We examine the gripes received by the Independent Sector Complaints Adjudication Service P24
Marketeer Simon Marett has ideas to drive loyalty among patients P34
Safety initiatives coming soon to private practice
IHPN boss David Hare scans the regulatory horizon for independent practice P42
By Robin Stride
The extent of the pandemic’s toll on independent practitioners has been revealed in a new survey for this journal showing that more than 44% of private doctors report feeling stressed and/or anxious on a weekly basis.
They shared their feelings in a joint Independent Practitioner Today survey with the Medical Defence Union (MDU), featured in this issue.
Of concern is that as many as three in ten admit to ‘often’ going to work when they do not feel fit or well, with 6.9% strongly agreeing this happened.
Dr Udvitha Nandasoma, MDU’s head of advisory services, said: ‘It is worrying that so many respondents feel stressed or anxious on a weekly basis and nearly a third are going to work when they do not feel fit to do so.
‘Consequently, it’s important for independent practitioners to be provided with the necessary support when dealing with the additional pressures.’
He said the MDU provides a 24-hour advice line for medicolegal queries and has a peer sup -
port network for members who are facing medico-legal challenges, such as complaints, inquests, GMC investigations and claims.
‘This enables them to speak with a fellow member who has “been in their shoes” and who can offer both practical and emotional support and guidance.’
Thirty per cent of doctors told the survey they were unable to spend adequate time with patients (strongly agree 7.3%, agree 22.3%).
However, over 80% said they felt they were making a positive difference to their patients (strongly agree 22.3%, agree 58.8%).
Some 16.5% revealed they believed they could not do their job effectively while 62.5% thought they could.
Most felt supported by their colleagues, with 15.4% strongly agreeing and 49.6% agreeing they were. Nearly 7% disagreed.
The survey received 260 responses, including 235 consultants, plus private GPs and independent practitioners doing other types of jobs.
Relationships at work were ‘strained’ for just over 35.8% of doctors, with 5% expressing strong agreement that things were uneasy. For 40.8% this was not the
case and 23.5% expressed no firm opinion.
When it came to work-life balance, only 40% of respondents considered they had a good one. 27.3% gave no verdict and nearly one-third believed they had got things in the right proportion.
When asked to rate their stress and anxiety levels now compared to before the pandemic, over half said things were worse – significantly worse 18%, a little worse 36.8%.
Thirty-one per cent reported no change, 10.3% found them a ‘little’ better and for nearly 4% things had significantly improved
The extent to which doctors’ private practices have been affected since the pandemic presents a mixed picture. While 29% report a decrease in activity, 38% have seen an increase, while 34% report their amount of work is similar to pre-Covid levels.
But only just over a third (36%) plan to do more private practice work over the next two years.
Four in ten (41.2%) do not plan to give more time to independent sector work in the foreseeable future at least. Around one in five (22.7%) answered they did not know what they would do.
Nearly two-thirds of independent practitioners provided additional NHS services during the pandemic. Thirty-four per cent did so throughout the crisis and continue to do so now.
But 28% who increased NHS commitment during the period are not doing so now. 37.9% supplied no extra NHS services.
Almost a third (30.4%) expect to do more NHS work over the next two years but this is not the choice for the majority (55.3%) while 14.3% are not sure what they will do.
The Covid experience has ushered in big changes, both good and bad, for many private practitioners and patients.
Being able to be seen quickly has always been an important attraction for patients facing long NHS waiting lists. But this private practice selling point has taken a knock and nearly a third of consultant respondents report their private patients are not being seen as quickly as they were.
➲ Turn to page ten to read doctors’ assessment of how their private practice has changed following the pandemic.
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Our ‘state of doctors in private practice’ survey, starting on this issue’s front page, throws up causes for concern.
Many responses reflect the effects of the pandemic on the way private consultants and GPs are working. They demonstrate the profession’s ingrained ability to take a battering but adapt quickly to changing circumstances and demands.
Around four-in-ten doctors report an increased use of remote consultations and telemedicine. And it is good to see a greater flexibility of work for some doctors and patients finding it easier to get appointments when they want.
However, the Covid-19 legacy has resulted in longer waiting times for nearly a third of doctors’ patients to get initial appointments and complete their treatments.
There is a mixed picture regarding business growth, with
38% recording an increase in activity, 28% a decrease and a third saying it is similar to before.
In this environment, the possibility of an employment role in private practice appears more attractive to consultants now than previously.
But, for now, there are some serious issues to address as more doctors find things not only a greater struggle in the NHS but their private work too.
A large proportion of those taking part in our joint survey with the Medical Defence Union confessed they were now more stressed or anxious on a weekly basis and nearly a third said they were going to work when they felt unfit to do so.
Now more than ever, they need to have strong support from their professional associations and those around them. We will be pleased to publicise what support is being offered.
Should I invest in marketing?
How does any clinic owner decide how much money to invest in marketing?
Our Troubleshooter Jane Braithwaite has some answers P22
How data breaches cause trouble
Dr Dawn McGuire shows how to avoid costly claims by looking at case studies of confidentiality breaches and what to glean from them P27
A plan to deal with Covid’s impact
Bupa’s medical director Dr Robin Clark explains how the insurer’s Wellbeing Index can be used as a template for improving the nation’s health P30
The wisdom of forming groups
Simon Brignall reflects on the challenges that consultants’ groups face with their billing and points out the differences from flying solo P36
Trust in the bounce
It is important to keep perspective on short-term market falls. Dr Benjamin Holdsworth of Cavendish Medical on the slow process of building wealth P38
When you’re called to an inquest
Solicitor Clementine Robertshaw shows how to prepare for giving evidence to an inquest both in writing and if called to attend in person P40
Start a Private Practice: Choosing the right team for success
The team you pick impacts the success of your practice, says Alec James of accountants Sandison Easson P46
Doctor on the Road: Worthy challenger to busy SUV market
Motoring correspondent Dr Tony Rimmer finds the MG ZS electric vehicle to be better than he expected P50
Profits Focus: Surgeons seem stuck in financial doldrums
Accountant Ray Stanbridge puts the fiscal performance of surgeons under the microscope P52
By a staff reporter
A leading consultant is encouraging colleagues with independent practices to engage with the Private Healthcare Information Network (PHIN) because it is ‘a no brainer’.
Plastic surgeon Mr Nigel Mercer, a former president of both the national organisations who represent the specialty, says the main reason consultants should engage is that it is a legal requirement –‘and you can’t choose not to engage with a legal requirement’.
But he tells Independent Practitioner Today in our news analysis (page 14) there are other good reasons for consultants to provide PHIN with the data that the Competition and Markets Authority (CMA) requires it to publish.
‘To me it is a bit of a nobrainer. I know of consultants who have complained for many years that they aren’t getting the referrals. This is a chance to put information about the quality of care you provide in front of patients.
‘No surgeon should be worried
about having their practice data published.
‘We would all want to know the data about the surgeon that we see for our own care, and the same applies to the public.’
Mr Mercer, who has taken on a role as a PHIN board member, describes the information being gathered as ‘golddust’ for doctors’ appraisal and revalidation.
‘You can push a button every year and out comes your private activity, which you can submit to your appraiser and, if need be, to your responsible officer. It will make the consultant’s life so much easier.’
He says he has found an enormous misconception among surgeons about what PHIN is about and recognises they have felt alienated from the process.
Describing his working relationship with the specialty associa
tions and Royal Colleges of Surgery as ‘good’, he feels he can now help bridge the gap with the consultant community.
‘People no longer have an easy way of knowing which consultants are ‘good’, in particular in the private sector. That’s why I think PHIN has a really important role in providing information for patients.’
With private healthcare ‘very expensive’, patients really do deserve to have better information, he says.
‘Don’t fear the drive for more openness’, see page 14
The Doctors Club and its partners raised £1,2 50 for charity at their firstever summer party.
The event was run in aid of Roald Dahl’s Marvellous Children’s Charity, who provide specialist nurses for seriously ill children and have supported more than 24,000 children.
Held at the impressive Auriens in Chelsea, the occasion was sponsored by Patient Billing, Top Doctors, Draycott Nursing, Phast Media and Private Care at Chelsea & Westminster Hospital.
Sponsors raised money, but The Doctors Club director Philip Archbold was delighted when Auriens ‘generously offered to
waive the not inconsiderable bar tab’.
He told Independent Practitioner Today : ‘After so long, it was just nice to be able to finally get out and do something social with our members and partners.
‘We can’t thank the sponsors
and our host enough for their generosity.’
The Doctors Club, set up in late 2019, is an exclusive, freetojoin benefits club for consultants, other doctors and health professionals.
It runs regular networking, educational and social events where members meet with peers and build their referral network.
They also benefit from preferential goods and services rates accessed through the membersonly Doctors Club website, plus other member only services.
More information is available at https://thedoctorsclub.co.uk/ about
It should be mandatory for medical experts’ reports to consider the role systems issues have played in an adverse patient outcome, according to a defence body.
Medical expert reports focus on scrutinising an individual doctor’s action – risking them being scapegoats for failings of the settings where they work, it says.
A report from the Medical Protection Society (MPS) entitled Getting it right when things go wrong: the role of the medical expert insists that organisational or systems failures which may have played a part in an incident must be included as standard in expert reports.
Medical director Dr Rob Hendry said experts had to address individual performance concerns, but ‘all too often’ doctors were blamed for workplace failings.
‘Patients and families also deserve a thorough explanation of what has happened and reassurance that the same thing will not happen again, and taking a broad focus and identifying all factors contributing to an adverse incident is vital in achieving this.
‘This, however, does not always happen and many expert reports focus solely on the actions of the individual without considering the wider context.
‘In reality, patient harm arising from medical error is rarely attributable to the actions of a single individual.
‘Inadequate staffing levels, lack of resources or faulty IT systems are just some issues which can contribute to adverse incidents. Doctors confront these issues every day and have little influence over them.’
The MPS report also sets out steps aimed at widening the pool of appropriately qualified medical experts.
By Edie Bourne
Doctors facing harsh tax penalties on their pensions will now see the issue debated in the House of Lords this month.
The news comes as more politicians are urging the Government to fix the healthcare workforce crisis, which has seen many senior doctors forced to reduce hours or retire early to minimise substantial tax charges.
It is expected that the debate will focus on the impact of the annual allowance and the link between the NHS pension and the Consumer Price Index (CPI) rate of inflation.
Every year, a doctor’s pension is uplifted by the September rate of the CPI plus 1.5 %. A higher CPI therefore results in a larger potential pension – but the increased growth can trigger a tax charge for breaching the annual allowance.
The annual allowance limits the growth of the yearly pension to as little as £4,000 for the highest earners. This means that once the growth goes beyond the figure
applicable to the member, tax at the doctor’s marginal rate of income is applied.
The CPI in September last year was 3.1%, up from 0.5% 12 months previously. By July 2022, the official rate was 10.1% already, with predictions from the Bank of England suggesting it might be as high as 13% in a few months’ time.
Patrick Convey, technical director at specialist financial planners Cavendish Medical, warned there was mounting concern among senior doctors that the soaring rates of inflation were going to
severely impact their pension tax.
The crucial September rate is not normally published until October, but many doctors had started to do the calculations and could see where their pension growth might be heading, he said.
With the annual total reward statements expected to now be ready for every NHS member, Mr Convey urged ‘everyone’ to download their document to check that the vital information was correct.
He urged doctors to remember to store this file for future use because
they could not download previous years retrospectively.
Mr Convey told Independent Practitioner Today : ‘We were surprised to see that this year’s statements do not contain any mention of the McCloud remedy, which will update figures for everyone, potentially for the last seven years.
‘The member’s actual position may now be completely different to the facts presented in the statement. This makes planning the best course of action to take based on your current outlook particularly challenging.
‘The statement does not contain any information about the annual allowance which is presented in a separate document and is only sent by default if the member’s total input exceeds £40,000.
‘The result is that many high earners caught by the muchlower tapered annual allowance may not be informed despite there being a potential tax charge.
‘As always, we would suggest you seek expert help from an adviser well versed in checking the nuances of your pay and pension.’
Doctors have been annoyed to hear that legislation to reshape the GMC, expected this year, has been put off until 202425.
The news brought frustration from senior medical leaders and led tothe Medical Defence Union (MDU) coordinating a protest letter to Health Secretary Steve Barclay signed by representatives of doctors’ trade unions and medical royal colleges.
Signatories included the BMA, the Royal College of Anaesthetists and the Royal College of Obstetricians and Gynaecologists.
In urging the Government to reconsider the timetable for reform, the medical leaders said
doctors would view a failure to reform their regulator this year as a broken promise.
MDU chief executive Dr Matthew Lee said: ‘The news that the Government has shelved longawaited reforms of the GMC until 202425 is disappointing, frustrating and surprising.
‘Doctors across the UK have waited a long time to see their regulator reformed. This was promised for this year and it is a promise that must be honoured.
‘A fitness to practise process is one of the most stressful experiences a doctor can have in their career, and current legislation is crying out for change.’
He said doctors deserved a fitness to practise process that was modern, proportionate, timely and, above all, fair. But currently, the GMC was operating under outdated legislation that disadvantaged the profession, patients and the GMC itself.
BMA Council chairman Prof Philip Banfield said: ‘The proposed reforms would have reduced the adversarial and combative nature of the fitness to practise process that is so stressful and damaging to doctors, with no additional benefit to patient safety’.
