (PAYE) scheme otherwise their personal allowances, currently £11,000 a year, will go to waste.

As long as the salary is commensurate with the work carried out, then it is tax-deductible in the practice accounts.

9

Some consultants pay secretaries as freelancers. Unless they genuinely are freelancers –for example, they work for more than one consultant and prepare their own tax returns – HM Revenue and Customs could challenge this and demand back tax and National Insurance.

On top of that, the tax inspectors would seek to gross up the actual amount paid to the secretary and charge tax and National Insurance on the gross amount.

This is very expensive in tax terms for obvious reasons. Therefore, before taking on a secretary and allowing them to be freelance, consultants should take advice.

10

Often consultants do not capitalise on available space in the practice premises.

Many consultants could bring other specialties into their practices – for example, physiotherapists working with orthopaedic consultants – to not only offer a better service for patients, but also to maximise income. 

Susan Hutter (right) is a partner with accountants

Shelley Stock Hutter

combATTing FRAUd

Fraudsters are finding new methods to target medical practices,

as Independent Practitioner Today revealed

Crompton

last month. Ian

highlights what they are doing – and shows how you can fight back

As with many other sectors, medical practices need to maintain a high level of vigilance in order to spot fraudsters who continue to develop new, increasingly sophisticated tactics to steal their funds.

this is particularly the case with cyber fraud attacks where criminals can easily hide their identity from unsuspecting victims.

Ransomware and cyber extortion are both relatively recent types of fraud seen targeting medical practices.

Ransomware

Ransomware is a type of malicious software, known as malware, which blocks or restricts access to the infected computer system.

Fraudsters usually infect a victim’s PC by encrypting files on the system’s hard drive and then threatening that the user will not be able to access their data again unless a ransom is paid.

the files will be almost impossible to decrypt without paying the ransom for the encryption key and this forces many victims into paying the ransom to the fraudster, usually in bitcoins which are difficult to trace.

cyber extortion

Cyber extortion is a crime which occurs when a fraudster issues a threat and demand via online methods to a potential victim.

As with ransomware, the demand is usually aimed at forcing a payment to the fraudster in bitcoins or they will carry out their threat.

t hreats can vary, but may include fraudsters leaking confidential data obtained from the victim’s PC out on to the internet, or they could threaten to post thousands of negative comments about the victim’s business using online review sites, causing reputational damage.

MOST IMPOrTanT

 never divulge online banking passwords or online banking secure codes to anyone on the phone, even if you think you are talking to the bank

 Do not rely on your phone’s caller display to identify a caller. Fraudsters can make your phone’s incoming display show a genuine number

 Be aware that a bank will never call you and tell you to transfer your money to a ‘safe’ account

 If you see unusual screens or pop-up boxes when using your online banking or unusual requests to enter bank passwords, log out immediately and call your bank

 If possible, set up your online banking so that two separate people are required to make any payments

Medical practices should protect themselves against these types of fraud by:

☞ Ensuring they have a good quality anti-virus software suite, which is scanned and updated regularly.

☞ Carrying out operating system updates as soon as they become available.

☞ Promoting awareness among practice staff to ensure they think before they click on unknown links.

☞ Considering where their data resides. Ransomware is usually restricted to local hard drives or locally available shared drives.

i nformation assets should therefore be held in at least two totally separated locations, such as a portable hard disk for daily back-ups of important data, and an additional network-attached storage for larger backups.

☞ Retain the original cyber extortion emails, with headers.

Maintain a timeline of the attack, recording all times, type and content of the contact and report it to Action Fraud.

Of course, it is still important to be alert to the other common fraud scams known to target the healthcare sector, including:

invoice fraud

this is where a fraudster sends an email or letter which appears to have been sent by a known supplier to the practice, asking them to make future payments into a new account number.

if the request is not verified to make sure it is genuine, the next payment could go to the fraudster.

cEo fraud

t his is the name given to the scam where fraudsters hack into or imitate the email account of a senior person within the practice and send an email to a member of

practice staff asking for an urgent and often highly confidential payment to be made.

i f the member of staff doesn’t independently verify that the email is genuine, funds will be sent to the account details supplied in the fraudulent email.

All fraud that targets your medical practice, even if you have been able to prevent it, should be reported to www.actionfraud. police.uk.

For more information, visit Lloyds Bank to review our online fraud guidance brochure at: www. lloydsbank.com/assets-businessbanking/pdfs/Lloyds_Bank_ Fraud_Guidance. pdf 

Ian Crompton (pictured right) is UK Head of Healthcare Banking Services at Lloyds Bank

Personality goes a long way PROBLEMS WITH THE TAX MAN?

HMRC tax investigations and disputes create difficult and stressful times.

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

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

‘Here to help. Not to judge.’

A doctor’s training can make your marketing material too stuffy, if you are not careful. Surgeon Mr Dev Lall shares ideas to put your personality into your practice’s shop window

One Of the most common things I am asked to do is to critique consultants’ websites. The subtext, of course, is ‘what changes should I make to get more patients from the internet?’

And one thing I have noticed is that almost every single website I see has the same problem.

In fact, this problem is not only present among websites but almost all marketing efforts that consultants put out there to grow their practices – from pay-perclick adverts to website content to adverts in magazines and newspapers.

The problem could perhaps best be described as ‘being soulless’. You see, people don’t buy anything from companies or organisations. They buy from people.

Specifically, they buy products, services – and, yes, even healthcare – from people they know, like and trust.

Don’t believe me? Here’s a little thought experiment. Imagine you want to buy a new laptop and you wander into a computer shop to

have a look at the one you’re interested in. The assistant who comes over to help you is clearly knowledgeable about the product and computing in general.

Unfortunately, he’s somewhat lacking in his social skills. He clearly looks down on you, thinks the questions you ask about the laptop are bordering on the inane and he makes no effort to explain things in a way you can understand.

In short, his whole demeanour is as if to say: ‘Why so many stupid questions? Do you want the thing or not?’

e ven if the price charged was very competitive, I’m sure most of us would leave the shop in disgust and go elsewhere. We would far rather buy the item at a shop where the assistant was warm, helpful and pleasant, even if that meant paying more for the item.

That’s what I mean when I say that people buy from people. You

Personality

might have gone to the first shop because it was part of a wellknown chain, but you didn’t buy because of the assistant.

Applicable to healthcare

And this principle is certainly applicable when it comes to healthcare. Because invariably when we have a health problem, we are discussing personal and sometimes embarrassing matters. We are talking about things that make us feel vulnerable and uncomfortable, and we all want to do that with someone who can not only help us but makes us feel secure and at ease.

It might sound rather touchyfeely, but that doesn’t make it any

the less true. But what does ‘soulless’ actually mean?

In general, we don’t have to demonstrate our expertise to the public – unless perhaps the patient has had a bad experience consulting with doctors in the past or is looking for a second opinion.

We are fortunate indeed that the prefix ‘Dr’ confers expertise upon us virtually automatically. Patients unquestioningly assume we have expertise.

But the second part of the equation is to make patients feel secure and respected. In my article for this journal last month, I talked about the need to differentiate yourself from your competitor

➱ p18

colleagues, to give patients a reason to choose you over all the other options they have.

And the way you differentiate yourself, apart from adding ‘soul’ into your marketing, is by allowing your personality to come through in your marketing efforts. That’s how you become a person rather than a business in the patients’ mind.

why formality is fatal

I am aware that most consultants reading this will think this is a small and fairly esoteric thing I’m talking about, but it’s actually very powerful.

And I am also aware that most consultants are not at all comfortable writing in anything but their normal formal tones. The thing is, throughout our adult lives, we have been taught to write in a particular way.

We are taught to write formally, ‘professionally’ and dispassion -

ately. To write in the third person. To avoid using emotive words. To use the passive mood (‘the study was conducted’). In short, to depersonalise our writing as much as possible.

n ow, that may be appropriate for scientific writing, but it is not how human beings normally speak to each other. In fact, writing as you would for a journal or grant application is quite literally the ‘kiss of death’ when it comes to getting potential patients to pick up the phone and book that appointment.

how to inject personality into your writing

When it comes to writing copy or content for your website or adverts, the overriding rule is to write like you speak. As simple as that.

Keep it personal by using ‘I’, ‘we’ and ‘you’. Use an informal style and a simple sentence struc-

Writing as you would for a journal or grant application is quite literally the ‘kiss of death’ when it comes to getting potential patients to pick up the phone and book that appointment

The importance of relatable content

Whenever you write for anybody, you’ve got to start by asking yourself what the reader wants to know about. It’s very much like sitting an exam – you’ve got to answer the question – in this case, in the readers’ mind.

ture. Keep it jargon-free as much as possible.

Your content should be readily intelligible to a ten-year-old –since that is the average reading age in the UK. And when it comes to sentence structure, think ‘Sun reader’ rather than ‘Times reader’. Use abbreviations. Generalise if you can, being careful not to mislead.

So now what do you actually write about?

If you don’t do this, you won’t get the marks and so capture the readers’ interest. And if they’re not interested, they’ll stop reading and go and do something else instead.

Clearly, if that happens, your chances of gaining them as a patient have also disappeared into the sunset.

So put yourself in the patients’ shoes before you write. Ask yourself what they would want to know about, and write about that.

A useful guideline is to answer in your copy the ten or 20 questions you are routinely asked about that topic. Also answer the questions

patients should ask you about but seldom do – such as the complications and risks of a given procedure, consequences of leaving the condition untreated and so on.

Always add case studies of how you have helped patients in the past. We’re not talking about rare and wonderful fascinomas that we as clinicians are interested in; we’re talking about real-life, bogstandard stories of how a patient presented with a given problem, how you treated them and helped them return to living a normal life.