GMC chief executive Charlie Massey expressed disappointment, saying: ‘The current framework
stops us from being responsive and flexible in how we address patient safety concerns and register doctors to join the UK workforce. That isn’t good for patients and puts unnecessary strain on doctors.’
Earlier versions of this story were notified to readers in August and may have been missed by those away.
The number of cataract patients being treated privately has soared 22% in the past year as people give up on NHS waiting lists, according to data from an independent eye clinic.
There are 6.6m patients waiting for treatment in England with 331,623 waiting over a year and 8,028 for more than two years.
OCL Vision said the increase in private patients had boosted its income by 30%.
Cataract operations, said to be the most common self-funded medical procedure, increased by 56% to 12,700 last year.
Mr Romesh Angunawela, oph -
thalmic surgeon and co-founder of OCL Vision, said: ‘The effects of the pandemic have caused record waiting lists to increase even further, hitting cataract patients disproportionately hard.
‘Cataract surgery has long been one of the most common selffunded medical procedures, despite the disruption that cataracts can cause to sight, and this trend looks set to continue.
‘More people are coming through our door as the private sector steps in to reduce the burden on the NHS.’
OCL Vision brands itself as the only surgeon-owned, comprehen-
sive private eye care facility in London.
Its flagship clinic on New Cavendish Street provides a wide range of eye-related surgical procedures including cataract surgery, LASIK and LASEK laser eye surgery, refractive lens exchange surgery as well as other types of surgical vision correction techniques.
The clinic offers glaucoma laser surgery, retinal therapy for diabetes and macular degeneration and now cosmetic and reconstructive eyelid surgery and facial rejuvenation. It has several additional locations across London, Hertfordshire and Kent.
Specialist eye hospitals network Optegra Eye Health Care is expanding with the launch of a new clinic in Kent.
Optegra Eye Clinic Maidstone, in Kings Hill, will initially focus only on NHS cataract surgery.
It aims to extend its treatment offering to also include private cataract surgery and vision correction surgery from laser eye surgery
to lens replacement and implantable contact lenses.
The clinic will treat all cataract and lens replacement patients on site, but laser eye surgery patients will have pre- and post-op clinics there and their treatment at Optegra’s flagship hospital in the London’s Harley Street district ‘with travel expenses covered’.
It will be run by Mr Ibrahim
Toma, who has worked in Optegra for almost three years.
Lead ophthalmic surgeon Mr Robert Petrarca said he was excited to join the new venture.
He added that Covid had led to a large backlog of cataract patients awaiting treatment and his team were delighted to be able to support people in the Kent region with speedy access to treatment.
Theatre staff at Nuffield Health Plymouth Hospital’s heart unit celebrate their CQC rating
Nuffield Health has announced it is the only UK-wide independent hospital provider to have all its hospitals rated ‘good’ or ‘outstanding’ by UK regulators. Its Plymouth and Bournemouth hospitals received ‘good’ ratings from the Care Quality Commission (CQC) in the summer and join the healthcare charity’s 32 other hospitals across the UK rated similarly. The group’s Cambridge, Leeds and Chichester hospitals have ‘outstanding’ ratings.
Plymouth Hospital and Bournemouth Hospital were previously rated as ‘requires improvement’ after their last inspections.
Ben Davies, the group’s interim clinical services director, said: ‘This achievement is testament to the hard work of our teams across our network of 37 hospitals and healthcare clinics.’
Nuffield Health’s medical centres and healthcare clinics, located within fitness and well-being centres, which have been visited by UK regulators, are all rated as ‘Good’.
Nuffield’s newly opened and 37th hospital at St Bartholomew’s in London will not be rated until the Care Quality Commission (CQC) completes its next inspection of the hospital.
Nuffield Health added: ‘In Scotland and Wales, there are no specific “outstanding” and “good” ratings like the CQC ratings in England. However, Nuffield Health’s three hospitals in Scotland and Wales have been assessed for safe delivery of patient care and leadership with good feedback from regulators.’
Compiled by Philip Housden
Most NHS trusts have now published their 2021-22 annual accounts.
Analysis of private patient revenues shows a mixed picture for the top ten central London trusts that, pre-Covid, accounted for 70% of all England NHS trusts’ private patient incomes.
The Royal Marsden, for many years by far the biggest earner, is one trust yet to publish and it will be interesting to see how close the trust is to parity with pre-Covid revenues of £132.6m in 2019-20 from the £102.3m reported in 2020-21.
Although Royal Free are also yet to report, a lot can be learned: Guy’s and St Thomas’ are now clear in second place – up from sixth, both because of the merger with Royal Brompton and Harefield – previously fourth – and growth.
Combined earnings in 2020-21 were £30.2m, but this has jumped to £50.6m in 2021-22 – but still well down on the pre-Covid combined earnings of £66.8m
On the up
Imperial College increased revenues from £28m to £38.1m and moved into second place.
Moorfields grew from £24.3m to £37.2m and third spot.
Chelsea and Westminster grew 54% from £5.7m to £16.3m, and a likely sixth spot from tenth and UCL also increased revenues from £5.9m to £7.3m
Fallers
Great Ormond Street experienced a further fall of £12.6m and 33% to follow the Covid-impacted fall of 58% the year before.
Private patient earnings are now £24.9m, down from £64.8m two years ago, leading to a drop from
second to fifth largest NHS trust by private patient revenues.
King’s College joined them with a reduction from £6.3m in 2020-21 to £5.5m in 2021-22
Private ward re-opened by UCLH Private Healthcare
UCLH has re-opened a private ward at the National Hospital of Neurology and Neurosurgery following a major refurbishment programme.
The Bloomsbury Private Ward –previously known at The Nuffield Ward – has had a major modernisation to create an environment specifically designed for patients with neurological issues.
All 17 ensuite bedrooms have been fully refurbished and remodelled with the needs of patients and staff at the centre of the design.
There is the capacity to interconnect two rooms to create a larger suite if required and a bedroom with an ensuite bathroom has been specifically created to accommodate bariatric patients.
One bedroom has been set up to be able to undertake dedicated private telemetry studies, where patients being investigated for
Overall, it seems that central London trusts on average achieved growth of 25% last year – but this remains nearly 30% down on revenues for the same trusts preCovid in 2019-20.
While many trusts in the Top 20 outside London have yet to publish annual accounts, we do now know that both Cambridge University Hospitals and also Oxford University Hospitals have overtaken King’s and UCL to join the England NHS trusts Top Ten for the first time.
Cambridge grew 9% from £7.8m to £8.5m and Oxford was up 10% from £6.7m to £7.5m.
Further analysis will follow in future issues of Independent Practitioner Today.
neurological conditions can be videoed during neurological events while brain activity is simultaneously recorded.
A private autonomics diagnostic service will be offered from Bloomsbury Ward from the Autumn.
Director of private healthcare Kerensa Heffron said: ‘I am delighted that we are able to provide such wonderful facilities, which we can be as proud of as the world-class treatment we are already offering to our patients.
‘This new environment reflects back the quality of the expertise and care we provide every day.’
UCLH reported private patient revenues of £7.3m in the recently published 2021-22 annual accounts.
This is a rise of £1.4m and 25% on 2019-20, although still well down on the pre-Covid earnings of £20.4m in 2019-20.
Philip Housden is a director of Housden Group
Private patients in NHS private patient units (PPUs) can make complaints like anyone else – but not to the Parliamentary and Health Service Ombudsman.
Now the Independent Sector Complaints Adjudication Service (ISCAS) has drawn attention to a ‘reminder’ from the Care Quality Commission (CQC), following cases where PPUs wrongly thought they had access to the Ombudsman.
The CQC said: ‘It has come to our attention that there is some misunderstanding about the rights of private patients to take a complaint to the Parliamentary and Health Service Ombudsman (PHSO) for independent thirdstage review.
‘Only NHS-funded patients have the right to take their complaint to the PHSO under the NHS Constitution.
‘Those receiving care or treatment within a private patient unit run by an NHS trust, who are not satisfied with the outcome of a complaint that has exhausted the trust’s internal complaints process, do not have the right to take their complaint to the PHSO.’
ISCAS director Sally Taber told Independent Practitioner Today : ‘It is an enormous concern to ISCAS that 277 PPUs do not have access to an external review stage for their complaints management.’
She said the problem was being considered as part of ISCAS’s work with the CQC arising from the 2020 Paterson Inquiry report, whose Recommendation 6 was: ‘Information about complaints pathways to be communicated more effectively in the NHS and independent sector and private patients to have the right to mandatory independent resolution of their complaint.’
By Agnes Rose
New figures raise the question of where the next generation of private doctors and senior specialists will be coming from.
According to a survey, around one-in-two junior doctors (45%), one-in-three GPs (36%), and onein-four (25%) specialty doctors are considering leaving medicine to pursue an alternative career path outside of their clinical profession.
Younger doctors – those under 45 – were more likely to be considering a career change than the over-45s (34% vs 27%).
The survey was conducted by clinical news and healthcare information provider Medscape UK Its managing editor Vanessa Sibbald said the research uncovered some concerning realities.
‘Given the current staffing crisis and the ongoing pressure on medical professionals to work considerably extended hours with less staff in high-pressure environments, it is understandable yet alarming that so many of our junior doctors are considering leaving the profession altogether.
‘It is also worrying that over a third of doctors believe their side gigs are more fulfilling than their primary role, and GPs are much less satisfied with their job as a clinician compared to specialist doctors.
‘Our findings underscore the urgency to address the current working conditions of UK doctors so they can continue to provide an invaluable service to our healthcare system.’
Of the 1,012 UK doctors surveyed, more than one in three (37%) cited ‘burnout’ – not tied to the Covid-19 pandemic – as the most common reason for wanting to leave medicine and pursue a non-clinical career.
GPs were more than three times more likely to report burnout as the main reason for waving goodbye to their profession than specialty doctors (16% vs 5%).
When describing the timeframe for making the switch, 28% hoped to make it within a year, and a further 30% anticipated this change to happen within two to three years.
Medscape, which is also a source of point-of-care tools for healthcare professionals, said these short time-scales for pursuing non-clinical careers suggest that the current pressures of working as a doctor in the UK, in both a GP and
hospital setting, are currently way too high.
When asked about the alternative career choices they would consider, the following professions were cited:
Healthcare business companies (33%);
Education/teaching (32%);
Pharmaceutical company work (22%);
Writing (20%);
Technology (17%);
Law (9%).
Specifically, for GPs and speciality doctors, the most popular choices were education/teaching (35% and 29% respectively) and
One-in-three doctors (34%) felt no guilt or regret about their investment in time and money on their medical education when asked about moving into a non-clinical career.
This sentiment was felt more by those aged 45 and over (43%) than under-45s (20%).
One in five (21%) felt the opposite sentiment with a lot of guilt or regret. Female doctors and the under-45s expressed this around twice as much as male doctors and 45 and overs.
Our findings underscore the urgency to address the current working conditions of UK doctors so they can continue to provide an invaluable service to our healthcare system
VANESSA SIBBALD, CHIEF EXECUTIVE OF MEDSCAPE UK
healthcare business companies (35% and 31% respectively).
Engaging in ‘side gigs’
The same report found that sevenin-ten doctors (70%) were already engaging in ‘side gigs’ alongside their primary job as a clinician, with around the same number of GPs as specialty doctors involved in these endeavours (29% and 34% respectively).
When questioned about how fulfilling their side gigs are compared to working as a doctor, more GPs than specialty doctors felt that their side gigs were more fulfilling than their primary role (55% vs 34%).
Despite just over half (55%) of doctors feeling ‘satisfied’ or ‘very satisfied’ with their primary role as a clinician, only 30% of GPs reported this compared to 62% of specialty doctors.
For more findings, view the full report on www.medscape.com/ uk-side-gigs-2022
The report is based on a survey of 1,012 practising UK Medscape member doctors between 22 February to 31 May 2022.
Nearly half of juniors intend to pursue non-clinical careers
The top reason (37%) is burnout, but this is not directly linked to the Covid-19 pandemic
29% would like to make a career change, with females more likely report this than males (36% vs 25%)
By Douglas Shepherd
The private hospitals national body is calling for Britain’s new Premier to support its push to educate NHS patients of the private sector option to end their long waits.
Its move followed performance figures last month showing a record 6.78m people awaiting health service treatment.
David Hare, chief executive of the Independent Healthcare Providers Network (IHPN), responded that the record waiting list was another stark reminder of the scale of the NHS challenge facing the new Prime Minister. He said: ‘An urgent priority for the new Prime Minister must be to commit to a national campaign to make NHS patients aware of their legal right to choose different providers for their treatment.
‘Recent IHPN research conducted with the Patients Association found that, across England, patients need to travel just 13.2 miles – around 30 minutes by car – to cut over three-anda-half months off their NHS waiting time.
‘The fact that patients report being willing to be treated at an alternative provider that can treat them more quickly – whether NHS or independent sector – should come as no surprise and the time has come for the Government to make patient choice a reality for far more NHS patients.’
BMA consultants committee chair Dr Vishal Sharma warned that the new Prime Minister was inheriting a beleaguered health service with a deep-rooted workforce crisis exacerbated by two pandemic years.
Richard Murray, boss of health
think tank The King’s Fund, said: ‘The intense pressure on NHS and social care services has barely featured in the Conservative party leadership race, yet the new Prime Minister will inherit a health and care system in a state of steady crisis.’
He predicted an even deeper crisis if Britain’s new leader failed to prioritise action to shore up health and care services.