In this way, the reader will recognise themselves in the case study you present and will be much more likely to book an appointment to see you. finally, testimonials. Use them liberally wherever you can. This acts as social proof of your abilities – your past patients are effectively endorsing your skills and abilities.

The power of emotions

To maximise your responses, you really do need to stir up emotions in your readers. And this is quite tricky, but not because writing in an emotive way is difficult – far from it.

Scaring people or making them feel good is easy. no, the reason it is tricky is twofold. first, we have been actively trained to avoid writing in an emotional way for many years. The whole point of scientific writing is to write objectively and dispassionately. Yet this hurdle can be overcome with practice and perseverance.

Second, you have to be very careful when writing in an emotive way for fear of overdoing it.

If you reassure a patient too much that their symptoms are unlikely to mean a serious problem – such as a cancer or whatever – they won’t attach enough weight to what you have to say and might not seek advice.

On the other hand, if you scare them witless, then, similarly, many people won’t seek help at all either. They will just go into denial and do nothing.

Another reason to tread carefully is not only the ethics of frightening people but also the regulatory aspect. If the GMC interprets your writing as being misleading, you’ll end up in no end of bother.

So for maximum response, use emotion liberally. But always make sure you can justify what you say. If there is a significant risk that a patient with a given set of symptoms has cancer, say so. But be careful not to give the impression that symptoms are more sinister than they actually are just to encourage a private consultation.

Don’t underestimate the power of images, particularly your own picture. You want to come across as a happy, kind, approachable

person, someone anyone would be happy to consult with.

The stiff, serious person in a sharp suit might look ‘professional’ but hardly warm and amiable. Choose your picture with care.

Final thoughts

To stand any chance of generating patients, your content needs to get read. Which means it needs to stand out from the crowd and it has to strike a chord to connect with the reader. And the best way of doing that is to ditch the formality and communicate like the human being you actually are.

The reason so many marketing approaches fail to generate as many patients as they should is because the only reaction they generate is ‘Meh’. 

Dev Lall is a surgeon who runs a specialist private practice consultancy www.privatepracticeexpert. co.uk

Dear Reader,

Subscribing to Independent Practitioner Today is the only way you can be sure you will see every issue and have the option of reading us online using our special page-turnable edition. Don’t risk missing out. Our personal subscription for doctors and managers is only £90 a year and £210 for organisations. But you can cut this to just £75 and £180 respectively if you pay by direct debit. So take advantage of this offer now for our unique business journal dedicated to supporting you in your private practice. We’re confident your subscription will repay itself many times over!

Editorial director

and full address of your bank/Building Society

my Mastercard/Visa/amex/diners

I encose a cheque made payable to The

Please debit my Mastercard/Visa/

Society

Banks and Building societies may not accept direct debit instructions for some types of account

Banks and Building Societies may not accept Direct Debit instructions for some types of account

post your application (no postage required – uK only) to: independent practitioner today subscriptions department, Freepost, po Box 36, plymouth, pl1 1Br

phone: 01752 312140 Fax: 01752 313162 email: lisa@marketingcentre.co.uk or subscribe online at www.independent-practitioner-today.co.uk if you want to pay by

Beware the vortex

Consultants in private practice continue to lose money. Could you be one of those whose cash is disappearing into a black hole? garry chapman reports

We visit practices and clinics on a daily basis and, amazingly, we are still uncovering independent practitioners who have big financial problems. And mostly because they have not got the money they should have for the work they have done.

Now, of course, i understand that the first priority for the practice or clinic is the medical side and the key focus is to

provide first-class care for the patient.

And, yes, i know this should always be the case.

But unless the practice takes a long, hard look at the way the other aspects function in terms of the billing and collection services, then it might not survive in private practice to treat the patients.

During the recent economic downturn, making sure their

finances were in order became even more important.

We found many practices either billing less year on year or, at best, standing still in terms of revenue generated. But the costs of running the practice were still rising. to make matters worse, the market also shrank during this time, with approximately two million people falling out of private healthcare.

the CC sD coding structures also changed in that period, which reduced the number of multiple codes that could be billed together.

And a number of private medical insurers also reduced the fee re-imbursement for many CC s D codes. t his ultimately led to consultants receiving reduced revenue for doing the same level of work.

p22

Taking the above into account, it became the perfect financial storm for many practices.

This resulted in a massive financial black hole with revenue dropping while costs continued to rise.

At this point, the most commercially-minded practices took action to deal with the problem. They restructured the practice to make sure it stayed profitable and would survive the perfect storm and be in a good position to take advantage of the UK recovery.

These practices focused on making sure:

 Their invoices were raised in a timely manner;

 Every procedure was billed correctly;

 Invoicing was completed with the correct codes for each private health insurer;

 Collecting the money was done in a timely fashion to avoid bad debts.

It has to be said that a lot of these practices achieved this by outsourcing these critical elements to a professional billing company.

Unfortunately, those practices were in a minority and today we are constantly surprised how rare it is to find these fundamental business practices being carried out within a medical practice.

What is also startling to me is that the problems are not limited to the size of the practice. Even those larger organisations where they are billing revenue in the millions do not focus enough on the commercial aspects.

The reason we know this is because the majority of our clients come to us in various states of financial distress.

Some have huge backlogs of outstanding debts, which quite often go back years. Others have clinics that have not been billed for many months. And some are years out of date with their fee levels. In the worst case scenarios, we find the practice suffers from all of the issues described above.

Why does this problem exist?

Well, the fact that practices are not getting paid all that they are entitled to can occur for a range of reasons. I have highlighted the main ones below:

 Everything being left to the secretary to do is a common cause of billing problems.

even those larger organisations where they are billing revenue in the millions do not focus enough on the commercial aspects

The secretary who is often the busiest person in the practice is frequently expected to be a medical secretary, receptionist, PA, sales ledger clerk and insurance guru as well as a debt-collector.

The individual with the combined skill-set required to complete all of these tasks as well as fit them all into a working week is either a very rare breed or simply does not exist.

It is an impossible task for one person to cope with once the practice grows beyond a certain point. It is our experience that as the practice continues to grow, the secretary is so busy dealing with the medical side of the practice that the billing and collection is the area that is most frequently neglected.

One of the most challenging aspects that the secretary has to deal with today compared to only six years ago is the rise in the use of email.

Today almost everyone uses email in their daily life and the patient is no different, except that when the patient sends an email they expect a very quick response. If they do not get one, many send yet another email which, in turn, creates even more administrative work for the secretary to deal with.

The secretary is constantly under pressure to respond quickly, because if these emails are not dealt with in a timely manner, then the patient perceives this as poor service from the practice.



Running a practice over the last few years has changed dramatically and the administrative burden has grown in the last few years, leading to more examples of the practice losing money.

We find some common sideeffects of the above are as follows:

1

The practice continues to see patients who have not paid for previous treatment and therefore continues to build up its debt.

So it ends up seeing patients who have no intention of paying, which means they are, in effect, working for nothing.

2

the administrative burden has grown in the last few years, leading to more examples of the practice losing money

When the practice has a lot of foreign patients who come to the UK for treatment, they tend to stay only for a short period of time, either in a hotel or rented accommodation. By the time the invoice is raised and sent to the patient for payment, they have left the country and gone back to their home country, which means it becomes almost impossible to get paid for that work.

3

Financial problems are not always apparent to start with, because, as the practice grows, a certain amount of money will continue to flow into the bank account.

This masks the real problem of the outstanding debt; this continues to increase and get older, which means it is less likely to be collected.

4

Another factor affecting the timeliness and amount of re-imbursement is that healthcare systems are constantly changing. New Government policies and regulations, billing rules, medical codes, new technologies and insurance products mean that the practice has to keep up with these changes, as they can affect the reimbursement for the practice – or worse, cripple a practice if not complied with.

 Next month: the tax impact, some case studies and how to give your practice a financial health check

Garry Chapman (left) is executive chairman at Medical Billing and Collection

hisToRy oF mEdicinE

medical tales

Independent Practitioner Today presents a new series by TV doctor and full-time writer Dr Michael O’Donnell (right), drawn from his new book Medicine’s Strangest Cases

ThE BiRTh oF

PRoFEssionAL FEEmAnshiP, Lyons, FRAncE, 1533

What little we know of the lives of doctors who practised in ill-documented times is often an indistinguishable mix of fact and legend. There seems, however, to be general accord that one such doctor introduced the concept of the professional fee.

The occasion was provided in October 1533 by Jean du Bellay, Bishop of Paris, when he was on his way to Rome to receive his cardinal’s hat. By the time he reached Lyons, he was so afflicted by pain in his back and hips that he had to be carried from his coach to a local inn.

There, the innkeeper sent an urgent message to the local teaching hospital, the Hotel-Dieu, but grew distinctly worried when he saw who responded. For along came a lecturer in anatomy who was thought by his colleagues to be dangerously mad because of his habit of picking fights with the church and its philosophers.

He would argue, cheerfully rather than angrily, with priests about the worth of their spiritual cures, with doctors and apothecaries about the value of their medi-

His books were enormously popular, their sales promoted by people like Pope Clement VII, who pronounced them as forbidden reading

cines, and with patients about the seriousness of their illnesses.

The innkeeper relaxed a little when the bishop seemed to take to this cheery man, middle-aged but young for his years, wearing a fur-edged robe and a skull cap decorated with a golden scarab.

The doctor quickly diagnosed the bishop’s pain as sciatica, probably brought on by sitting too long in a cramped position in the coach, rubbed in some balm that he said would give temporary relief, advised his patient to get out of his coach occasionally and walk a mile or two, then demanded a fee of ten gold Louis.

‘outrageous’ fee

The bishop was outraged. ‘That’s a fortune,’ he complained. And, indeed, it was a quarter of the doctor’s annual stipend from the Hotel-Dieu. ‘Your fee is unjustified because of the brevity of your visit and the amount of attention you’ve given me.’

‘For the time and the balm, the fee is one Louis,’ said the doctor. ‘The other nine are for my ability to tell you the nature of your illness.’ And thus was born a maxim that has since served the profession well.

In 1952, for instance, when a

writer to make use of his encounters with his patients. True, his stories make fun of vices and foolishness that doctors often see, but his mockery is aimed not so much at people as at institutions, particularly the Catholic Church.

Accused of heresy

And, for that, he could draw on other personal experience because, before he became a doctor, he was a priest.

The humour he unleashes in his books is genial and bawdy, yet often beneath the ribaldry lies acerbic mockery of self-regarding teachers, politicians and philosophers – so acerbic that he had to spend some time in hiding from those who sought to prosecute him for heresy, the catch-all charge used at the time to silence unwelcome voices.

His books were enormously popular, their sales promoted by people like Pope Clement VII,

who pronounced them as forbidden reading and thus provoked a special edition, printed and bound to look like a holy book, to be read by those who feared excommunication.

The author’s imaginative description of bodily functions, his exploration of the quirks of human anatomy, particularly of the genitalia, and his erudite, if irreverent, references to philosophy led many commentators to say, ‘Only a doctor could have written such a book.’

The French medical establishment, however, was not best pleased. It responded in the traditional way of medical establishments by deciding to expel Rabelais from the profession, only to be thwarted by the fact that he no longer claimed to be a doctor.

 Medicine’s Strangest Cases, recommended price £7.99, ISBN 9781910232941. Published by Portico, an imprint of Pavilion Books

patient accused a London anaesthetist of charging an exorbitant fee of 50 guineas ‘just for putting me to sleep’, the anaesthetist replied: ‘The fee for putting you to sleep was only five guineas; the other 45 were for waking you up.’

The doctor who begat the maxim was François Rabelais. And he profited from his encounter with the bishop to much greater measure than the ten Louis. Jean du Bellay was so taken with the cheerily eccentric doctor that he invited him to accompany him as his personal physician.

Rabelais readily agreed. He had recently published the first collection of his stories about the giants Gargantua and Pantagruel, and was enjoying the sense of freedom that can come with an independent income.

He resigned from his job at the Hotel-Dieu and left for Rome with the bishop. They became good friends. Later, when Rabelais gave up medicine and spent much of his time travelling around Europe, he often stayed with Cardinal du Bellay and, when his third book was condemned as heresy by the Sorbonne, his friend’s protection saved him.

It is sometimes said that Rabelais was the first doctor-

UK Top 20 accountants specialising in the healthcare sector

• National firm of the Year 2013

AISMA member (Maidstone and Leicester offices)

• 12 offices including London City

• Tax Structures for Hospital Consultants - dispelling myths

• Surgeon groups and consortia

GP Practices including mergers and federations

• Solvent liquidations (for companies at the end of their lives)

For more information please contact: South East

James Gransby FCA

E: james.gransby@mhllp.co.uk

T: +44 (0)1622 754033

M: +44 (0)7712321899

East Midlands

Robert Nelson DChA FCA

E: robert.nelson@mhllp.co.uk

T: +44 (0)1162 894289

M: +44 (0)7814009160

General email: healthcare@mhllp.co.uk www.macintyrehudson.co.uk

inTo mEDico-lEgAl woRk

Keep them briefed

In Independent Practitioner Today’s continuing series to assist doctors acting as clinical negligence expert witnesses, Michael R. Young gives his tips for producing a current condition and prognosis report

When T he solicitor wants to know how things are at present, and what is likely to happen in the future, they will ask you for a current condition and prognosis report.

The barrister will rely on this report to prepare a Preliminary Schedule of Loss.

You will nearly always have to examine the client as part of your evidence-gathering process.

As with a liability and causation report, the first page should be the introduction, which should set out:

 Why the report has been written – its purpose;

 Your name and qualifications, as the report’s author;

 The name of the firm of instructing solicitors, not the individual solicitor’s name;

 The name of the solicitor’s client;

 Whether the client is the claimant or the defendant;

 A summary of your instructions, including the date of the letter of instructions – this is the terms of reference. It is best not trying to paraphrase the instruc-

tions because, in doing so, you may unknowingly alter their meaning. Therefore, it is advisable to copy the instructions word for word from the solicitor’s letter;

 The sources of the evidence. This should be comprehensive and must include where the evidence has come from, the dates it relates to and – perhaps equally as important – what is missing;

 A list of the contents and page numbers. This helps the reader find information quickly.

The report must also contain a declaration that you understand your duty to the court and that you have complied with that duty (see box opposite). The declaration can be set out on the second page.

On the next page is a summary of your conclusions. One question that you might ask yourself is ‘ h ow much of the history do I have to include in my report? The answer is ‘As much as you think is necessary to put your report into context.’

Write no more than a page on the history and be careful that you do not stray into the realms of talking about liability or causation. Set the synopsis of the history out in Section 1.

Stick to the facts

Section 2 is the current condition and should be restricted to the findings of the clinical examination and special tests, and the interpretation of any X-rays. Confine it to the facts and do not offer any opinions about how or why things are currently how they are.

Section 3 is the prognosis. Think of the prognosis in terms of the short, medium and long term. Define what you mean by each of these. The solicitor will want to know the worst-case scenario, but beware of painting too bleak a picture. Stick to what can realistically be expected to happen.

Section 4, the final section is the recommendations. This is as much to help the client by pointing him or her in the direction of other specialists. It may also help the solicitor decide if additional reports are needed.

The final paragraph of your report is the statement of truth. It says:

‘I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.’

The report must be signed and dated.

Don’t ‘pad out’

The majority of current condition and prognosis reports are, by their very nature, shorter than liability and causation reports and certainly shorter than combined reports.

It is tempting to pad them out to make them look more substantial than they really are and to justify your fee.

I came across a number of ‘current condition and prognosis reports’ written by other experts that were actually liability and causation reports with a little bit of condition and prognosis thrown in for good measure.

The worst example was a 42-page report in which less than half a page actually dealt with current condition and prognosis. This expert had obviously not read or understood the solicitor’s instructions. The solicitor would be quite within their rights to withhold the fee for such a report.

 Adapted from The Effective and Efficient Clinical Negligence Expert Witness , by Michael R. Young, price £60 from Otmoor Publishing

It is tempting to pad them out to make them look more substantial than they really are and to justify your fee

deCLARATION

I,

1

 next time: The combined report

sPeCIAL OffeR! BuY THe BOOk ANd sAve £20

The book costs £60, but Independent Practitioner Today has secured discount of a third off for readers, so you pay only £40.

Listen to the audio content which accompanies the book at: www.otmoorpublishing.com/audio.

for more information and to order, email stephen.bonner@otmoorpublishing.com, quoting reference ‘Young/IPT’.

declare THAT:

I understand that my duty in providing written reports and giving evidence is to help the court, and that this duty overrides any obligation to the party by whom I am engaged or the person who has paid or is liable to pay me. I confirm that I have complied and will continue to comply with my duty.

2

3

4

5

I confirm that I have not entered into any arrangement where the amount or payment of my fees is in any way dependent on the outcome of the case.

I know of no conflict of interest of any kind, other than any which I have disclosed in my report.

I do not consider that any interest which I have disclosed affects my suitability as an expert witness on any issues on which I have given evidence.

I will advise the party by whom I am instructed if, between the date of my report and the trial, there is any change in circumstances which affect my answers to points 3 and 4 above.

6

7

8

I have shown the sources of all information I have used.

I have exercised reasonable care and skill in order to be accurate and complete in preparing this report.

I have endeavoured to include in my report those matters of which I have knowledge or of which I have been made aware that might adversely affect the validity of my opinion. I have clearly stated any qualification to my opinion.

9

I have not, without forming an independent view, included or excluded anything which has been suggested to me by others, including my instructing lawyers.

10

11

I will notify those instructing me immediately and confirm in writing if, for any reason, my existing report requires any correction or qualification.

I understand that:

11.1 My report will form the evidence to be given under oath or affirmation;

11.2 Questions may be put to me in writing for the purposes of clarifying my report and that my answers shall be treated as part of my report and covered by my statement of truth;

11.3 The court may at any stage direct a discussion to take place between experts for the purpose of identifying and discussing the expert issues in the proceedings; where possible, reaching an agreed opinion on those issues and identifying what action, if any, may be taken to resolve any of the outstanding issues between the parties;

11.4 The court may direct that, following a discussion between the experts, a statement should be prepared showing those issues which are agreed and those issues which are not agreed, together with a summary of the reasons for disagreeing;

11.5 I may be required to attend court to be cross-examined on my report by a cross-examiner assisted by an expert;

11.6 I am likely to be the subject of public adverse criticism by the judge if the court concludes that I have not taken reasonable care in trying to meet the standards set out above.

12

13

I have read Part 35 of the Civil Procedure Rules and the accompanying practice direction and I have complied with their requirements.

I have read the ‘Protocol for Instruction of experts to give evidence in Civil Claims’ and confirm that my report has been prepared in accordance with its requirements. I have acted in accordance with the Code of Practice for experts.