However, The King’s Fund saw ‘a faint glimmer of light’ with the virtual eradication of two-year waits for planned NHS care.
It said efforts would now be focused on hitting the April 2023 target of no patient waiting more than 18 months for care.
The figures brought a renewed call from the Royal College of Surgeons of England for Ministers to make £1.5bn funding promised for surgical hubs available immediately.
The NHS waiting list rose from 6.6m in May 2022 to 6.7m in June, 59% higher than before the pandemic
People waiting a year or more for treatment increased from 331,623 in May 2022 to 355,774 in June.
53,911 are waiting over 18 months for treatment (a 9.8% decrease from May ‘22) and 3,861 waiting at least two years (a 52% decrease).
Orthopaedics continues to have the largest waiting list at 760,108.
NHS figures quoted here were released in August
Queen Square Imaging Centre, London, has installed the UK independent healthcare sector’s first MR-guided focused ultrasound system – a treatment that can give immediate relief for people with essential tremor. Over 1m people are diagnosed with the condition in the UK and around 25% suffer from disabling tremors. The treatment uses precision-guided sound waves to achieve targeted thermal tissue ablation of key areas in the brain that cause the uncontrollable shaking or trembling associated with the condition.
A unique collaboration with functional neurosurgeons at the National Hospital for Neurology and Neurosurgery enables Queen Square to offer patients the choice of all primary surgical treatment options for essential tremor –
alongside deep brain stimulation and radiofrequency ablation.
Consultant neurosurgeon Mr Jonathan Hyam said: ‘We have been using minimal access techniques to treat tremor at Queen Square for many years. This new focused ultrasound technique will be a further leap, as there is no requirement for an incision in the scalp or skull or passage of instruments through the brain.
‘Many patients find this more
The Queen Square team with the first patient to undergo the new magnetic resonancefocussed ultrasound treatment
acceptable and desirable. Focused ultrasound therapy provides the opportunity for patients to undergo brain treatment as a day case or outpatient procedure.
‘It also increases the number of patients who can be offered treatment, since patients with other significant medical conditions can usually be treated this way.’
The ultrasound system is owned and operated by QS Enterprises Ltd, a not-for-profit trading sub -
sidiary of the UCLH Charity. Chief executive Jodee Cooper said: ‘While we will begin as a private patient service, it is our intention to seek NHS commissioning in time to assist with the burden on growing NHS waiting lists. We are also looking forward to collaborating with the neurosurgeons on research which will hopefully develop new applications for this treatment beyond essential tremor.’
The first patient to be treated, Linda, experienced ‘an immediate and significant reduction in the tremor in her right arm’ after 20 years with the condition.
Operations manager Peter Sutton said: ‘To achieve the result we saw with our first patient would previously require much more invasive surgical intervention, with longer recovery times and higher risk.’
Here are the detailed results of a survey Independent Practitioner Today has conducted in conjunction with the Medical Defence Union on the impact of the pandemic on private practice
THE DOCTORS surveyed came to the following assessment of how their private practice has changed following the pandemic:
Waiting times for patient initial appointments have increased –30.8%;
Waiting times to complete treatments have risen – 29.6%.
Patients present with more advanced pathologies – 25.8%;
Increased demand for routine screening and tests – 27.3%.
The pandemic has ushered in more frequent use of remote consultations/telemedicine for 42.3% of respondents and a greater flexibility of appointments for patients (12.7%) plus more flexibility of work for doctors (12.3%) too.
According to 11.2% of doctors, it is now easier to communicate with patients. But they are in a minority – 14.2% find it harder; 25.8% cited other changes.
The move by a minority of independent hospital operators to try and attract doctors to work for them on an employed and salaried basis, rather than practising privileges, has been fiercely resisted by most consultants and our survey results sprung no surprises.
However, the salaried option received stronger support than might have been expected before the pandemic.
Asked how likely they were to undertake employed rather than
self-employed work in private practice, nearly two-thirds were not in favour: 33.8% said ‘not likely’ and 31.8% ruled it out, saying ‘not at all’.
But 10% said ‘highly likely’ and a similar number opted for ‘somewhat likely’. 11.1% were neither concerned nor unconcerned about the issue. Five per cent stated they were already working as employees in private practice.
The pandemic’s experience may be a big factor in whether around one-in-five doctors with a private practice decide to carry on.
We asked: ‘To what extent do you agree with the statement: I am more likely to retire from private practice due to the pandemic?’ 4.6% said they strongly agreed and 14.2% answered they ‘tend to agree’.
But 31.2% strongly disagreed, 20% tended to disagree and 30% expressed no firm opinion.
Thank you to all the doctors who took time to take part.
The salaried option received stronger support than might have been expected before the pandemic 2
The pandemic’s experience may be a big factor in whether around one-in-five doctors with a private practice decide to carry on
4. Did you provide addition NHS services during the pandemic?
5
6 In what ways has your private practice changed following the pandemic? (Please tick all that apply)
6. In what ways has your private practice changed following the pandemic? (Please tick all that apply)
6. In what ways has your private practice changed following the pandemic? (Please tick all that apply)
Greaterflexibilityof appointmentsforpatientsIncreaseduseofremote consultationsPatientsMoredemandforroutinescreening&tests withmoreadvancepathologiesappointmentsWaitingtimesforinitialhaveincreased Waitingtimestocomplete treatmentshave increased
Waiting times for patient initial appointments have increased
Waiting times to complete treatments have increased
Patients presenting with more advanced pathologies
Increased demand for routine screening and tests
Increased use of remote consultations/telemedicine
Greater flexibility of appointments for patients
Greater flexibility of work for doctors
Easier to communicate with patients
Harder to communicate with patients
Other – Write in
7 How likely are you to undertake employed, rather than self-employed, work in private practice?
7. How likely are you to undertake employed, rather than self-employed
8.
8 To what extent do you agree with the following statement: I am more likely to retire from private practice due to the pandemic?
b)
c)
b) Tend to disagree
e)
9. How has working during the pandemic impacted upon your health and well-being? Please rate (agree or disagree)
I
The principal aim of the Competition and Markets Authority Order
is to improve patient safety – and no consultant should be against that, says consultant plastic surgeon Mr Nigel Mercer (right).
He shares his views with Independent Practitioner Today as a member of the Private Healthcare Information Network (PHIN) board
Your previous national roles included being immediate past president of the Federation of Surgical Specialty Associations (FSSA). Why did you join the PHIN board?
I have worked with PHIN pretty much since the start when I was president of the British Association of Aesthetic Plastic Surgeons (BAAPS).
Even from the early conversations, I felt PHIN’s work was clearly very important, particularly at that stage for cosmetic plastic surgeons like myself. Historically, we haven’t been great at recording our activity – particularly our private work.
I’ve continued to be part of the conversation in my presidential terms with the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the FSSA.
It became clear to me that there was an enormous misconception among a lot of surgeons with what PHIN was about and they felt alienated from the process.
I have good working relationships with the specialty associations and Royal Colleges of Surgery and feel that I can play a role in bridging the gap with the consultant community.
What role do you think PHIN can play in supporting patients?
Twenty odd years ago, the local GPs would know consultants in their area and, in particular, who was ‘good’ for any particular procedure. Unfortunately, the breaking of the link between primary and secondary care has been an enormous detriment to the public.
People no longer have an easy way of knowing which consultants are ‘good’, in particular in the private sector. That’s why I think PHIN has a really important role in providing information for patients.
From personal experience, I have had family members who needed pretty rapid private care in a part of the country where I don’t have many contacts, and the amount of information which I could get about the surgeons in the area was a problem.
Private healthcare is very expensive and patients really do deserve to have better information. After all, they are buying a bespoke, luxury service.
Providing information for patients is what the Competition and Markets Authority (CMA) Order is about. PHIN was set up by the CMA to make sure that the CMA Order is fulfilled; it is a legal requirement, after all. This whole project is about making sure information is transparent and easily available to patients.
Earlier this year, the CMA wrote to all hospitals encouraging better engagement with PHIN and the CMA Order. Is the CMA ‘upping the ante’?
I think this is more about the CMA putting a marker in the sand. The Order is secondary legislation, so it has to be done and, to be honest, it’s probably about time they did put pressure on to get it finished. At this stage, the Order can’t be changed and so we do need to get it done.
I would also say that, in the last few months, there’s been a real sea change in terms of the relationship between PHIN and the providers, the private medical insurers and consultants. It’s definitely much more collaborative now than it was previously. There is also a genuine understanding now that we do need to change things.
Why should consultants engage, and what would you say to consultants that are wary?
The main reason consultants should engage is that it’s a legal requirement and you can’t choose not to engage with a legal requirement.
However, there are other good reasons for consultants to engage. To me it is a bit of a no brainer. I know of consultants who have complained for many years that they aren’t getting the referrals. This is a chance to put information about the quality of care you provide in front of patients.
No surgeon should be worried about having their practice data published. We would all want to know the data about the surgeon that we see for our own care and the same applies to the public.
The information that PHIN is gathering is also golddust for our appraisal and revalidation. You can push a button every year and out comes your private activity, which you can submit to your appraiser and, if need be, to your Responsible Officer. It will make the consultant’s life so much easier.
What do consultants need to do?
We have to remember that we’re still coping with the pandemic and there’s been another big increase in hospital admissions and infections with Covid.
We also have to be mindful that most consultant surgeons have
been working their tails off to try to catch up with the backlog and are very tired.
What I would say to surgeons is what we’re asking you to do – and what you’re mandated to do – is actually extremely quick and straightforward to do. It would take you or your secretary probably an hour to submit your fees.
Having done it myself for my own private practice some time ago, I know that it used to be a little laborious, but the way that the portal is set up now it crossreferences everything and it’s quick to do.
Everything else that PHIN publishes about consultants is collected and submitted via the private hospitals in which you work.
Of course, we encourage you to look at your activity and other data. If your hospital has you down as having operated on a toenail when, in fact, you are a hip specialist, then that will give patients a very odd view of your work. It will also ensure you are paid correctly for what you do.
It doesn’t have to be you who looks through the data – most consultants working privately have very good medical secretaries, who probably know what we do better than ourselves.
Essentially, this is about making sure what is recorded in your billing correlates with what your hospital has recorded and submitted to PHIN. If the information submitted about your practice is not correct, you can correct it.
What should consultants do if they have any questions?
PHIN has an excellent consultant relationship team, led by Anne Coyne, whom many people will know. They can be contacted at consultants@phin.org.uk
And if people want to talk to me directly, I’m very happy with that. I view that as part of my role on the PHIN board. That can be set up through Anne and her team at PHIN.
The final thing I would say to anyone concerned about this is that no one is the ‘enemy’ in getting the CMA Order completed. We have a law to comply with and PHIN is the co ordinator of the industry’s response. The principal aim is to improve patient safety, and no consultant should be against that.
Mr Mercer chairs the MHRA’s Plastic Reconstructive and Aesthetic Surgery Expert Advisory Group
Independent provider Genesis Care has released a paper setting out its position on the future of cancer care across the UK.
It aims to address the challenges the Government faces in cancer care and provides ‘viable solutions’ to reset and transform this.
Responding to the Government’s call for evidence on its ten year cancer care plan, the report outlines these areas for greater focus:
➤ Insufficient capacity to meet rising demand: The number of patients requiring treatment is more than the current system can handle. Clinicians’ time is stretched, waiting lists are growing, and care among regions is variable, meaning inequitable outcomes for patients.
➤ Lack of agility across the current system – including approval and implementation of
techniques and treatments: The Covid 19 pandemic highlighted how quickly processes can adapt, regulatory bodies can act and guidelines can be updated in periods of crisis. This now needs to be implemented in areas which need it most, primarily oncology.
Achievable solutions
GenesisCare, a global oncology specialist working with over 5,000 cancer experts, says it is dedicated to early investment in worldleading technology and treatments. Its paper outlines achievable solutions it believes could be adopted without major financial outlay, including:
➲
Utilising all available assets in the most effective way possible in the immediate term. It says the move to Integrated Care Systems offers an opportunity to
take a regional and sectoragnostic approach to utilising assets, ensuring the NHS can help to reduce the patient backlog and reduce pressure on staff capacity and resource by using all available infrastructure at maximum capacity.
➲ Prioritising investment and delivery of innovative diagnostic techniques that deliver the best possible treatment options and technology that reduces the burden of aftercare.
This includes personalised, precision medicine through Next Generation Sequencing (NGS) and cell free DNA (cfDNA) and stereotactic ablative radiotherapy (SABR) on modern equipment, such as MR LINACs, can significantly reduce the burden on aftercare and support services.
➲ Integrating data sharing and international evidence to
deliver a more integrated approach for cancer patients that allows comprehensive records to be shared across general practice, community provision, local hospitals, the independent sector and regional tertiary care.
➲ New regulatory systems to ensure new treatments can be quickly appraised and approved in a routine way, including greater acceptance of clinical evidence gathered outside the UK.
Dr Eliot Sims, the company’s clinical oncologist and chief medical officer, said: ‘It’s clear that, with the current landscape, we need to fundamentally change the way we approach the care crisis in order to deliver the best quality of care possible for all patients – achieving the Government’s goals of making our cancer care systems the “best in Europe”.’
A look back through our journal’s archives of a decade ago reveals that although times change, some issues are not so new
Rising numbers of consultant group bust-ups were costing specialists ‘vast sums of money’ because they had never bothered with a proper practice agreement.