An accident, but still your fault

Doctors

who are involved in managing employees in private practice

need to be

aware of the risks of vicarious liability. Joanne Payne (right) puts the spotlight on an important but often overlooked area

In prIvate practice, the practice and partners could be held vicariously liable for the actions of any salaried consultants or G p s and other employees or workers.

as the cases below demonstrate, courts will apply the principle broadly and it is not just reserved for traditional employment relationships.

the Supreme Court has recently decided upon two vicarious liability cases, each dealing with different aspects of the vicarious liability test.

vicarious liability means that an employer can be held responsible by the courts for the actions of its

employees. this happens where a connection exists between the contract of employment and the act of wrongdoing.

For example, in a discrimination claim, either the practice itself or the individual partners would be named in the proceedings for alleged acts undertaken by employees or contractors of the practice.

Extending the law

t here are certain employment claims (discrimination and whistleblowing victimisation claims) where the practice/partners could plead the ‘reasonable

steps’ defence, but this defence is not available for other claims, such as unfair dismissal.

In more recent cases, the courts have decided to extend the law of vicarious liability to cover other types of working relationships.

For example, in the Catholic Welfare Society and others v various Claimants [2012] UKSC 56, the Catholic Institute was held liable for abuse carried out by teachers at a boy’s school, despite the fact that the teachers were employed by the school and not the institute. It was deemed there was a sufficiently close connection between the institute and the teachers to warrant this.

this demonstrates just how farreaching the principle of vicarious liability can extend. When considering risks, a practice should look not only at its ‘traditional’ employees, but also at other individuals it engages with, to assess whether the

The courts are able to treat other workers as ‘deemed’ or ‘virtual’ employees for the purposes of vicarious liability

practice/partners could be held responsible.

When determining whether the principle of vicarious liability can be applied, there is a two-stage test to adopt – and both stages of the test must be satisfied.

stage 1

Is there a relationship between the wrongdoer and the practice which is capable of giving rise to vicarious liability?

In the case of Cox v Ministry of Justice [2016] UKSC 10, the Supreme Court assessed the first stage of the test and made a helpful determination.

t his concerned a personal injury claim brought by a manager of a prison kitchen, who had suffered a back injury when a prisoner working in the kitchen had dropped a bag of rice onto her back.

t he County Court found that the prisoner was negligent, but also found the employer to be liable. t he Ministry of Justice (MoJ) argued that the work undertaken by the prisoner did not give rise to an employment relationship, as working for the prison was mandatory and it was for the benefit of the prisoner for rehabilitation purposes.

t he MoJ argued that it would not be just to impose an employment relationship in these circumstances.

t he Supreme Court disagreed with the MoJ and applying a recent case involving liability for the abuse by a priest on a resident in a children’s home (JGe v trustees of p orts mouth

r oman Catholic Diocesan trust [2012] I r L r 846), it was found that vicarious liability can arise outside of the typical employment relationship where an individual

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

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

undertakes work for the benefit of the business.

the fact that the prison was able to control the allocation of duties and the work undertaken was also an influential factor in the decision making. a lso, the Supreme Court found that the fact that the prisoner was compelled to undertake the work, strengthened the case for vicarious liability.

Does your practice utilise individuals who are not employees, but who benefit your business and over whom you have some element of control?

stage 2

Is the employment sufficiently connected with the wrongful act/ omission?In the case of Mohamud v WM Morrison Supermarkets plc [2016] UKSC 11, and in another personal injury claim, the Supreme Court assessed the second stage of the test.

the facts of this case arose from a physical assault of a customer by an employee of Morrisons at a petrol station.

Following a verbal altercation with the customer within the petrol station shop, the employee left his kiosk to chase the customer.

t he employee warned the customer not to return to his employer’s premises again and then proceeded physically to attack the customer on the forecourt.

In defending the injury claim, Morrisons argued that they should not be found vicariously liable because his actions were outside the scope of his duties. they argued that his duties did not include confrontations with customers and that he had metaphorically taken off his uniform when he stepped out from behind the kiosk.

t he Supreme Court disagreed with the defence put, and found that it was the employee’s role to attend to customers and to

respond to their inquiries. t he employee had been responding to the customer’s inquiry, and the attack following on from this was part of that chain of events.

the court took into account the fact that the employee was warning the customer not to return to the petrol station.

It appeared to the Supreme Court that the employee was purporting to act about his employer’s business and it was found that there was a sufficient connection between the employment relationship and the assault, making Morrisons vicariously liable.

so what does this all mean for you?

Both cases and other case law in this area, demonstrate that the courts will adopt a broad approach to the question of vicarious liability, even in those cases where the employee’s behaviour is seemingly outside the scope of their duties – as demonstrated in the Morrisons case.

the courts are able to treat other workers as ‘deemed’ or ‘virtual’ employees for the purposes of vicarious liability.

this means that contractors and other ‘non-employees’ of the practice – for example, locum practitioners – should also be made aware of their expected conduct if they are undertaking the business of the practice.

a s a private practitioner, you should ensure that your practice has robust policies in place to deal with equality and diversity, and bullying and harassment.

Furthermore, it is important to ensure that your practice manager and your employees are trained on and are aware of these policies.

In cases of discrimination, it is important when pleading a ‘reasonable steps’ defence to be able to demonstrate you have in place whistleblowing/detriment training and staff awareness of equality and diversity policies and other relevant policies.

Further to this, it is important that you take swift action in accordance with such policy where complaints are raised to ensure that it is clear such policies are taken seriously.

Joanne Payne is a solicitor with Hempsons’ employment team

bUsinEss DilEmmAs

The dangers of going the extra mile

Dr Beverley Ward brings answers to two more questions raised by our readers

Dilemma 1 Can I take photo of patient’s skin?

QI am a consultant dermatologist. I would like to take a photograph of a skin condition on a patient to send to a colleague for a second opinion. Am I allowed to do this?

I would also like to use it in a presentation I am giving to other colleagues. Is this allowed?

AIt may help the patient to get a speedy diagnosis if you take a picture of their skin condition, but it is important that you make sure you have obtained the patient’s consent before taking the photograph.

If the patient is a child or lacks capacity, someone with legal authority will need to give consent on their behalf. It is important to explain the reasons for taking the photograph to the patient and document details of this discussion in the patient’s notes.

You may also be able to use the photograph for secondary purposes, such as in a presentation to other healthcare colleagues; however, you should gain consent for this at the same time as gaining consent for taking the photograph. If you do use the photograph for secondary purposes, you should anonymise it.

And if you plan on using the photograph in a presentation to a wider public audience, consent should be obtained in writing. Make sure you record the details of the discussion in the patient’s notes.

It is important to make sure the picture is transmitted and stored securely. If you are using a mobile

phone, tablet or laptop computer to store the photo for example, it could easily fall into the wrong hands.

It is essential that these devices are encrypted and password protected to protect patient confidentiality and comply with the Data Protection Act 1998, any information security policies at your private practice and also your ethical obligation to protect patient confidentiality.

Do not use photo-sharing apps or websites to seek your colleague’s opinion, as these may not be secure.

When anonymising the photo, bear in mind that this does not mean just removing the patient’s name and other obviously identifying labels.

Consider whether there are any wider features in the photograph that could allow someone, including the patient, to become aware of the identity of the person in the photograph.

Inappropriately obtaining or disclosing information about a patient could result in you facing a complaint or even a disciplinary or GMC investigation. In addition, unlawfully obtaining or disclosing personal data is an offence under section 55 of the Data Protection Act 1998. Ask your

medical defence organisation for advice if in doubt.

Dilemma 2 Can I be sued for Samaritan act?

QA colleague recently travelled abroad for leisure and was asked to assist when a man became ill at the airport. He was surprised to hear on his return that the patient had made a complaint against him.

This has worried me. On several occasions, I have come to the assistance of others when travelling for leisure or commuting to work on the busy local transport network.

I always thought I had a professional obligation and have always been more than happy to help if someone falls ill unexpectedly. Could I be held liable if something goes wrong?

AAlthough there is no legal obligation to do so, all doctors registered with the GMC have an ethical obligation to offer to help if an emergency arises in the community.

It is not uncommon for doctors to witness an incident that requires their assistance. Indeed, a recent MDU survey of members demonstrated that most (88%) had been called upon to help in an emergency while off duty, so this is not an unusual situation for doctors to find themselves in.

If you are called upon to help in an emergency, you should take into account:

 Your own safety – do not put yourself at unnecessary risk;

 Your competence – do not work outside of your abilities;

 The availability of other treatment options. If there is someone more appropriately qualified than you at the scene, then they may be better placed to assist.

If you do help out in an emergency, you will still need to obtain patient consent, where possible, and explain to the patient what you are doing, respect patient confidentiality and keep detailed records of what took place, just as you would do in your normal clinical practice.

While, in theory, you could be held liable if something went wrong, it is extremely unusual, if not unheard of, for Good Samaritan acts to result in legal action. However, if you do assist and have concerns about a complaint, you may wish to contact your medical defence organisation for help.

Some doctors who are nearing retirement are concerned that, when they retire, they may no longer be able to offer assistance in an emergency, as they will no longer have a licence to practice.

The GMC advises that not having a licence shouldn’t stop doctors from helping in emergencies. Non-licensed doctors must, however, be clear about their GMC status. Indeed, it is a criminal offence for a doctor to suggest that they have a licence to practice if they do not.

It is important to remember that Good Samaritan acts are quite different from so called ‘good neighbour acts’ such as volunteering to provide medical support at local events. In such instances, doctors should check that they are properly indemnified before the event takes place. 

Dr Beverley Ward is a medico-legal adviser at the MDU

You can

continues his journey following a year in the life of a NHS private patient unit (PPU). This month: improving staffing

So, we Brexited then!