Many partnerships formed during the surge in group growth over the previous decade had set up their structures on a basis of trust between like-minded doctors.
But lawyers warned that increasing numbers were now paying the price when business pressures lead to disagreements and they found they had no binding deeds to fall back on.
They then faced ‘horrendous’ legal costs – eating up years of private practice profits in some cases – while trying to get their dispute sorted out.
Lawyer Chris Inson urged all private partnerships to review their existing arrangements to ensure they were ‘fit for purpose’.
The Independent Practitioner Today columnist called on consultant groups to try to avoid litigation at all costs: ‘Whether due to the ever-evolving world of private practice or facing the ongoing challenges to remain at the top of the game, medical partnerships find themselves under constant pressure.
‘This inevitably gives rise to tensions within partnerships, both in relation to clinical and financial management.
‘But problems can be avoided, or at least mitigated, by ensuring that partnership agreements are comprehensive and up to date.’
Bleak figures on the state of private medical insurance (PMI) showed a further fall in the numbers of people covered and a record low among patients buying policies themselves.
Healthcare intelligence provider Laing and Buisson (now LaingBuisson) said policies dropped by 0.2% to reach 3.971 million at the start of 2012 following an 8% drop in the previous two years.
It reported individual PMI demand was down by 4.2% in 2011 after similar falls of 4.6% and 3.7% in 2010 and 2009, moving to under one million for the first time in recent years.
‘Good news’ was a small growth in company-paid PMI, up 1.2% from the previous year following falls of 3.3% and 4.7%.
The British Association of Aesthetic Plastic Surgeons (BAAPS) expressed delight at a government move to clamp down on cosmetic cowboys.
Consultant plastic surgeon and BAAPS president Mr Fazel Fatah said the review followed years of campaigning for better regulations of the cosmetic surgery sector to protect patients.
GPs were significantly more likely to ask patients about whether they had private medical insurance, a survey found.
More than half of family doctors did not perceive a conflict of interest between provider and commissioner when directing a patient for private treatment.
Survey results from Spire Healthcare revealed that over half of GPs in the UK (54%) reported feeling comfortable when directing patients to private treatment, irrespective of whether they had private medical insurance or not.
But one-in-three GPs said they still felt uncomfortable about doing this.
Doctors who practised outside the NHS were warned that they needed to ensure they had a suitable appraisal in 2012 in case they were among the first tranche of doctors called upon to revalidate after April 2013.
An article in Independent Practitioner Today said that although appraisals might not have been a feature of working life for all private doctors in the past, annual whole-practice appraisals were at the heart of the GMC’s revalidation process, which was only a few months away.
Consultants at BMI Healthcare had seen an 87% rise in the number of international patients treated since a team was set up to manage growing business operations in the Middle East, Asia and north Africa.
How about making the news today? Independent Practitioner Today is always keen to hear from doctor entrepreneurs willing to share their stories in private practice – and from independent practitioners embarking on the journey. Contact our editorial director Robin Stride at robin@ip-today. co.uk
If your clinical practice is called into question by your employer, the GMC, or others, you have the right to request our assistance. Our experts are always there, ready to provide you with support, advice, and to help protect you when you need us.
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Don’t let GMC reform become a casualty of a change of government. The MDU’s Tom Reynolds (below) explains why action is vital now
The Government has now said that substantive GMC reforms have been shelved until 2024 at the earliest
A NEW GOVERNMENT is set to be installed as I write and it has been far from business as usual in Westminster during the Parliamentary recess
We are halfway through this Parliament and awaiting several important pieces of legislation. This includes longawaited reform of the GMC and its fitnesstopractise procedures. Sadly, this legislation has been derailed yet again.
When the Government published its consultation on proposals to modernise healthcare professional regulators in March 2021, chapter six set out the next steps for reform.
This promised that ‘following this consultation, we will bring forward draft legislation to implement these changes in relation to the GMC’ for consultation ‘in the autumn and for the legislation to come into force in the spring of 2022’.
This timetable was welcome, but the Government has now said that substantive GMC reforms have been shelved until 202425 at the earliest.
This is hugely disappointing and frustrating. The Medical Defence Union (MDU) believes that the original timetable should be kept and is spearheading a coalition of senior healthcare organisations to make the case for that.
We coordinated a letter to the Health Secretary Steve Barclay, signed by leading healthcare organisations, including the BMA and a number of medical royal colleges, urging the Government to bring in the legislation this year as promised.
We all want to see a regulator that protects the public while dealing with doctors fairly and compassionately. However, the GMC’s fitness to practise procedures are rigid and still governed largely by outdated legislation.
The GMC’s fitness-to-practise procedures are rigid and still governed largely by outdated legislation
While limited progress has been possible, such as the introduction of provisional inquiries, only a complete reset of the GMC’s legislation can bring about a system that is truly modern, proportionate, timely and, above all, fair.
Of course, the MDU had some concerns about some of the proposals within the 2021 consultation, such as scrapping the ‘five year rule’ on historic complaints.
However, there is much we did support, particularly the creation of a three tier fitness to practise process comprising initial assessment, examiner stage and panel hearing.
This would allow more cases to be appropriately resolved at an earlier stage, without in any way detracting from the GMC’s responsibility for protecting patients.
We agree that case examiners will need a full range of disposals available to them to conclude cases, including through the accepted outcome process. There should be sufficient oversight of fitness to practise decisions via the proposed ‘registrar review’ power.
It is also highly welcome that the GMC’s ability to appeal decisions by the Medical Practitioners Tribunal Service (MPTS) is to be removed.
As a medical defence organisation, the MDU has supported and
defended many thousands of doctors at the GMC over the years and we have a strong track record.
In cases heard by MPTS between 2016 and 2020, MDU solicitors representing members achieved no finding of impairment in 42% of cases, compared to the average of 21.5%.
At the same time, MDU members tell us repeatedly that undergoing a GMC investigation is one of the most difficult experiences of their professional lives.
The stress of being under scrutiny during a lengthy and potentially careerending process would have an impact on anyone, but it is particularly traumatic for doctors whose mental health is already a concern or those who do not have a support network around them.
Tragically, according to GMC statistics, at least five doctors died by suicide while under investigation or monitoring by the GMC in the three years up to 31 December 2020.
This follows the GMCcommissioned Horsfall report of 2014, which found that involvement with the regulator was one of several risk factors for suicide, particularly in cases of multiple jeopardy – concurrent investigations by different bodies.
Of course, there are usually multiple factors in such cases, but in the current climate where many doctors are already exhausted and working under huge strain, it is more important than ever to have a humane regulatory system. With the GMC powerless to properly change without the promised legislation, the status quo endures.
Further delay is not in the interests of doctors or the patients who depend on them. The Government needs to keep its promise and deliver reform without delay.
Tom Reynolds is head of government and external relations at the Medical Defence Union
Fertility treatments in private practice are booming. Gynaecologist Mr Rehan Salim (right), subspecialist in reproductive medicine at the new Lister Fertility Clinic at HCA Healthcare’s The Portland Hospital, shares his perspective
FERTILITY AND related services
have been seeing an ongoing growth and rise in demand.
This has lead to an increase in the number of fertility clinics, as well as associated services, including alternative medicine practitioners such as acupuncturists and fertility nutritionists.
This growth would imply there is a rise in fertility-related medical problems and that, as a species, we are increasingly becoming less fertile. The theory is appealing, but it is unlikely to hold true.
Overall, data suggests that for age matched populations, we are no less fertile today than we were in previous years.
However, society has changed, certainly in western societies and increasingly in the developing world as we are choosing to delay childbearing.
This choice is driven by societal and economic change. Fundamentally, as we face common challenges and choices around careers and our personal funds, individuals now prefer to wait until they are best placed both professionally and financially to have a child.
This makes sense: why bring a child into the world when we cannot guarantee it a good life?
But this societal shift is not without consequences for some, especially women. Biology dictates they are most fertile in their youth and with advancing age comes depleting fertility rates.
This paradigm forms the basis of an unfair and unjust situation, where biology has not kept pace with society. Thus, as women delay childbearing – as is often
seen in many developed and now developing societies – their chances of conception unfortunately decline.
This leads to them turning to fertility treatments to help, which is the main driver of the increase in fertility services we see today.
But, human nature, being what it is, who wants to admit the decline of their youth; especially when you have achieved career and life success?
As a result, many women turn to alternative medicine before seeking science-backed medical fertility treatment such as IVF.
There is also the patchwork provision of fertility services within the NHS. While NICE has provided a clear and unequivocal set of recommendations for provision of fertility treatment, most clinical commissioning groups are noncompliant.
The driver for this divergence from recommended good medical practice is undoubtedly public finances. Full implementation of NICE guidelines would enable couples to have their medical needs met by the NHS. But, in an era of limited public finances, no one should be hasty to judge the prioritisation of other services over fertility treatments, as something has to give.
This situation also drives patients to seek private fertility treatments. The range and quality of services available privately has meant that increasingly, when given the option between an NHS provider of private fertility treatment and a full private clinic, the patient chooses the latter.
Private providers have the freedom to invest in technology, staff and premises. This undoubtedly gives a better patient experience, driving more people to use them and resulting in the continuous growth of private fertility treatments, which we will see for years to come.
Given the demand and rewards for private fertility providers, it has allowed for investment into the advancement of technology and quality equipment, allowing outcomes to continue to improve.
The Human Fertilisation and Embryology Authority dataset shows that over the last 10-20 years
Future growth in private fertility services will come from patients choosing clinics providing quality medical care and novel technologies that may ultimately improve outcomes of licensed fertility treatment in the UK, pregnancy rates continue to grow for most patients.
Given the returns on investment, there is a strong driver for research and innovation within the private fertility clinics, many of whom are at the cutting edge of reproductive medicine. This will continue to differentiate the highquality clinics from the rest.
Future growth in private fertility services will come from patients choosing clinics providing quality medical care and novel technologies that may ultimately improve outcomes.
The latter has been controversial, with a Competition and Markets Authority investigation making recommendations around transparency.
Ahead of the curve
Greater transparency will improve information provision in the best clinics – which are probably ahead of the curve with this anyway –and separate a market within which quality clinicians are better placed to explain and deliver best practice. Demographics and NHS provision will also drive the market further.
Society will change and, especially for women, awareness of potential fertility issues will allow access to fertility preservation and leave open options for delaying motherhood.
The NHS has an important place in the delivery of fertility treatments and should continue to provide this.
However, as the provision of NHS-funded care develops, there is undoubtedly a place for private providers of NHS-funded care. And this equity of provision will also drive the growth of fertility clinics that are able to invest and deliver the very best outcomes for patients.
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How does any business owner decide how much money to invest in marketing? Should the marketing budget be based on a percentage of income? Or is it best to identify the projects for the year and the cost of each one to build up the overall budget? Our troubleshooter Jane Braithwaite (left) gives her views
IF A BUSINESS invests £1 in marketing and generates £5 of income there is an argument to spend as much as possible on marketing to generate the highest income. Most businesses need to be more mindful of cash flow and are not able to deliver exponential growth to justify that level of marketing spend.
When making any business decision it is wise to look at what other companies are doing to learn from their experience. The Gartner report titled ‘The state of the marketing budget 2021’ provides some insights into post-covid trends about marketing expenditure.
Gartner reports that marketing spending as a percentage of income is at the lowest point in history. In 2020, marketing spending as a percentage of income was reported to
be an average of 11%. In 2021 this reduced drastically to 6.4%. Before 2020 the percentage had typically sat between 10% to 12%.
We can assume that in the coming years, as business confidence returns, we will see this percentage increase again to pre-covid levels.
In many small to medium businesses, decisions on marketing budgets are made on a project-byproject basis. This creates a shortterm approach and stunts the creativity of the marketing manager or team.
I am totally against micromanagement, as I firmly believe individuals can contribute more when they are given responsibility and accountability and allocating the
marketing budget in this way does not encourage either.
Setting a budget, ideally for the next 12-month period allows you to work with your marketing team to make sensible, long-term decisions.
If you are new to the concept of marketing your business, then setting a budget for the whole year may seem too large a step. In that case, start with a budget you feel comfortable with and invest wisely. Measure the success of your campaigns and invest more in those that are most successful.
Before allocating any of your budget, you must set out your objectives for your marketing activities. What do you want to achieve, when do you want to achieve it, and how will you meas-
ure success? Success can be so subjective in marketing, so it is critical in any plan to define your SMART objectives. So your business goals must be Specific, Measurable, Achievable, Relevant and Timebound.
The subjective and individual nature of your objectives means that there is no boilerplate plan for marketing your business. This is why you must work with your team to set out how your marketing will help achieve your vision for the business.
Your marketing budget is not going to be infinite, so it must be carefully allocated to projects and campaigns that are likely to bring revenue to your business. There may be larger projects, for example, a new website or a large event,
which will take up a large proportion of your overall budget.
Allocation of budget to these ‘big-ticket’ items needs to be done with care to avoid using all your resources up too early in your financial cycle.
One of the decisions you will need to make is how often to review your marketing results. The risk from checking too often is that you may feel the effects are taking too long.
On the other hand, if you only look at the outcome of your efforts once a year, you will be unable to make adjustments to projects that are underperforming or to double down on your successes.
One possible approach is to sit down with your marketing team and have a full review of your activities and results every quarter. This way you can start to see which of your activities are having the right
effect, and which are having no effect at all. This will allow you to make alterations to your approach if required, or to cut projects when needed.
The essence of good marketing is measuring the outcome of your campaigns so that you can calculate your return on investment; in essence, how much ‘bang for your buck’ you are getting.
Tied to this is the concept of ‘lifetime value’ (LTV), which is the average revenue you will earn from a patient throughout the entire time they are with your practice.
This figure will vary hugely between clinicians. Those that usually see a patient to treat a oneoff problem will derive a very different lifetime value than those who treat patients with lifelong conditions.
Your marketing team will help you review the data for your practice to work out the average LTV for your patients. If the amount you
Marketing has the power to bring greater success to your business if done properly
spend to acquire a patient is less than the LTV that the patient will bring, then you can begin to generate a profit.
If you spend £100 on marketing to attract two new patients to your practice and the lifetime value of each patient to your practice is £1,000, then your return on investment is excellent.
There would be a strong argument that you should invest £1,000 in the same form of marketing and generate 20 new patients. You could invest more, of course, and
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soon the limiting factors will be your time and how many patients you can see each week.
Marketing has the power to bring greater success to your business if done properly. With the help of your marketing team, you should set a sensible budget with specific goals, and a reasonable time span to take effect. Your success, or otherwise, should be measured against specific targets.
Marketing is an investment in the future success of your business and should be viewed as a worthwhile expenditure to achieve your goals.
If you have any specific questions that you would like answered in upcoming editions, please do feel free to get in touch.
Jane Braithwaite is managing director of Designated Medical, which offers flexible, customised support for private practice needs including accountancy, marketing, medical PA, HR, and recruitment
Fee complaints received by the Independent Sector Complaints
Adjudication Service were highlighted in a news story in our July-August issue. Here Independent Practitioner Today reports on other complaints received – and learning points – relating to consultants and medical care
IN THE financial year of 2021-22, the Independent Sector Complaints Adjudication Service (ISCAS) reviewed 75 heads of complaint about consultants and/or medical care and has analysed its key areas of concern.
Its code covers:
Complaints about doctors and other health care professional staff working in subscribing organisations, including consultants with practising privileges;
Complaints made by or on behalf of patients regarding all aspects of their care or the services provided by or in a subscribing organisation. These include complaints about medical care or treatment or a clinician’s behaviour.
At the same time, there may be parallel procedures relating to the same events; for example, involving a professional regulator or in the courts.
In recent years, ISCAS has identified an increase in the number of complaints made about consultants and other doctors and the medical care provided.
ISCAS’s review for the last year reminds consultants of their obligations to comply with the GMC document Good Medical Practice (2013) and to follow all its guidance about Decision-making and consent (2020)
Consultants and doctors are also reminded about their obligation to comply with record-keeping guidance.
It says consultants should work
in partnership with patients, act with integrity, and listen to and respond to their concerns and preferences, ensuring any information is provided to patients in a way they can understand and to respect their decisions about treatment.
ISCAS found consent forms completed by consultants were not always properly finished and specialists did not always clearly document details of the proposed procedure to be carried out and the intended benefits.
‘From the cases that have come to ISCAS, we note that the consent forms also often lack information relating to the potential risks and complications,’ it says.
‘ISCAS wishes to remind consultants that it is neither sufficient nor acceptable for them to list a small number of risks followed by “etc” in the relevant section of the consent form, nor is it appropriate for them to refer in the consent form to other documents that have been
shared or discussed with patients rather than clearly documenting the relevant risks and complications.’
Patients were not always provided with written information about their proposed procedure either at their initial consultation or as the consent process progressed.
ISCAS says this information, which could be in the form of a general patient information leaflet relating to the proposed procedure or specific written advice, should be provided as early as possible, ideally at the initial consultation.
It stresses that all written information provided should be reviewed regularly and kept up to date.
Consultants are also criticised in the review for not always adequately documenting details of conversations held with patients, including those relating to the consent process.
Phone conversations should be included too.
The complaints service highlights that patients sometimes feel ‘rushed’ during the consent process and ‘under pressure’ to sign the relevant consent forms, while others felt they had undergone procedures without fully understanding any associated risks.
It reminds consultants to ensure patients get time to consider and reflect on their proposed procedure and ensure they know about any associated ‘cooling-off’ period.
Patients do not always fully understand the potential benefits from procedures, ISCAS found. This can result in their expectations often not being managed when the outcome is not as anticipated.
‘ISCAS notes that consultants should be clear with patients from the outset about the intended ben-
➱ continued on page 26
ISCAS found consent forms completed by consultants were not always properly completed and specialists did not always clearly document details of the proposed procedure to be carried out and the intended benefits
efits that may be obtained from treatment or surgery and encourage them to ensure that patients understand that there can be no guarantee that a specific outcome will be achieved.’
An increasing number of patients have complained about the level of pre-operative instructions and postoperative advice and guidance that they have been given and about the lack of the provision of associated written information.
ISCAS reminds consultants in its review of obligation as directed by the GMC (2020) to ensure patients are provided with all relevant information to enable them to make an informed decision about treatment.
It says consultants should ensure they:
Clearly document in the patient’s record all relevant postoperative advice and guidance;
Ensure patients are given written information, including contact details of the relevant person to contact for assistance or in an emergency.
Concerns are also growing about the standard of record-keeping among consultants and doctors.
The inadequacy and lack of comprehensiveness of some clinical records are highlighted and also an increasing trend in the number of entries by consultants and doctors in clinical records that are illegible.
In another ‘reminder’, ISCAS states consultants are obliged to ensure they keep accurate records of all interactions with patients, including when complaints have been made.
‘This includes keeping detailed records of any and all consultations and communication, including consultations that have been held virtually and phone conversations.’
All doctors should ensure each entry in the patient’s clinical record is dated, timed and signed as per the requirements.
Consultants are also asked to remember the importance of providing the treating hospital or organisation with a copy of all records relating to their interac -
tions with patients, including consultation notes and correspondence to the patient’s GP.
‘Where agreed with the organisation, this could take the form of uploading consultation notes and correspondence to the patient’s electronic record.’
Increasing complaints about the conduct and attitude of some consultants and doctors are also noted.
While recognising difficulties in communication can sometimes arise for various reasons, ISCAS draws attention to doctors’ obligation under the GMC to listen to patients, respond to their concerns and preferences, treat them with integrity and respect, and provide them with reassurance when required.
It says some patients might sometimes perceive the consultant’s attitude as being patronising, disinterested, dismissive or lack-
ISCAS recommends that subscribing independent healthcare providers inform consultants when complaints have been made about them and provide them with a copy. It also recommends that:
Consultants should always provide written comments or a statement in response to complaints made about them
They should send detailed letters to patients after the initial consultation that confirm the discussion that has taken place about the proposed procedure and the associated risks and complications
That these letters refer to the patient information leaflets or other information, a copy of which should be shared with them. ISCAS finds this approach provides a stronger basis for subsequent concerns raised by patients who often have a different recollection of what was discussed
Subscribing independent healthcare providers remind consultants and doctors about their requirement to actively and positively engage in the organisation’s complaints process when complaints have been made about them or the care or treatment provided, this being a requirement of their practising privileges agreement.
ISCAS says this includes the requirement for consultants to provide written comments or statements when requested to enable the organisation to respond to complaints.
It is hopeful that adherence to its guidance will see a reversal in the number of complaints about consultants and the medical care provided.
Increasing complaints about the conduct and attitude of some consultants and doctors are also noted
ing in empathy and, in some cases, patients think they have been treated aggressively.
ISCAS emphasises the need to treat patients politely, considerately, professionally and with dignity at all times and to respect their confidentiality.
It adds that it’s important to agree with patients at the outset the mode and frequency of communication with them to enable their expectations to be managed effectively.
More complaints have also been looked into where people were after an apology from the treating consultant. Increasing numbers of cases claim apologies were insincere and lacking in empathy.
ISCAS draws attention to guidance issued by Ombudsman Offices in the UK on what constitutes an effective apology and how this may be delivered.
When providing an apology, doctors should acknowledge any wrongdoing or offending action or behaviour, accept responsibility for the offence and any harm done and acknowledge the impact of any wrongdoing on the complainant.
It is also important to explain any steps or actions taken to prevent a recurrence.
‘ISCAS considers that an apology should be issued as soon as possible after wrongdoing has been established and should be meaningful, unconditional, and empathetic. ISCAS also considers that that the language used when making an apology should be clear, plain, direct, sincere and unambiguous.’
Most patients who are seeking an apology require this in writing. ISCAS highlights, however, that an apology, including a written apology, is not the same as an admission of liability.
Indemnity surrounding data and confidentiality breaches can be complex, but by taking steps to understand it and ensure appropriate protection is in place doctors can potentially avoid a costly claim. Dr Dawn McGuire (right) looks at some cases and what to glean from them
CLAIMS ARISING from data or confidentiality breaches are not uncommon. A claim may arise, for example, after medical information or test results have been divulged to a patient’s relative or representative without the patient’s consent.
They have also been reported following doctors or their secretaries:
Accidentally sending medical information to the wrong recipient or address;
Losing medical records in their care;
Accidentally leaving medical records in a public place.
These case examples demonstrate how data or confidentiality claims can come about:
CASE STUDY 1
LEAVING MEDICAL RECORDS IN A PUBLIC PLACE
Dr P, a private consultant psychiatrist, treated Mr B for anxiety and depression following a traumatic childhood assault.
He took his printed paper records with him after a meeting one day and accidentally left the bundle of records on a public car park paying machine as he was fumbling for coins. He returned an hour later but the bundle had disappeared and was never found.
Dr P complied with his duty of candour and informed Mr B about the incident. Mr B pursued a claim against Dr P for data and confidentiality breach. Mr B alleged that
A psychiatrist left his patient’s notes on a car park paying machine while fumbling for cash
someone somewhere had possession of sensitive information about him and his anxiety had deteriorated as a result of this fear of uncertainty.
The public liability insurer (PLI) of the clinic where Dr P worked declined to assist with the claim because the incident did not take place on the clinic premises and Dr P was an independent contractor, not an employee.
As the incident did not arise from clinical practice, the claim was also out of scope for assistance from Dr P’s medical defence organisation (MDO).
Dr P therefore sought independent legal advice and the claim was eventually settled at his own personal expense.
CASE STUDY 2 NOT CONFIRMING WHO YOU ARE SPEAKING TO
Miss A, a consultant gynaecologist and director at a women’s clinic, treated Mrs F for dysuria and a recent test came back positive for chlamydia. Miss C, a receptionist at the clinic, was asked to contact Mrs F and arrange for her to attend for a consultation.
Miss C called the landline number on record and spoke to a ‘Mrs F’ but did not confirm other personal details such as date of birth.
Miss C was very sympathetic about the infection; she reassured ‘Mrs F’ that this was very common and that she was not judgemental at all. Unbeknown to her, she was speaking to the patient’s sister-inlaw, who was also ‘Mrs F’.
Mrs F, the patient, pursued the clinic for a data breach claim and psychological injury following the breakdown of her relationship.
Miss A was familiar with data protection law and also knew that indemnity protection had to be obtained from a PLI or another appropriate insurer. As Miss C was an employee, the clinic’s PLI took over the conduct of this claim.
It is vital that doctors and their administrative team are familiar with data protection laws, confidentiality and information security, and are adequately trained.
The Information Commissioner’s Office provides a useful guide to data
protection for organisations and employees who have day-to-day responsibility for data protection. Claims or fines arising from data loss or breaches fall outside of healthcare indemnity and so are out of scope for MDO assistance.
This is in line with NHS Resolution’s position where the Clinical Negligence Scheme for Trusts and the Clinical Negligence Scheme for General Practice also do not protect against issues arising from data breaches. NHS organisations, however, can turn to NHSR’s Liabilities to Third Parties Scheme for data breach claims.
In a private healthcare setting, hospitals and clinics need to ensure adequate protection is in place for these claims. Directors and managers can explore protection options with a PLI or other appropriate insurer; for example, employers’ liability or directors’ liability insurances.
Private consultants who hold practising privileges in private hospitals, and are not employees, may not be protected for confidentiality or data breach claims and may find themselves personally liable for these claims.
It is therefore imperative that doctors are familiar with these matters, take steps to protect themselves on a personal level and take care to ensurethat patient confidentiality is protected.
Dr Dawn McGuire is a medical claims adviser for Medical Protection
With an increased focus on planning for ESG – environmental, social and governance – in the healthcare sector, what should doctors in private practice be considering? ESG experts Jamie Foster and Gemma Badger share their recommendations
AS GOVERNMENTS , organisations and individuals around the world focus more on ESG, it is becoming increasingly important to understand what this is and how its principles apply on a practical level.
This is the case no matter the sector in which we work or the scale on which we do so.
The independent healthcare sector, as a major potential contributor, both positively and negatively, to goals associated with ESG is no exception.
For larger organisations bidding for public sector contracts, looking to secure finance or satisfy shareholders, there are already many compulsory hoops to jump through relating, for example, to net zero or social value targets and activity.
That public sector is becoming more attuned to this need and adapting accordingly, with whole teams of individuals tasked with doing so.
But what about individual healthcare practitioners working independently and/or at a much smaller scale? What do they need to know, why should they know it and what are the practical steps which can be taken now to respond to the ESG imperative?
What is ESG?
ESG initiatives encompasses a huge area of focus taking their starting point from the United Nations’ 17 Sustainable Development Goals, ranging from the elimination of poverty to clean sanitation, gender equality, climate action, sustainable cities and communities, and good health and well-being.