I guess you will be using your time on the airbed or lounger by the pool during the holiday period to reflect on the performance of your private practice this last year and I urge you to find room to think ‘how could I have used my PPU more?’

w hile I encourage you to do that, I think we should reflect on the eU referendum and its impact on some of the bigger operational and strategic challenges for NHS PPUs.

one of these issues is staffing in NHS trusts and the increasing reliance on professionals from across

the eU to staff our wards and provide our junior doctors. on our PPU, we have recruited nurses from Spain and Portugal, but also have staff from the Philippines and New Zealand. Quite a typical mix, I think. we find that the draw of the varied patient mix, the pleasant working environment, the improved staffing ratio, the strong identity and local leadership – these all help to maintain a healthy range of candidates for vacancies.

I mention these factors because these are touchstones that all grades of hospital staff and also consultants as well as patients can identify with as the indicators of a successful PPU. So how does your ‘offer’ to potential new staff recruits measure up?

Industrial dispute

The recent industrial dispute between the Government and junior doctors has potential challenges as well as opportunities for PPUs.

At the heart of the dispute is, depending on whom you agree with, the issues of weekend working and patient safety, and/or pay and conditions and career pathways.

So, why is this of relevance to a PPU? well, two things I want to explore: the opportunities for PPUs that derive from developing a seven-day NHS and also options for junior support to consultants for their private patients in your PPU.

First, seven-day working, by definition, aims to achieve an extension of the ‘normal’ working week.

essentially, this means elective care, as non-elective/trauma cover is in place already in an NHS trust.

By flattening out some of the peaks and relative troughs of activity from Monday to Friday to

get the staff

The larger PPUs provide cover by resident medical officers 24/7 that mirrors the practice in independent hospitals

at least include Saturdays, then improved use will be made of scarce operating sessions and staff cover is enhanced.

For a trust’s private patient service, this has the potential twin benefits of opening up some weekday operating slots for private patients when five-days scheduling becomes shared over six, and also increasing the feel of ‘a normal day’ across the hospital on Saturdays. This is often a busy day for private sessions at the moment, so that private patients increasingly become business as usual.

Second, I am using the juniors’ dispute to prompt a discussion of the options for the provision of medical cover for PPU beds.

Private patients are clearly in the trust’s PPU under the personal care of the named consultant and it is up to him/her to direct the treatment and care pathway.

Access to juniors

In an NHS trust, this means that the consultant cannot rely on the juniors in the specialty team to provide a service within NHS contractual terms.

However, there are inevitably some clerking, work-up and patient management activities that aid that treatment and care that, on occasion, the consultant cannot deliver personally.

Many of these the nursing team can provide, but access to a junior

i believe in PPUs

The juniors offer occasional support to private patients on the PPU and only through the request of a lead consultant and, in return, the PPU pays a monthly stipend in to the mess

doctor is certainly a benefit to the service provided.

So what are some of the the options for providing junior doctor input to a PPU?

what you have in your PPU may depend on a number of factors, not least of these being size. The larger PPUs provide cover by resident medical officers (RMo) 24/7 that mirrors the practice in independent hospitals.

These RM o s may, in fact, be trust juniors that are engaged on an additional roster or they could be provided separately by a specialist provider as an agency would.

Some trusts have pro-actively sought to utilise the home-grown local junior resources.

Agreement with juniors

one option is to engage a separate roster of juniors directly on PPU payroll, often using academic post-holders who are not otherwise required for on-call work.

Following my 2014 independent Practitioner Today series on PPUs, i have continued to work with many nHS trusts to help develop and grow profitable private patient services. This has enabled a real insight into the day-to-day challenges of delivering a private service within a public sector environment. i am passionate about how PPUs can be part of the answer to the strategic and financial challenges that the nHS faces and so, in these articles, i plan to share learned, practical insights and also comment on how PPUs can best respond to changing policy issues and healthcare current affairs.

A further option – probably the most cost- and time-effective for a small PPU ward – is to have an agreement with the junior doctors’ mess or equivalent for ad hoc emergency and out-of-hours cover.

To work well, this needs to be a

tri-partite agreement: endorsement by the trust medical director and PPU medical advisory committee and agreement by the juniors as a group.

The juniors offer occasional support to private patients on the PPU and only through the request of a lead consultant and, in return, the PPU pays a monthly stipend in to the mess.

Monitoring of the implementation of such an agreement in one trust has shown that the instances of junior doctor attendance to a private patient under this protocol are few, but the arrangement and approach does deliver an added level of patient care valued by admitting consultants and the PPU ward staff alike.

In the next issue’s article, I will share some thoughts on a PPU’s competitiveness and commercial responsiveness using examples of how to react to actions your local private hospital may take to retreat from provision of paediatric services and also when they close capacity for building works to take place. 

Philip Housden (left) is a director of Housden Group, a management consultancy specialising in commercial support in the healthcare sector

What to do when ‘that letter’ arrives

So you’ve received a letter of claim? Multi-million-pound medical negligence claims are no longer a rarity, but receiving a solicitor’s letter can feel like a shocking blow. Dr Nicola Bailey recommends some ways independent practitioners can help themselves

If you are feeling anxious about a negligence claim against you, it may help to find a colleague you can trust and share your feelings

In recent years, we have seen a disturbing rise in the number of high-value claims against consultants, including our highest settled claim to date: £9.2m in compensation and legal costs for a patient left tetraplegic after spinal surgery.

In 1995, the MDU settled one medical negligence claim for over £1m, but by 2015 there were 12 such claims.

Within the private sector, certain specialties like plastic surgery and orthopaedics are at greater risk of a claim than ophthalmologists and general surgeons.

Despite what some commentators might suggest, the increase in high-

value claims and the rise in negligence claims generally is not caused by a fall in clinical standards.

In fact, during 2014 we successfully defended almost 80% of claims brought against our medical members. If you are unfortunate enough to receive a claim, here are the five most effective ways that you can help us to help you.

1

Don’t respond directly to a solicitor’s letter t he first you are likely to know about a claim is when you receive a solicitor’s letter, which sets out the allegations and is accompa -

nied with the patient’s signed consent to release their records. this is known as a letter before action and can be upsetting, but do not be tempted to write to the solicitors or contact the patient directly to refute the allegations. Doing so can make the claim more difficult to manage. Instead, tell your medical defence organisation (MDO) straight away. It will guide you throughout the process.

2 get your paperwork in order

It is not a good idea to leave a solicitor’s letter on a pile of papers. the civil litigation process

runs to a strict timetable: there are 40 days to respond to a letter requesting clinical records and four months to respond in full to a letter of claim.

It might seem a long way ahead, but time is always pressing and your MDO will need to assemble the necessary documentation. We ask members to send us all the correspondence from the patient’s solicitor, a signed note formally instructing us, your contact details, the patient’s records and a factual report of your involvement with the patient and details of any other clinicians involved.

If a case proceeds to the next stage, where you receive a letter of claim – and many cases do not –we might also decide to seek advice from an independent medical expert as to whether there is any liability.

If the expert evidence suggests a claim should be settled, then that should be done at an early stage, with your agreement to avoid causing unnecessary distress to all concerned. However, it is important not to settle defensible claims on purely economic grounds. rest assured, though, you will be involved in such decisions.

3 Seek support if you need it

It is natural to feel angry or upset. You may even feel ashamed at being involved in a case, but remember that a claim is not an indictment of you or your practice.

c laims are increasingly common nowadays and you may face one even if your clinical management has been exemplary. remember that the vast majority of claims do not result in compensation being paid and that this is very unlikely to be career-ending, as many doctors assume. If you are feeling anxious or stressed, it may help to find a colleague you can trust and share your feelings – always respecting patient confidentiality, of course. You can also talk to your claims handler about your concerns, as he or she will be able to provide support, advice and reassurance, based on experience of managing hundreds of similar cases.

4 Respect the claimant’s confidentiality If you are approached by the media for comment about a case, do not be tempted to give your side of the story. t here is a real

Claims are increasingly common nowadays and you may face one even if your clinical management has been exemplary

risk of breaching patient confidentiality and being censured by the GMc, as well as helping the journalist get more column inches from the story. the best approach is to explain that your duty of patient confidentiality prevents you from commenting – even if the claimant has spoken to the press. Depending on the outcome, you may want to make a brief statement at the end of a case, but your MDO can advise you on this when the time comes.

5 let your medical defence organisation do the work t he civil litigation process can move quite slowly. Years can pass between receipt of a letter before action and a formal letter of claim, and many claimants will decide not to take things further. e ven after formal proceedings have begun, it is not unusual for claims to be discontinued, par -

“ Kay and her team answer our calls, delivering more enquiries and outstanding service levels.”

Moneypenny client since 2013

Moneypenny will support your existing team by looking after overflow calls, or by providing a fully outsourced switchboard facility.

moneypenny.co.uk 0333 202 1005

ticularly after expert reports have been obtained and exchanged. For this reason, it is advisable to leave the day-to-day management of the claim to your MDO. they will liaise with the claimant’s solicitor and prepare carefully, according to a timetable determined by the court.

It is very unlikely that a claim against you will proceed to a trial, but for the few cases that do, your MDO can provide you with legal representation and help you to prepare you for a court appearance.

the good news is that even in these increasingly litigious times, if you do receive a claim, it is more likely to be successfully defended than for compensation to be paid. It is always helpful to know that your MDO is on standby just in case. 

Dr Nicola Bailey (left) is a claims handler with the MDU

ThE impoRTAncE oF mAking A will

Things to think of before you

Don’t leave your estate in a mess. Simon Bruce (right) examines what happens when you don’t organise your affairs before you die

It’s faIr to say that it has not been a good year for celebrities. the BBC has announced that it will struggle to include all the high-profile deaths in its annual tribute slot at the end of 2016.

s adly, in the digital age, the collective mourning of the nation is reduced to a frenzy of r IP tweets. Indeed, the ‘ r IP’ hashtag (the # symbol used to identify a particular topic on social media) is officially one of the most-used tweets of the year.

a mong the most interesting stories was news that pop idol Prince died without a valid will in place – and he’s not the only wealthy icon to do so. r ik Mayall, Bob Marley, Martin Luther King, Jimi Hendrix all left this world leaving a trail of anxiety for loved-ones. Even abraham Lincoln did not have a will and he was a lawyer.

a s such, their estates are deemed intestate and the law decides who will inherit, sometimes leading to expensive legal battles and family disputes.

Prince died in april aged just 57 with an estimated $300m estate. future song-writing royalties and rights to his music mean his overall wealth could be much more. after all, death appears to be a good career move: Michael Jackson’s record sales have reached over $2bn since he died.

While a bank has been appointed executor of the estate, Prince’s sister has applied to receive the inheritance along with his five halfsiblings. Interestingly, unlike in the Us, UK law does not recognise half-siblings, so in this country the full estate would pass to his sister alone.

inheritance tax

Comedian and actor rik Mayall failed to leave a valid will to deal with his £1.2m estate which is rumoured to have left his family with a large inheritance tax bill in 2014. although he died suddenly, aged 56, of a heart problem, he had nearly died in 1998 in a quad bike accident, so was presumably aware of his own mortality.

If a will had been in place, the bulk of the estate would have passed tax-free to his wife. Instead, under intestate laws at the time, his wife Barbara received up to £250,000 of his assets with the rest being split between her and their children. Under rules in place before October 2014, the spouse could only receive ‘interest’ on the sum above the £250,000 threshold but not spend the capital.

If his children’s share of the estate was worth more than £325,000 as expected, inheritance tax (IH t ) of 40% would have been due.

With a will in place that stipulated that all money went to Mayall’s wife, no tax would be payable on his death. the couple would have a joint couple’s inheritance allowance of £650,000. she could then have used IH t planning herself, which could have included giving assets to the children. these issues can take years to rectify, often costing thousands of pounds in fees. they add an extra burden of stress and anguish on loved-ones at an already difficult time. Importantly, the individual does not get to decide what happens to their estate after they have gone, leaving the key decisions

to people unconnected with the family in any way.

Making a will is the first step, but it is also essential to ensure that the important people in your life know where the original will is and also, what it contains. It seems unreasonable that while all other important documents can be filed online today, the original will must be presented to remain valid.

Michael Jackson was declared as dying intestate before his mother later revealed in a court of law that she had actually found a will after all. It seems that sometimes it can benefit loved ones to ‘lose’ the estate-holder’s wishes.

There are a few key points to remember. There is a common misconception that a ‘common law spouse’ will automatically inherit an estate. If you are unmarried and do not make a will, nothing will pass to your partner regardless of your time spent together. Your long-lost twice-

removed cousin would inherit before your significant other. Also, care should be taken to ensure that children from previous relationships are not overlooked in the case of inheritance. Bob Marley’s Rastafarian religion meant he refused to accept the notion of death. When he died in 1981 at the age of just 36, he left his wife and three children fighting with his nine other children and their mothers for a share of his estate.

Succession planning

Business owners also need to think about what would happen to their practices in the event of their deaths or serious illness. There are many preferred exit strategies which you may wish to explore in order that the assets of your business do not fall into the wrong hands, particularly having worked very hard to build your company.

Again, individuals in the public eye provide an interesting ‘how not to do it’ case study. Sumner Redstone, for instance, who, at the age of 93, continues to be embroiled in legal disputes and power struggles relating to his company CBS and Viacom, which he has ruled for over 50 years.

A court case was, as I write, due to decide whether Redstone is mentally capable of making decisions regarding the company and, in particular, the ousting of the chief executive and chairman of the trust which will take over the business on the event of his death.

Redstone wanted the men removed; they argued that he was being unduly coerced into the decision by his once-estranged daughter. This comes after several years of public feuding with his former carer (and partner) some 40 years his junior.

But you do not have to be a

billionaire to face such challenging family disputes.

For the sake of your own peace of mind and the security of your loved-ones, make sure what you would like to happen to your assets is clearly and legally transcribed. 

Simon Bruce is managing 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.

• how to start in private practice

• how to maximise private practice income

• computer software

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

• tax and financial advice re: car purchases

• how to start in private practice

• ways to reduce tax payments

• computer software

• how to maximise private practice income

• setting up in Chambers/Groups

• ways to reduce tax payments

• limited companies and LLP’s

• setting up in Chambers/Groups

• financial planning

• limited companies and LLP’s

• record keeping

• tax and financial advice re: car purchases

• pensions: NHS, personal and employee schemes

• pensions: NHS, personal and employee schemes

• purchase of consulting rooms and surgeries

• inheritance tax and capital gains tax planning

• purchase of consulting rooms and surgeries

• VAT

• inheritance tax and capital gains tax planning

• VAT

For more information please contact us by: Wilmslow

For more information please contact us by:

Wilmslow

Phone: 01625 527351 Fax: 01625 539315 Harley Street

Phone: 01625 527351

Harley Street

Phone: 020 7307 8759 Fax: 01625 539315

Phone: 020 7307 8759

Email: info@sandisoneasson.co.uk

Fax: 01625 539315

Fax: 01625 539315

www.sandisoneasson.co.uk

Email: info@sandisoneasson.co.uk

Website: www.sandisoneasson.co.uk

yoUR TRAding sTRUcTURE

Freedoms of incorporation

ChanCellor GeorGe osborne is part of his family business and, according to The Times, received a dividend of around £70,000. he does not work in that business and receives a dividend because he owns shares.

There is no need for commercial justification to own shares. But you may wish to control the amount of dividend you pay to shareholders who do not work in the business and you can do this using different classes of shareholding.

Provided that these carry the same rights on voting, windingup and distribution, there should be no concerns with hM revenue and Customs (hMrC).

Is a company still a good choice for my private practice? It’s the big question many independent practitioners are asking.

In my opinion, you should also own some of these shares to ensure you retain commercial control with more than 50% ownership. Individuals owning shares should be adults, so those of you waiting to wave goodbye to your university-bound adult offspring should be considering if they are ready to own shares in your business – it can provide them with an income.

In the second part of her response for Independent Practitioner Today, Vanessa Sanders (right) makes clear it is important to think carefully about what you wish to achieve with your business. But do not discount using incorporation, as there are many advantages – and not always in terms of just tax

If they also work for you, this could amount to £16,000 taxed at 0% with a further £26,000 at 7.5%. This depends on how much you want to distribute, as you must also take a dividend for yourself. Waivers are not allowed in non-commercial circumstances. as a profitable trading company, you must pay out some amount of dividend, as your investors would expect a return on their shareholding. however, decisions as to when dividends are payable remain with the directors.

Uncertain times

It may be that during uncertain times such as we currently face, dividends can be kept to a minimum. Decisions on distribution can also be limited if there is an investment strategy for capital growth.

This growth could include shares or land and property. The property can include residential property, which is let out at full market value. Using a company would keep the profits taxed at the lower rate of corporation tax with the added bonus of unrestricted relief on any loan interest. This may be useful, as interest

deductions are being limited to the basic rate over the next four years and are being given as a tax relief rather than a deduction against taxable income.

Protecting the profits using your company for the investment may therefore be useful in reducing your taxable income for pension tax relief restrictions.

If you already own property, you may wish to consider introducing it into a company. There are certain steps you may need to consider before this can be done taxefficiently to ensure that Stamp Duty land Tax (SDlT) charges are minimised. But for future growth, and passing onto offspring, this could prove very efficient.

Protecting pensions

Many doctors will be facing tax bills on their pension contributions because their adjusted taxable income exceeds £150,000. Potentially, the use of a company could control how much in excess of £150,000 is taxable.

r emember, sole trader profits are taxable when they are earned. Dividends are taxable when they are paid – as a director, you choose when dividends are paid.

In an extreme example, you may decide to pay out dividends every two years or so, thereby allowing pension tax relief restrictions to be minimised by keeping your nh S adjusted salary packages and other taxable income below £150,000.

o n retirement from private practice, you have a few options to consider.

If you decide to sell your business, you can sell the shares in your company or the asset of goodwill from your company. If it is a mixed company with a trade and assets, then it is possible to separate these two elements, if sufficient time for planning is given, and to access entrepreneurs’ relief on the sale of the trade. You can then maintain the company with the assets and continue to derive benefit from any profits or liquidating assets to pay out dividends over a controlled time period.

once the company is no longer trading, the main contributor disappears and the shares can be split into any shareholding desired. Between spouses there is

no gain/no loss, so movement of shares can be dealt with efficiently.

Gifting shares to offspring can also be done over a period of time, reducing SDlT costs, with annual exemptions for capital gains tax planning being used efficiently. Provided you live seven years after the gift, the value will come out of your estate for inheritance tax.

Some doctors may have concerns that gifting shares in a family business may dilute wealth. But as the company is owned by shares, it is a simple matter of a shareholders’ agreement to control what happens to those shares on incidences such as divorce or bankruptcy.

a lthough there will be some value to the holding, this is usually reduced by virtue of the element of control of the company and the shares can be forced back into appropriate hands. This is much easier to deal with than assets outright, such as property.

Liquidating your firm

If, on retirement, you no longer want your company, you can formally liquidate it. This will involve engaging a licensed liquidator if the assets are more than £25,000.

The company can pay out the balance potentially as capital. While it may not be at the entrepreneurs’ relief rate of 10% in all cases, it may be that hMrC can be persuaded to allow the capital distribution as a gain, which would be taxed at 10% for basic-rate taxpayers and 20% for higher-rate payers.