It is a framework within which organisations can demonstrate a shift in emphasis of their operations from short-term profit maximisation as the primary objective of a business model to positive societal impact from an environmental, social and governance perspective.
Increasingly, there are non-negotiable reasons for building this shift into business operations – for example, needing to demonstrate credentials in this area to be considered for contract opportunities, together with less pressing factors. But equally important reasons for that focus surround the moral imperative to positively influence the communities in which organisations operate.
Healthcare professionals practising on a smaller scale may be tempted – or, given workloads, too busy – to assume that they either need not or cannot influence ESG factors in their work or that doing so is something which can be put off to another day.
But this is not the case. While they may not have immediately pressing compulsory targets to satisfy, this may change in the future. For example, if supplying services to the NHS, from April 2023 the NHS will require all suppliers with a contract value of £5m plus to publish a carbon reduction plan for their direct emissions.
The NHS target of achieving net carbon zero for its carbon footprint – that is the emissions within its supply chain which it does not control directly – by 2045 and its stated plan to no longer purchase from suppliers who do not meet or exceed its carbon zero commitment by 2030 also needs to be borne in mind.
Also to be considered are targets set by larger independent sector organisations if they envisage supplying services to them. Steps to conform to targets cannot be met overnight and so thought needs to be given to it now.
The UK Government has also set a binding target to reach net zero emissions by 2050.
And there are, likewise, many positive reasons to focus on ESG, now as viewed from both a moral perspective and in responding to increasing staff and consumer awareness of the agenda. Doing so can prove a rewarding endeavour either resulting from satisfaction at ‘doing the right thing’ or increased ability to attract and retain patients and staff who view ESG aims as important and want to use providers who share that belief.
FROM AN individual practitioner perspective, the key areas to target are environmental and social.
While some goals may not be achievable overnight, the key action is pulling together a plan to achieve them. Carbon reduction considerations should include analysing your baseline to see where you are now and starting to draft a carbon reduction plan.
Stage one is understanding what the relevant goals and targets are, what they mean and who is setting them.
For example, we have already noted the NHS target to reduce its carbon footprint to net zero by 2045, but it is also targeting an 80% reduction of this between 2036 and 2039 and intends a target of net zero by 2040 for the emissions it does control.
These targets are ambitious, with the NHS aiming to be the world’s first net zero public health service.
Closer to home, the Independent Healthcare Providers Net work (IHPN) has announced an industry-wide commitment for independent healthcare providers to go beyond the NHS target to achieve net zero by 2035 – with a net zero supply chain by 2045 –with some members committing beyond that ambitious target to achieve net zero by 2030.
With consumers taking note, there could be competitive advantage through attracting patients and staff by demonstrating commitment and that practical measures are being taken.
This being the case, stage two is taking steps – or planning to do so. But what might these be?
From an environmental perspective, there are many areas to target; for example, considering
more environmentally friendly products such as low plastic, low emissions alternatives for drugs such as anaesthetics and inhalers, and re-usable rather than single use products.
Another area to look into is the process of re-manufacturing – a step beyond recycling, which involves breaking down products or their components before restoring them to useful life.
This is currently being trialled for healthcare products including neonatal monitors and a range of surgical tools. Engaging with relevant suppliers now would be a useful initial stage in the plan.
A further aspect to consider is the use of digital options, including for consultations and treatments, such as apps for use in the treatment of mental health conditions or for physiotherapy.
This enables carbon reductions to be made through reducing the need for patients to travel to access services. This has increased as a result of Covid in any event, so we can expect an evolution rather than an entirely new step to build into the plan.
Also worth thinking about is energy sourcing. Can a move to entirely renewable sources of supply be made. Can electric vehicles be used?
From the social perspective, getting involved with supporting local communities is a clear step to take if that is not already happening.
Considering employment practices and whether there are ways to adjust these to ensure that they support the entry of under-represented or disadvantaged groups into the workforce is another point to bear in mind.
The above, non-exhaustive list of proposals for ‘ticking’ ESG boxes is
a good starting point, but it is essential to remember that responding to ESG concerns is more than a tick-box exercise.
You may have heard the term ‘greenwashing’, which involves presenting an environmentally responsible public image when this is not the case.
This is problematic both from a legal perspective, as a breach of consumer rights legislation and advertising standards and also reputationally, as organisations engaging in such activity have been recently named and shamed in the press.
Where does this leave us? This summary has flagged reasons for healthcare practitioners to take note of the ESG agenda together with a few of the measures which you might want to initiate to respond in the shorter term.
But the most important first step is having a plan for steps which can be taken and reviewing what might be possible or desirable from your practice’s perspective.
Engaging with consumers and employees to finalise the plan is likely also to prove productive as will their enthusiasm for taking it forward.
The task in hand may appear daunting at first, but taking initial steps towards doing so will ensure the overall goals can be achieved in the longer term.
Jamie Foster is a commercial lawyer and Gemma Badger is professional support lawyer, both at Hill Dickinson LLP
Bupa’s WELLBEING INDEX
In our July-August issue, Dr Robin Clark (right), Bupa Global and UK’s medical director, explained how the insurer is embarking on the first step towards finding ways to improve the nation’s health with the launch of its new Wellbeing Index.
Now he digs deeper into what the findings mean for the future – and the challenge for healthcare professionals trying to turn around the impact of Covid-19
Carried out by Censuswide, this rolling dataset will track five key health and well-being metrics for 8,000 UK adults each quarter, capturing a range of health, wellbeing, lifestyle and behaviour datapoints to help us and our healthcare partners understand more about the nation’s health.
The survey population is split by demographics including sex, age and geographic location, which enables us to explore key trends and spotlight where there are potential issues, so that we can continue to design and deliver healthcare in the most impactful way.
Unsurprisingly, the Bupa Wellbeing Index shows that physical health aligns with age – 51% of 16 to 24-year-olds and 56% of 25- to 34-year-olds assessed their health positively, compared to 45% of those over 65s.
And this trend is also seen when looking at those who rated their physical health as ‘very good’ –18%, 15% and 11% respectively.
For over-65s, the Index shows that some of people’s most pressing health concerns include back, neck or joint pain (27%), their weight (25%), and their level of physical fitness (22%).
One study from the US shows that overall sedentary behaviour has also increased, with physical activity among the already active dropping by a third and already sedentary people remaining so.1
Sedentary lifestyles are now a public health emergency, with the World Health Organization warning that physical inactivity is the fourth leading risk factor in deaths globally.2
Researchers define sedentary behaviour as anything we do when we are awake which has a metabolic equivalent task (MET) of 1.5 or less. MET is a measure of how many calories we are burning.
This raises important questions about how we can best support an ageing population in continuing in good health for as long as possible.
However, we should not be disheartened; studies show that each positive change a person makes, no matter how small it may seem, will deliver benefits. Every journey is a series of small steps.
We know that physical activity such as walking, gardening, lawn bowls or swimming is one of the best things people can do to reduce dementia risk. Given rising dementia rates, one of the simplest steps we can take is to encourage people to take up an active hobby.
In some areas where exercise on prescription is available, it may be suitable to encourage increased activity which has already been used to help mental health.
The UK Chief Medical Officers recommend3 at least 150 minutes of moderate intensity activity –such as brisk walking or cycling –or 75 minutes of vigorous intensity activity, such as running, a week for adults aged 19-64 years. And for those aged 65 and over, 150 minutes of moderate intensity
➱ continued on page 32
In our previous issue, Dr Robin Clark explained how and why Bupa embarked on its Wellbeing Index to benchmark the country’s baselines of health
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With people demonstrating so much good intention to prioritise their health and well-being, we could be forgiven for thinking our work is done. However, it seems that some of these changes for good have gone awry as they have a habit of doing.
The findings show that three-quarters of those surveyed (73%) have failed to maintain the health and lifestyle interventions they started a year ago.
People’s most common challenges revolve around health and diet, with 8% admitting they have given up on weight loss diets and the same number abandoning plans to eat more healthily.
Those most worried about their weight were between 25 and 45, the phase of life that’s important for building and maintaining muscle mass and lung function to set the scene for a healthier old age.
And while over-65s were the least likely to make positive health changes, they were – by far – the most likely to stick with them. More than half (54%) of those who have taken steps to improve their health have maintained this momentum, compared to only 20% of 16- to 24-year-olds.
Of those who increased the amount they worked from home during the pandemic, 61% said that the overall health impact has been negative. The Index found that:
Almost a third (31%) of people who work from home reported they have eaten more in the past two years as a result;
15% said their alcohol intake has risen;
Almost a quarter (23%) said it has eroded their self-confidence;
19% said they have done less exercise;
A third (32%) reported an overall decline in their mental health.
We know that the first lockdown was a huge learning curve for all of us; decisions had to be made at pace and many existing practices and guidelines around health and safety, line-management and health and well-being support were overtaken. It is important that we review the pluses and pitfalls of these changes and then take forward and embed the lessons we have learned, both in our capacity as clinicians and employers of practice teams.
aerobic activity is recommended each week, building up gradually from current levels.
Those who are already regularly active can achieve these benefits through 75 minutes of vigorous intensity activity, or a combination of moderate and vigorous activity, to achieve greater benefits. Weight-bearing activities, which create an impact through the body, are also important in helping to maintain bone health.
We can also harness technology to help us support the ageing population remaining in good health.
Over time, the data from the Index will tell us where the particular health concerns of our over-65s cohort lie and, as we get a better picture, we can use it to help us plan to address those concerns.
It is encouraging to see that the data highlights people’s renewed focus on the importance of health and well-being, and the breadth of their good intentions.
Over the past year, four out of five respondents (84%) have taken steps to improve their diet or lifestyle, with the most common interventions being:
Better diet (35%);
Exercising more regularly (30%);
Trying to get a full night’s sleep (28%).
Women were slightly more likely to have made positive changes (88% compared to 80% of men), as were younger adults –87% of 16 to 24-year-olds compared to 81% of 55- to 64-year-olds and 71% of over-65s.
As we might expect, over-65s were the most likely to have had a full health check in the previous 12 months (10%), closely followed by the 55- to 64-year-olds.
This is good news, as these are the years when the risk of many age-related issues such as heart disease, diabetes, cancers and musculoskeletal problems begin to climb significantly.
Regular health checks increase the chances of catching problems quickly and we know that early diagnoses and interventions can make a huge difference in terms of treatment options and outcomes.
However, it is concerning that nine out of ten over-65s have not had a health check over this period.
Another finding which also points to potential for improvement was the fact that 29% of over-65s take regular exercise to try to improve their health and head off problems – the same percentage as those aged 35 to 54 and ahead of the youngest demographic –16- to 24-year-olds, at 26%.
The data highlights some important gender divides. Twice as many women as men attempted a weight loss diet in the past year – 23% compared to 11%. They are also more likely to have tried to improve their diet – 41% of women compared to 28% of men.
Similar gender divides can be seen on sleep-related interventions, with 36% of women having tried to improve their sleep patterns compared to 20% of men, and also efforts to maintain a better work-life balance, with 29% of women trying versus 17% of men.
Men were marginally more focused on regular exercise (30% compared to 29% of women), cutting down on alcohol (23% versus 22%) and stopping smoking (8% versus 6%).
These findings show that there is clearly a strong appetite for healthier lifestyles and each and every one of these interventions will deliver real benefits for both physical and mental health.
As positive steps also have a habit of snowballing, we need to encourage our patients to continue on this journey.
Regular exercise supports weight loss and improves mood and sleep patterns, a healthier diet makes it easier to lose weight and generally makes people feel more energised and upbeat, and everyone feels better after a good night’s sleep.
These findings show that there is clearly a strong appetite for healthier lifestyles and each and every one of these interventions will deliver real benefits for both physical and mental health
ONE OF the biggest motivators for those who took part in the Index was family.
Family is hugely influential –more than two-thirds (69%) of those surveyed said the biggest driver for taking care of their health and well-being was the desire to ‘be there for my family’.
The other top motivators the panel reported was wanting to improve their life expectancy (67%) and 66% wanted to do what they could to head off serious health problems.
Knowing this is a great tool to have when we need to persuade a patient to consider making a lifestyle change.
We need to lock onto these drivers and develop support which will encourage people to take more ownership of their health and well-being.
It is also important to recognise that the pandemic has impacted people in very different ways. For example, while 33% of those surveyed reported a decline in their mental health as a result of two years of home-working, almost a quarter (23%) say their emotional well-being is better than before.
Similarly, although 22% believed their overall health has
declined, 16% say it has improved over the past two years.
One in five (19%) of those surveyed has become more anxious about their appearance as a result of more online meetings, but 16% are now less likely to worry about the way they look.
More work is needed to identify why some groups have been more resilient than others and we must find ways to tackle the negative impacts while also exploring strategies and support which will amplify the positive changes.
The evidence is beyond doubt. People who are active and healthy are less likely to develop a huge number of health issues including coronary heart disease, high blood pressure, diabetes and many cancers.
Older adults who are active experience fewer musculoskeletal aches and pains and are less likely to suffer falls and the pain and problems which can flow from them.4
Identifying the barriers to good health and well-being will be essential if we are going to find ways to overcome them and develop health systems which
focus on prevention and reducing the burden of avoidable issues, rather than dealing with the damage they cause.
The Bupa Wellbeing Index will help provide the data and insight needed to help achieve this.
References
1. Changes in physical activity and sedentary behaviour due to the COVID19 outbreak and associations with mental health in 3,052 US adults. International Journal of Environmental Research and Public Health, 2020.