The use of a limited company is for the life of a business. It allows control over when and how you use the profits. It is never a shortterm fix from which you can dip in and out.

In fact, once the decision is made to incorporate, coming out is hard work, particularly if you wish to carry on trading. So think carefully what you wish to achieve with your business, but do not discount using incorporation, as there are many advantages, albeit not always in terms of just tax. 

Vanessa Sanders is a partner at specialist medical accountants

Stanbridge Associates

Filling

Things move on in your business and they have to in the car world too. Dr Tony Rimmer (right) finds the wide choice available from Volkswagen’s new offering would make a lot of sense for independent practitioners whose budget doesn’t stretch as far as some we know

We now have a new Tiguan that takes advantage of all the advances in automotive technology that have occurred during its lifetime

EvEry businEss needs to keep an eye on market trends and movements of client preferences. For that reason, independent practitioners would do well to monitor what is happening outside of their own practice.

A flexible and forward-looking approach means that the business will be better positioned for taking advantage of changes in patient demand and available services.

i n the world of cars, over the last 18 months, there has been a steady increase in the popularity of the compact sports utility vehicle (suv) and crossover segment of the market.

buyers are shunning the standard family hatchback and estate car and are being attracted by the greater space and versatility of an suv. All of these vehicles have a higher driving position, giving a more commanding view of the road and most of them offer fourwheel drive as an option.

One of the first manufacturers to offer a vehicle in this market sector was volkswagen. b ack in

in the gulf nicely

2008, it launched the Tiguan, which was based on the Golf Mark 5, had roughly the same amount of space and was similarly priced, model for model.

This was pretty forward-thinking for v W and despite a static design, sales increased strongly year on year. in 2015, more were sold than in any previous year and it is now the third-best seller in the uK after the Golf and Polo.

Technological advances

so after eight years, we now have a new Tiguan that takes advantage of all the advances in automotive technology that have occurred during its lifetime.

improvements in styling, engineering, space, safety, performance and economy can only mean good news for the buyer. it is vW’s first suv to sit on its new advanced MQb platform that has been so impressive in the Golf Mark 7 and Passat models.

The 4MOT i O n all-wheel drive system is standard on all but the lowest-specification models.

Engine choice is wide with the option of three petrol and four diesel units ranging in power from 115 to 240bhp.

There are four trim levels: s, sE,

sEL and r-line, with other options such as leather upholstery. Prices range from £22,510 up to £36,375. i n other words, there is a model available to suit every kind of independent practitioner buyer. s o what does it look like and what is this new Tiguan like to drive? Well, i was lucky enough to be invited to the u K launch in sunny Gloucestershire and had the opportunity to drive various models to assess and compare.

The new car certainly looks better. b enefiting from a longer wheelbase, the styling is sharper and gives the Tiguan a modern and classy appearance. its predecessor had a slightly dumpy look that has thankfully been eradicated.

The interior is pure volkswagen. High-quality plastics and clear fascia design make it a pleasant place to be.

Passenger room is definitely improved, particularly in the rear, and the bootspace is huge and is now on par with suvs in the class above, such as the bMW X5. i n top models, the Active information Display, first seen on Audis, gives the option of viewing the sat-nav screen straight in-front of the driver, giving a real high-

room is improved in the rear

tech feel to the driving experience.

The engine most suited to the new Tiguan will also be the biggest seller: the 2.0-litre turbodiesel TDi 150bhp model. i drove versions of this car with both a manual gearbox and the new seven-speed DsG (direct-shift gearbox) dual-clutch automatic.

Despite the whole ‘DieselGate’ vW debacle, this is still an excellent choice of power unit. Punchy, smooth for a four-cylinder diesel and reasonably quiet, it works best with the D s G box that smooths out the whole powertrain and is just as economical as the manual.

Handling characteristics

Although the laws of physics do not allow any suv to handle as well as a saloon or hatchback, the Tiguan does a pretty good job.

Mild body roll on corners is the only price to pay as the steering remains sharp enough to place it accurately on the turns.

Wind noise is nicely suppressed, but the ride, very impressive on other cars using the MQ b platform, is a bit firm and can get a little unsettled on rough surfaces.

Fortunately, adaptive chassis control is available as an extra cost option on many models.

i am in no doubt that vW has another winner on its hands. The up-to-date chunky appearance, modern technology and a classless image will appeal to many independent practitioners looking for a quality compact suv and whose budget doesn’t stretch to the premium-class products from the likes of Audi, bMW and Mercedes.

if you do go for the new Tiguan, you certainly won’t feel shortchanged. 

Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey

VW Tiguan SEL 2.0TDi 4moTion 150PS DSg

Body: Five-seat SuV. Permanent four-wheel drive

Engine: 2.0 litre four-cylinder twin-turbo diesel

Power: 150bhp

Torque: 340nm

Top speed: 120mph acceleration: 0-60mph in 8.7 secs

Economy: Realistically 40-45mpg overall

Co2 emissions: 149g/km on-the-road price: £32,810

The interior is pure Volkswagen. High-quality plastics and clear fascia design make it a pleasant place to be and passenger

STARTing A PRivATE PRAcTicE

Many independent practitioners have a secretary or spouse involved in the business and, sooner of later, the inevitable question arises of whether to employ them.

One thing i come across frequently is the belief that if a secretary issues their doctor boss with an invoice, then they must be self-employed.

 they provide their own equipment to do the job;

 they set the rate and payment terms;

PAYE Make your practice

Our monthly series for doctors at the beginning of their private practice career continues with an explanation of the PAYE scheme, by Ian Tongue. But we are sure many long-standing independent practitioners will want to read it too

Employed or self-employed?

But that is simply not the case, i am afraid.

t his article looks at a pay-asyou-earn (paye) scheme in detail and when employment is a requirement, together with an overview of the new pensions legislation for employers.

Employed or self-employed?

it can be a fine line between the two, but it is very important that you understand the difference, because getting this wrong could cost you dearly.

even in situations where a job contract is in place, it can be challenged if the practical circumstances are not consistent with the actual role of the job.

Why is it important? Simple. national insurance is payable by the employer to employ a member of staff and under self-employment you do not.

So therefore, HM Revenue and Customs (HMRC) wants to argue, where possible, that a person acts an employee.

Self-employed individuals operate under a ‘contract for services’ in contrast with an employee which is a ‘contract of service’.

to make a contract for services stick, you have to be able to demonstrate that the contractor is not effectively acting as an employee.

While not exhaustive, the following are some of the important conditions that you would expect in a contract for services:

 a requirement to supply the services outlined in an agreement;

 t hey retain liability for the work done;

 they have the right to provide a substitute to complete the work. Get evidence if this is actually done, if only to cover holiday periods, and it is important for the contractor (not the consultant) to pay this direct to the substitute;

 no holiday pay;

 no sick pay;

 no maternity pay.

i f the person working for you cannot satisfy most of the above, the chances are that they should be on the payroll and a ( paye ) scheme maintained.

However, if the monthly pay is less than £485 a month, a paye scheme is not required. the person employed may need to declare these earnings if they earn money elsewhere, as the combination may require them to pay some tax, but this is mainly their responsibility.

A PAYE scheme

Maintaining a paye scheme became more work a couple of years back with the introduction of a new system called real time information or Rti. i nstead of sending payroll details to HMRC annually, you now have to do this monthly. t his creates more work and means that you need to be up to date with matters. Most consultants and private Gps choose for their accountant to maintain the scheme for them and, with the associated costs being tax-deductible, the price is quite low for the work involved. they find it makes sense rather than taking this on themselves. Various paperwork is required to create the scheme and add employees. the scheme requires you to collect tax and n ational insurance from your employee(s) and pay this over periodically to HMRC, usually quarterly for a small private practice.

i f you are maintaining the scheme yourself, you will need software and hit monthly deadlines to avoid penalties – which can quickly mount up if you get behind even by a month or two. in most cases, it is not worth the time and effort of maintaining your own scheme.

Pensions

Over the last couple of years, a new set of regulations has been introduced which forces employers to provide a pension scheme for the employees, known as auto-enrolment.

in some private sectors, this has been welcomed, but it is burden on a small business such as a private practice. you must, however, be compliant with the legislation. each paye scheme in operation is given a date at which time you must be compliant and ready for auto-enrolment. this is known as your ‘staging date’ and the pen-

sion regulator recommends starting the planning process up to a year in advance. in reality, it can all be dealt with in the few months up to the staging date.

t he main work is identifying which of your workers are to be auto-enrolled and those that have the right of access to a scheme if they want to.

d epending on the outcome, you may have to auto-enrol employees into a pension scheme or offer one.

a nyone earning over £10,000 who is between 22 and state pension age will be auto-enrolled. t his is even if they say beforehand that they do not want to be in the scheme.

Once enrolled, they have a period to opt out of the scheme if they wish. Other types of employees may not be automatically enrolled, but have to be given the option of joining. your accountant should be able to assist

you in classifying your employees. For those that do not opt out or decide they would like to be in the pension scheme, you will need to contribute a minimum of 1% which is matched by them.

From 6 april 2018, this increases to 2% for the employer and 3% for the employee with a further increase from 6 april 2019 to 3% for the employer and 5% for the employee.

i f you have workers who can request to be in the scheme but they earn less than the lower earnings limit for national insurance, currently £486 a month, you do not need to contribute as the employer.

t here are a few exceptions to having a pension scheme, but these mainly relate to companies where the only employees are the directors themselves.

your accountant should be able to provide you with an autoenrolment solution.

Advantages of a payroll

While it is more hassle than in the past and pensions need to be considered, it can still be beneficial to maintain one, particularly for family members who are involved in running your private practice.

p rovided that a salary can be justified because they are doing something for the money, paying a salary to a spouse or older children can be particularly tax-efficient.

paye is a necessary evil for anyone running a business with employees being paid anything of any significance.

it is important that the scheme is run properly to avoid issues with paye or pensions compliance. your accountant is best placed to assist you with taking the headache out of maintaining a scheme. 

Ian Tongue is a partner with accountants Sandison Easson & Co

Hard graft for same pay

Our latest analysis of general surgeons’ profits shows they are working harder for lower per unit fees, reports Ray Stanbridge

When W e last looked at this specialty in our July-August 2015 analysis, we predicted: ‘We would expect to see some further income squeeze in future as a result of the changing pattern of work and ongoing pressures on fees from both insurers and, we suspect, the nhS.’

Broadly, this conclusion has held true and we have observed a ‘steady as she goes’ environment between 2013 and 2014.

Our headline figures suggest that the average gross income from private practice for general surgeons increased by 1.5% between 2013 and 2014, going up

from £128,000 to £130,000. So, in real terms, it was fairly constant.

Costs rose by about 1.8% from £55,000 to £56,000 on average. As a result, average taxable profits for the year went up by about 1.4% from £73,000 to £74,000. As indicated above, there was essentially a ‘no change’ situation.

Working harder

General surgeons would have started to feel the effect of the Bupa ‘open referral’ problems in the 2013-14 year with a squeeze on their fees.

More general surgeons, particularly in the country areas, are

any income growth seems to have resulted from having to work harder for lower fees per unit

undertaking generally lowermargin Choose and Book work. Any income growth seems to have resulted from having to work harder for lower fees per unit.

There have been one or two interesting cost changes. Staff costs rose gradually from £17,000 to £18,000 between 2013 and 2014. As previously reported elsewhere, this is largely the result of increasing ‘family’ salaries in line with the growth in the tax-free personal allowance.

cheaper premiums

Surprisingly, there was a modest reduction in average professional indemnity costs. We are seeing that an increasing number of consultants are looking beyond the traditional defence bodies to obtain cheaper premiums. For some, there are short-term gains. The long-term costs, if any, are yet to be seen.

We are seeing that an increasing number of consultants are looking beyond the traditional defence bodies to obtain cheaper premiums

Expenditure

There was a modest drop, on average, in use of home costs for reasons that are not immediately obvious.

Similarly, there was a small increase in bad debt costs. These were largely the result of a failure, for obvious economic and time reasons, to pursue some patient shortfalls. Slow payments from overseas patients also seems to have increased.

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

Source: Stanbridge Associates Ltd.

Uniting both the Surgical and Non-Surgical Communities

5000+ Visitors

200+ Exhibitors

5 Conferences

FEATURING NEW:

& Non-Surgical Workshops

Demonstrations

THE UK’S LARGEST MEDICAL AESTHETIC EXHIBITION

The go to event for anyone getting started in aesthetics, launching a clinic or completely refitting their existing premises.

Find out about training, regulation, insurance, ethical marketing, recruitment, clinic design, patient after care and much more.

Boutique recruitment. Highly qualified admin staff for doctors & private clinics in London.

Helping doctors find optimal candidates to complement their teams, from reception staff through to medical secretaries & practice managers.

Having worked in the medical sector 15+ years, we fully understand our clients’ requirements.

Our experienced personnel have advanced organisational, IT, communication & administration skills.

Focusing on establishing long term relationships with clients to ensure continuity.

Located in the vicinity of Harley Street, enabling us to meet our clients in person to discuss their specific requirements.

For further information contact our team.

There has been continuing growth in ‘other’ costs, which are primarily marketing, business development and PR-related. As we have pointed out many times, the evidence is strong that effective expenditure on marketing does lead to an increase in the number of self-pay patients.

So what then of the future? A brief look at 2015 figures – many of which are still in draft – suggests that the ‘steady as she goes’ scenario has continued.

Given that the full effect of the

insurers’ squeeze on fees would have been effective from 2014-15, this seems to be largely the result of working harder for lower per unit fees. Perhaps a story of life today.

increasing difficulties

As we have reported when looking at other specialties, we are concerned at the increasing difficulties in producing a reliable and consistent series of income and expenditure analysis for consultants’ profits, and that holds true for general surgeons in private practice.

This is because of the increasing number of subspecialties among general surgeons, the reporting and comparison problems arising from new means of trading, such as limited liability companies and groups, and the growth in nh S Choose and Book work.

In addition, some general surgeons have chosen to focus increasingly on medico-legal work with the result that the income and cost structure of their practices has changed significantly.

As a result of all these changes, we are working on new models to try to reflect, consistently, what is happening in the market.

Details will be announced shortly in Independent Practitioner Today

note that our survey consists of general surgeons who:

 h old either an old or a new style nhS contract

 May or may not have incorporated their businesses

May or may not work with a group

 have a keen interest in private practice

 h ave been involved in the private sector for at least five years

e arn a private practice gross income more than £5,000 a year.

THe RaTIO BeTWeeN geNeRaL SURgeONS’ eXPeNSeS aND PROFIT ReMaINS CONSTaNT

what’s coMing in our septeMBer issue

Make sure you don’t miss our next issue, published on 22 September. you may not receive every issue if you have not yet subscribed to the journal. Don’t risk missing out on vital topics we tackle next time, including:

 as consultants nationwide take part in a Federation of Independent Practitioner Organisations’ (FIPO) private practice earnings survey, garry Chapman looks at what can be done to protect you from losing money. He finds in the worst cases some specialists have accrued more than £250,000-worth of unpaid bills

 Don’t miss Independent Practitioner Today‘s free supplement to help you make the most of your visit to the Practice Management expo, part of this year’s Clinical Cosmetic Reconstructive expo at London’s Olympia from 6-7 October

 More private practice opportunities. Companies are continuing to pour money into new and existing private hospitals. We report on the latest plans for new services, hospital developments and additional consulting rooms

 get cracking now with your 2015-16 tax return. Susan Hutter warns not to leave it too late

 Data Protection – check out your responsibilities as a practice owner

 More from Medicine’s Strangest Cases – Dr Michael O’Donnell’s new book

 Being open and saying sorry are the best policies when things go wrong, says Dr gordon McDavid, medico-legal adviser at Medical Protection

 From next april, all private healthcare organisations will be required by the Competition and Markets authority’s order to collect and publish PROMs data. Dr andrew vallance-Owen, chairman of PHIN – the body tasked with translating this information for the public – urges all private consultants to encourage the hospitals they work with to go beyond simple compliance with the order and fully embrace PROMs, as they can help patients, consultants and hospitals

 a guide to liquidating your company by accountant Ian Tongue

 Dr Tony Rimmer reviews the new audi a4

 Using email to grow your practice

 Breaking in to medico-legal work – advice for doctors writing a combined report for low-value cases when solicitors want to keep the cost down

 Property Matters: Dylan Mitchell explains the tax benefits of owning property in Mauritius, how to buy, and finds some best buys

 Plus all the latest news, views and regular features

aDveRTISeRS: The deadline for booking advertising for our September issue falls on 26 august

Published by The Independent Practitioner Ltd. Independent Practitioner

Today is editorially independent and thanks Bupa for its assistance with distribution. Printed by Pepper Communications Ltd 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 2016

Registered office: 7 Lindum Terrace, Lincoln LN2 5RP

Write to Independent Practitioner Today PO Box 198, Cranleigh GU6 9BB

eDITORIaL INqUIRIeS

Robin Stride, editorial director

Email: robin@ip-today.co.uk

Tel: 07909 997340

aDveRTISINg INqUIRIeS

Margaret Floate, advertising manager

Email: margifloate@btinternet.com Tel: 01483 824094

Publisher Gillian Nineham Tel: 07767 353897.

Email: gill@ip-today.co.uk

SUBSCRIPTIONS

£90 independent practitioners.

£90 GPs and practice managers (private & NHS). £210 organisations.

But if you pay by direct debit, individuals pay only £75, and organisations £180

Call Proact Ltd on 01752 312140

Email: lisa@marketingcentre.co.uk

Robin Stride, editorial director

To guarantee your copy of Independent Practitioner Today by taking out a subscription (at the rates shown on the left), phone 01752 312140 or send off a subscription form on page 20 or email lisa@marketingcentre.co.uk or go to the ‘about’ page of our website www.independent-practitioner-today.co.uk

If you pay by direct debit, individuals pay only £75 for a subscription. Just fill in the form on page 20 and send it to the Freepost address shown at the bottom of the form.

BaCk ISSUeS: £12.50 including post & packaging CHaNgINg aDDReSS OR

Phone 01752 312140 or email lisa@marketingcentre.co.uk

The business journal for doctors in private practice

When we established our medical billing service, an e-billing capability was essential. Healthcode’s system has all the benefits: ease-of-use, efficiency and minimising our postage costs.

Rebecca Deering, Nuada Group

Securely manage your patient billing

As the UK’s official medical bill clearing company, Healthcode’s ePractice solution incorporates electronic billing to all major insurers and paper billing for self-pay patients, allowing you to have both paper and electronic bills under one system.

Using ePractice to bill, you can:

• Raise electronic or paper invoices

• Receive payment quicker for ebills

• Improve cash flow

• Ensure fewer errors

• Confirm your ebill is with the insurer

Healthcode’s ePractice solution offers:

Patient Billing

Patient Management

Payment Tracking & Financial Reporting

Appointments

Membership Enquiry

Complimentary ePractice App

Experts in Online Solutions for Smarter Healthcare... ‘code for success.