2. Global Recommendations on Physical Activity for Health, World Health Organization, 2010.
3. UK Chief Medical Officers’ Physical Activity Guidelines, 7 September 2019.
4. Risks of Physical Inactivity, John Hopkins Medicine
DELIVERING AN outstanding first-time experience for patients is crucial to delighting them and generating positive word-ofmouth recommendations.
But in my final article in this series, let’s look at taking things a step further: turning patients into advocates of your practice
Remember, it is estimated to cost seven times as much to acquire a new patient than retain an existing one.
In my first feature on patient acquisition back in May, I covered the challenges independent practitioners face in finding new patients and how it is not as easy as many think.
It can often take months and even years to perfect your acquisition strategy, so once you have onboarded a patient, how can you retain them and keep them loyal to you?
In many healthcare fields, active or existing patients can be your best marketing tool by recommending you to other people and driving word of mouth – which can result in you spending less marketing budget on patient acquisition.
Here are a few ideas and initiatives that you might want to try.
➲ Patient communications
Remaining front of mind with your patients is important for the future growth of your clinic, so make sure you are communicating with them on a regular basis.
Investing time and effort on creating interesting and informative content on your website and then emailing or text messaging patients is a great way of keeping patients engaged.
In the last of his marketing series, Simon Marett continues the patient experience theme by giving ideas to help grow patient retention and drive loyalty and advocacy among patients
This can relate to conditions that you treat, treatments you offer or subject matters closely linked to your clinic. Make it interesting and encourage patients to share this content with their friends, colleagues and family to organically build your network and database of prospects.
➲ Case studies
New patients love nothing more than reading stories about patients who they relate to and have had a great experience – from symptoms and diagnosis through to successful treatment.
Contact those patients who have left a positive review about you and ask if they would be happy to share this story on your website and social channels. This can take the form of a written blog or a short Q&A video recorded over Zoom or Teams.
Once you have published the content on your website, include it in newsletters and share it on your social platform to share these stories.
➲ Patient surveys/reviews
Patient surveys are now very common, but that has not always been the case. They can be a very effective way of keeping in touch with patients and getting valuable feedback on their experience and how it can improve.
Positive reviews can then be presented on your website to help attract new patients, but you can also take it one step further.
Frequent patient research and surveys into symptoms, conditions and treatment options can help create interesting content that you can then share with patients and build loyalty by bringing them back to your website and clinic
Regular patient webinars on Zoom or Teams can be a fantastic way of building loyalty amongst your existing patients and attracting new ones.
Collating frequently asked questions (FAQs) from patients and building a calendar of content on topics that you know your patients will find useful and informative is a great first step.
Promoting these webinars to patients and incentivising them to invite friends and family can also help build your database of future patients at minimum cost. You can also post recordings of these webinars on your website and link to them through your website homepage, blog and newsletters.
If you have a physical clinic and can invite patients to a location, it can be a great way of engaging with them.
As well as answering burning questions, it can be an opportunity to visit the clinic or theatres
Active or existing patients can be your best marketing tool by recommending you to other people and driving word of mouth and meet other clinicians and the patient care team who will be supporting a patient throughout their journey with your clinic.
Acquiring new patients can be one of the biggest challenges for some in private practice and therefore any exercise that makes it easier and keeps a lid on marketing spend has got to be explored.
Retaining patients and generating positive word of mouth and recommendations can be an incredibly cost-effective way of driving new patients.
Simple marketing initiatives such as patient reviews, webinars and case studies are all very useful for creating loyalty among your patients and gaining new ones.
These ideas and initiatives can be all be managed internally, but if you have a small team and you are already stretched, it is worth considering some temporary marketing support to get you up and running.
This can offer tried and tested methodology and valuable advice and guidance to help you avoid the pitfalls and common mistakes.
At Ellerton Marketing, we provide a free 60-minute business ‘health check’ for Independent Practitioner Today readers and can help guide you through some key steps you should think about to build loyalty among your patients and leveraging positive word of mouth.
Simon Marett (below) is a director of Ellerton Marketing
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Simon Brignall reflects on the challenges that consultants’ groups face with their billing – and points out some of the differences from running your own sole practice
CONSULTANTS FORMING groups are nothing new and they have always formed a key component of our client base at Medical Billing & Collection (MBC). But their popularity has grown over the past decade.
There are many reasons for this including:
Groups’ ability to provide clinical services to the NHS and private sector;
Economies of scale that can help reduce costs;
Private medical insurers favouring the group model;
Super-specialisation and cross referral opportunities within the group;
Brand identity and marketing opportunities;
Patient Recorded Outcome Measures (PROMs) data;
Confidence and capacity as a proven referral pathway.
Some specialties such as anaesthetics and radiology naturally favour the group model, especially when they supply clinical services to a private hospital or NHS trust.
Group structures improve the quality of care provided to the patient by having several consultants working together within the same specialty, yet with each doctor having specific expertise within their own field.
Specialties such as urology often form groups where one consultant urological surgeon may focus on stone removal and another whose subspecialty is uro-oncology.
Groups can also benefit from increased volume, as insurance
companies and GPs are more likely to refer patients to them because they know they have capacity and expertise as centres of excellence in their field.
Orthopaedic groups allow a group of surgeons to have a brand identity for treating a wide range of patients, who may require a hand and wrist, shoulder and elbow, hip and knee, spinal or foot and ankle surgery.
Groups can provide many benefits, but, in our experience, many find the medical billing side of the business challenging and unless professionally managed, this vital area can very quickly run into difficulties.
We partner with more than 50 groups across a wide range of specialties and well know the problems that arise. So I will use this
and next month’s article to discuss some of the key points you should consider when setting up or joining a group.
The term groups can include consultants working under a variety of models depending on their group dynamic and specific needs.
The simplest is a virtual model where consultants continue to operate as individual practices under common branding that often includes a website. Virtual models can still allow for shared administration costs and still appear unified from a patient perspective.
More formal structures can be utilised such as consultants forming chambers, limited liability partnerships or limited companies.
We have had several group practices join us that have hundreds of thousands of pounds outstanding and who have written off tens of thousands of pounds in bad debt
promptly means that problems with invoices are not identified early, which can impact their chances of resolution.
Delays at this key stage mean that all the further stages of the revenue cycle are impacted, which not only makes the practice look unprofessional but can lead to patient dissatisfaction and negatively impact cash flow.
Groups who employ practice managers and medical secretaries are required to make binary decisions about staffing to facilitate their activity. The organic nature of many groups means that managing their workload can be challenging as new consultants join the group or members leave.
This is a major reason why groups choose to outsource their medical billing and collection, as this provides it with excess capacity on tap when required. Outsourcing also offers the added benefit of a cost structure linked to received income.
An often-overlooked benefit of outsourcing is the improvement to the patient journey because staff are freed up to focus on their customers. And that can lead to an increase in revenue as a result of more referrals and quicker responses to new inquiries.
Of course, groups have many benefits derived from their economies of scale. But it is important to ensure these are not lost by ineffective management.
These group structures often have centralised pooled funds. Some have founding partners and can have various rules around the distribution of funds and the allocation of costs.
Some well-established groups require a consultant to hit a revenue target or work for a specified time before their income and cost allocations is equitable to other participants in the group.
But groups often become a victim of their own success.
Managing the volume of activity generated by the group is the single biggest issue that they deal with and the more successful the group, the bigger this issue becomes.
The administration required for
consultants working together is often underestimated. This covers all aspects, from the raising of the invoices to the volume of phone calls and emails that require answering on top of dealing with private medical insurers, clinics and hospitals.
In our experience, often the first job to be set aside is the reconciliation and chasing of invoices.
Delays in reconciliation mean that debt and cash flow suffer, because if you do not know what is outstanding, then it is impossible to raise shortfall invoices in a timely fashion and chase any money owed.
This situation can easily escalate, as the busier the group practice becomes, the less time is spent on this function and money owed to the group accumulates .
In some cases, this can result in
consultants earning less money than they did before they formed or joined the group, which obviously defeats the point. Even when the group takes steps to remedy the situation, it is often only a short-term fix and the problem recurs worse than before.
We have had several group practices join us that have hundreds of thousands of pounds outstanding and who have written off tens of thousands of pounds in bad debt. But we average a bad debt rate of less than 0.5% across the firm.
It is not uncommon for busy groups to get behind on the raising of invoices and, as the first stage in the revenue cycle, this leads to delays all down the line.
Failure to raise invoices
Next month in Independent Practitioner Today , I will cover groups’ billing and pricing, bank accounts and reporting.
This will also feature a check list for the group you are considering joining, examining each of these key areas.
If you are seeking to establish a new group, this article will also act as useful guide to some of the challenges you may face. Often the best solution is to seek the advice of a professional medical billing company.
Simon Brignall (right) is director of business development at Medical Billing & Collection
Recent research from fund managers Dimensional showed that, on average, returns following market falls tend to be quite strong, historically delivering a cumulative 50% rise in value over the subsequent five years in the US after a 30% fall
It is important to keep perspective on shortterm falls. Dr Benjamin Holdsworth (right) on the slow process of building and spending wealth
AT TIMES like this, when it can feel like there is much doom and gloom in the news, it is worth taking a step back to gain a little perspective.
For most investors, the accumulation of wealth is a slow process as money is put aside month on month into pensions and ISAs, inheritances are invested or the proceeds of company sales are put to work in the markets.
This multiple-decade journey to a level of wealth that provides choice, freedom and financial security is punctuated by moments of market turmoil that lead to temporary falls in portfolio values.
When accumulating wealth, such falls provide the opportunity to buy equities at lower prices and with higher expected returns. Income from employment provides a sense of security and, for some, surplus cash flow to accelerate contributions to the pot.
Alternatively, options remain for some to retire later or to work parttime.
When workplace income stops, and portfolios take over the role of providing cash flow to fund lifestyles, it is entirely understandable that falls in their values may make some investors feel a little bit uncomfortable.
No one wants to go back to work, curb their plans or – in extremis –risk running out of money.
It is helpful to remember that, as part of the financial planning process, the financial capacity to suffer losses is modelled to test the suitability of the portfolio chosen to meet a client’s goal with a high degree of confidence.
Regular meetings with advisers also provide updates on how the plan is evolving against its target and the opportunity to talk through any areas of concern and, if necessary, to make informed choices to ensure the plan stays on course.
As part of this analysis, financial planners will be fully aware that investing is a three-steps-forward,
one-step-back type of process and will strive to help clients to understand the nature of the journey they face.
However, when markets fall, much of this can be momentarily forgotten. There will be times when portfolio returns are well ahead of inflation and other times when they are not.
Despite all of the bad news, portfolio returns in 2022 are not as bad as some might have imagined, helped by broad diversification and, to some extent, by the weakness of Sterling. Remember, overseas assets are now worth more priced in Sterling terms.
Outcomes in 2022 still sit well within expectation. In fact, a 60% global equity, 40% global bond portfolio could fall by 30% or more and still be within the bounds of expectation.
It is helpful at times like these to remember that the process of spending wealth in retirement is a
slow process too, similar to its accumulation.
Imagine that the withdrawal rate from a portfolio is 3% of its starting value per year adjusted for inflation – in other words, £30,000 on an initial £1m invested. A couple of years of returns below inflation, is going to make very little impact on portfolio outcomes over a 20- or 30-year or more retirement horizon.
There should be plenty of years ahead when portfolio returns will be above inflation, although there are no guarantees. Even if there are not, the annual planning process will provide the opportunity to adjust future plans in a calm and informed manner.
Those who have been invested over the past few years will already have accumulated strong growth in the purchasing power of their portfolios, providing a solid
Outcomes in 2022 still sit well within expectation. In fact, a 60% global equity, 40% global bond portfolio could fall by 30% or more and still be within the bounds of expectation
on average – as ever, no guarantee – returns following market falls tend to be quite strong, historically delivering a cumulative 50% rise in value over the subsequent five years in the US after a 30% fall. Investing is indeed a slow process that cannot be rushed.
Dr Benjamin Holdsworth is a director of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS.
financial buffer against times like these.
Investors are well served by measuring the value of their wealth against their long-term plan, not against the latest highwater mark of the markets. Portfolio values are still materially above where they were a couple of years ago, even when measured from pre-Covid levels in 2020.
Recent research from fund managers Dimensional showed that,
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.
Independent Practitioner Today has joined forces with leading healthcare lawyers Hempsons to offer readers a free legal advice service.
We aim to help you navigate the ever more complex legal and regulatory issues involved in running and developing your private practice – and your lives.
Hempsons’ specialist lawyers have a long track-record of advising doctors – and an unrivalled understanding of the healthcare system as a whole.
Call Hempsons on 020 7839 0278 between 9am and 5pm Monday to Friday for your ten minutes of free legal advice.
Advice is available on:
Business structures (including partnerships)
Commercial contracts
Disputes and litigation
HR/employment Premises
Regulatory requirements and investigations
In this three-part series, inquest solicitors from Hempsons explain how the inquest process relates to independent practitioners. This month, Clementine Robertshaw (right) shows how to prepare for giving evidence to an inquest in writing and if called to attend in person
ANYONE WHO works in medicine may be involved in an inquest at some point in their career. It can be a nerve-wracking experience, particularly for independent practitioners.
Inquests are very different to other types of legal proceedings you may have experienced as a doctor, as the process is effectively an investigation led by a judge and each case can run very differently.
If you are asked by a coroner to provide evidence for an inquest, either a request for a report or witness statement or to attend court to give evidence in person, it’s important to react quickly.
Your role will vary depending on whether you were providing a key service related to the cause of death, involved shortly before the death occurred or had a more tangential or direct role in care.
Generally, you should inform your indemnity insurer, medical defence organisation or legal team for advice and support through the process.
As a witness, your role is to provide the evidence you can to help the coroner answer four key questions: who died, where they died, when they died and how they came by their death.
The family and friends will often have wider questions, but the coroner will seek to focus the inquest process on those matters which will help them understand the nature of the death.
As a witness, you are not expected to provide all the answers, because the coroner will be gathering evidence from a range of people and organisations.
In preparing a witness statement, you should bear in mind that it will be key in whether the coroner decides to call you to attend the hearing. You are less likely to be called if it is clear that you have provided all the evidence you can in your statement and that it answers any obvious questions.
So make sure you review relevant
records, explain key terms and acronyms, and explain your role and your service. You should make clear what role you personally played in the care, what information comes from your memory or mainly from the records and what is the context which you weren’t involved in but helps your evidence to make sense.
It is very useful to bookend your evidence with confirmation of your first and last direct involvement – or that of your team – so the coroner can see that you have included everything relevant.
As the coroner’s focus is on the details, nature and cause(s) of the death, the narrative should end at the death, other than to offer condolences to the family.
Keep in mind that the family are very likely to read your statement, so while it is factually clear, ensure it is also appropriately sensitive. Details such as spellings must be accurate to reflect the care you take in your work and how seriously you take the family’s loss.
The coroner has a second duty alongside investigating specific deaths: to consider whether an inquest brings to light issues with care which could risk other deaths in the future.
So it can be prudent to reflect on the events and whether there should be any changes in your individual practice or in the systems involved in the deceased’s care.
If so, do include that in your statement, along with any action being taken to enact improvements in care. If you have changed role since the relevant time, make sure you include that, so the coroner knows you aren’t able to comment on current process.
If you are called to attend and give evidence at an inquest, you should alert your defence body or solicitor for individual preparation and advice. The request will come through the coroner’s officer and they will be able to give guidance on when the hearing will happen,
In a statement and in court, you should not speculate nor go beyond your expertise how long it is listed for and other practical details.
This will be handled by your representative, if you have one for the hearing, and you will only need a lawyer with you at that point if you are an ‘interested person’, which is usually only for family and those individuals or organisations most relevant to the care or the death.
Many coroners remain flexible in allowing evidence to be given remotely where this will allow less disruption to clinical care, so you can ask if the hearing will be remote or if your evidence can be.
There are advantages and disadvantages to attending remotely rather than in person. There is less travel time and it is easier to review medical records should the coroner want confirmation of a specific detail in your evidence. But we have all learnt of the dangers of accidentally leaving a camera or microphone on at the wrong time. You should have your witness
statement with you when you give evidence, which is another reason to ensure it is comprehensive. The coroner will explain the process and will lead the questioning.
They will take you through your statement, sometimes also asking questions based on the medical records, evidence of the family or other witnesses or on other reports.
The family may then also ask questions, either directly or through a legal representative. If they are unrepresented, the coroner will usually help them frame their queries into questions that you can answer.
If there are others involved in the inquest, they may also have a representative who might ask you questions, and finally your own representative – if you have one –can do so.
It is a good rule of thumb to answer the question put to you and then to stop, allowing the questioner to ask for more detail only if they need it.
In a statement and in court, you
should not speculate or go beyond your expertise. Remember that you will be giving evidence under oath, so it is important to understand the questions put to you.
You can ask for them to be repeated or explained and if the honest answer is ‘I don’t know’ or ‘I don’t remember’, then that is a perfectly acceptable answer.
Clinicians deal with a lot of patients, and coroners understand you won’t have perfect recollection of every detail so as long as you are clear that you can explain that you do not remember an event in that specific instance but you can explain the usual process.
Above all, remember that you are called to help the coroner with those four key factual questions, and not to justify yourself or because you are in any way being blamed for the death.
You probably spend a good amount of time explaining care and decision-making to patients or
families, and it is that skillset, although in an unfamiliar setting, that you need in the coroner’s court.
While you might want to give word-perfect answers, it can be more important to demonstrate your professionalism and compassion to the family and coroner through how you answer the questions.
Finally, remember that support is always available, including from solicitors, to guide you through the process and support in the hearing if necessary.
For an introduction to the inquest process, see our previous article entitled ‘When you’re asked to go to an inquest’ ( Independent Practitioner Today, July-August) and for more on the outcomes, keep an eye out for the final article in this series on inquest conclusions and what they mean.
Clementine Robertshaw is an associate at Hempsons solicitors. For further information, you can email her at c.robertshaw@hempsons.co.uk
What’s on the safety and regulatory horizon for independent practitioners? David Hare reports
RESPONDING TO Covid-19 has, of course, dominated the lives of independent practitioners for the last few years.
And while we can expect another winter of potential new variants of the virus and the return of the flu season, we are gradually starting to get back to ‘normal’. This includes the introduction of a number of new safety and regulatory initiatives that have been delayed due to the pandemic that independent practitioners should be aware of in the coming months.
1The Care Quality Commission (CQC) is continuing to develop its new regulatory model
While the CQC will continue to use its existing five key questions around a service – is it safe, effective, caring, responsive and wellled? – under each key question, there will be a set of topic areas and quality statements which describe what good care looks like.
The CQC has now published those quality statements and include for example: ‘We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.’
Another example of its quality statements is: ‘We work effectively across teams and services to support people.
‘We make sure they only need to tell their story once by sharing their assessment of needs when they move between different services.’
Independent practitioners and providers are rightly proud of their high CQC scores. Currently, 94%
Secondary care providers will, by the time you read this, have been asked to prepare for the transition to the new Patient Safety Incident Response Framework from September
by the time you read this, have been asked to prepare for the transition to PSIRF from September, with all organisations transitioning to PSIRF by Autumn 2023.
This will replace the current Serious Incident Framework (SIF), with the aim of moving away from reactive and hard-to-define thresholds for ‘serious incident’ investigation and towards a proactive approach to learning from incidents.
change with be around amending the Medical Certificate Cause of Death to enable the recording of the Medical Examiners’ view.
We will be liaising with the team at the National Medical Examiners Office on this to ensure independent providers and practitioners are fully aware of what they need to do.
4of Independent Healthcare Providers Network (IHPN) member locations are rated good or outstanding.
Moving to a new regulatory framework is, however, always both an opportunity and a challenge.
It is an opportunity to make sure that innovation and new models of care are considered, and a challenge due to an approach where, for example, ratings could be changed without an on-site inspection.
At the IHPN, we are fully engaged with the CQC through our regular engagement activities and also as a member of its Provider Implementation Steering Group.
And we will be working with our members to ensure they are fully prepared for the CQC’s changes and can continue to demonstrate the high-quality care they deliver.
2Next up is a major change in the way patient safety incidents will be conducted
As I write, we will soon see the publication of the new Patient Safety Incident Response Framework (PSIRF).
Secondary care providers will,
Ultimately, PSIRF will give individual organisations the responsibility for deciding which incidents are to be investigated, and expectations will be clearly set for informing, engaging and supporting patients, families, carers and staff involved in patient safety incidents and investigations.
This will very much be a new way of working for providers and practitioners, and the IHPN will be working to support members through this transition.
Sharing best practice and learning among members will be included, as well as ensuring that independent providers and practitioners are fully part of local system working on PSIRF.
Each NHS Integrated Care System (ICS) is expected to employ a PSIRF lead, who will support patient safeguarding reporting within the ICS.
3
Another change this year will be around preparing for the implementation of a statutory medical examiner system
This is designed to introduce an additional layer of scrutiny of the cause of death by a medical practitioner.
The aim is to help both improve the quality and accuracy of the medical certificate of cause of death and inform the national data on mortality and patient safety.
Once secondary legislation has been laid and the statutory medical examiner system commences, the intended requirement is for medical examiners to provide independent scrutiny of all deaths not taken for investigation by a coroner, including in the independent sector.
This system will formally commence from April 2023 and a key
This autumn will see the refresh of IHPN’s Medical Practitioners Assurance Framework (MPAF) The MPAF is currently part of the CQC’s inspection framework and is designed to foster a more standardised approach to medical governance in the sector and ultimately drive up the quality and safety of care for patients.
Always designed to be an iterative document, the refresh will include strengthened wording to ensure it remains in keeping with current best practice around medical governance in the health system.
We have been so pleased with how independent practitioners and providers have embraced the principles in the MPAF and we will be working in the autumn to ensure the refresh is fully embedded in the sector’s work to drive continuous quality improvement. It is clearly going to be a busy time for safety and regulation in the independent healthcare sector this autumn.
And here at the IHPN we will continue to play our role in making sure providers and practitioners are fully factored into all regulatory and policy changes, enabling them to continue delivering high-quality care to so many millions of patients.
David Hare (below) is chief executive of the IHPN
QI am a private respiratory consultant and one of my patients, who suffers from asthma, has asked me to complete and sign a form for him to take part in a SCUBA diving introductory course.
He has specifically been asked to fill in a medical form due to his asthma. There are also other questions on the form about his health that I don’t have information for, such as neurological conditions like migraine.
The patient has ticked these boxes saying he does not suffer from any other medical condition than asthma. Should I complete the form?
APatients often ask doctors to complete forms for sporting or other activities to confirm they are fit to take part. The difficulty lies in the fact that the doctor may not have any expertise in the activity and may not be aware of the stresses or issues that might arise during the event.
The GMC says that when you complete or sign forms, reports and other documents, you must make sure that you take reasonable steps to check the information is correct and you must not deliberately leave out relevant information. And you must also make sure that any documents you write or sign are not false or misleading
As SCUBA diving is a specialist sport, you may not know what the implications of the patient’s asthma are for his safety while diving and the patient would be best placed to be examined by a doctor
Dr Kathryn Leask discusses what to do if asked to complete a medical form for an introductory SCUBA course
who specialises in diving medicine.
You are also having to rely on the patient’s account of their health with regards to other body systems without any direct knowledge of this.
If you were to complete the form you should take appropriate steps to verify the information; for example, by contacting the patient’s GP, with the patient’s consent.
What you could offer the patient, in this situation and any other where a patient requests information for such events, is to provide a factual medical report detailing the medical conditions you are aware of and what treatment the patient is receiving. However, in this case, the patient will need to complete specific forms for their diving club and confirm that they are fit to dive.
A factual report is unlikely to satisfy this requirement. Drawing the GMC’s guidance to the patient’s attention may be helpful in explaining to them the difficulties signing such a form may present for a doctor without specialist knowledge.
Dr Kathryn Leask is a medico-legal adviser at the Medical Defence Union (MDU)
Is a new healthcare assistant able to carry out cervical screenings? Dr Kathryn Leask (below) gives her advice
QI am a private gynaecologist who has just employed a new healthcare assistant (HCA). She is a former practice nurse with extensive experience but wanted a change of pace before retirement.
The nurse who used to carry out cervical screening for me is not currently available. My new HCA has completed all her training, including a recent update, to carry out cervical screening and was carrying out the procedure up to the point she left her previous role.
While my nurse is unavailable, can the HCA carry out screenings in the interim?
AWhen you delegate a task, such as the consultation and clinical examination associated with cervical screening, you must be satisfied that the person to whom you delegate has the knowledge, skills and experience to provide the care. As such, you are still responsible for the overall management of the patient.
According to the Government’s
A person who takes a cervical sample must have the required level of knowledge and understanding of the cervical screening programme
guidance, a person who takes a cervical sample must have the required level of knowledge and understanding of the cervical screening programme.
While your new HCA may have the competency to carry out cervical screening in view of her previous role and employment, only certain groups of healthcare professionals are eligible.
This includes registered nurses and registered nursing associates. If your new employee is in a HCA role and not registered, they would not, therefore, be able to carry out cervical screening.
It is also important to ensure that the staff who assist you also have the appropriate indemnity in place for the work they do.
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A PRIVATE PRACTICE – Our series for doctors embarking on the independent journey
As your private practice grows, you will need to build a team to support you. This may be a secretary or administrative support or another healthcare professional.
Unlike your work in the NHS, where these resources are likely to be already available, you will need to build your own team. The team you pick can impact the success of your private practice and can have different financial implications, says accountant Alec James (right)
A MEDICAL SECRETARY will likely be your first – and possibly the most important – role you recruit for. Your secretary will often be your patients’ first point of contact as they look to arrange an appointment with you.
Medical secretaries are usually either:
Employed by the private hospital where you work;
Work on a self-employed basis or via a limited company;
Employed by your business.
In most cases, secretaries are employed by the private hospital or the secretary is self-employed. You will be billed monthly for the hours/days the secretary has supplied or, occasionally, a percentage of your fees.
You should be provided with an invoice detailing the hours they have worked for you and then the amount. For accounting purposes, you should keep either a physical or electronic copy for seven financial years.
Secretaries paid in this way have no employment rights from your business. This means that if they are sick or on annual leave, they should not be paid or alternatively a replacement should be provided to you.
Secretaries working in this way will often be working for a number of consultants.
As your private practice grows, it
may be that you find you require a secretary that works exclusively for your business. Where someone is working exclusively for you, it is likely that HM Revenue and Customs (HMRC) would class them as an employee rather than someone who is self-employed.
This status is not a choice, but a question of fact. To help you determine the status, there is a toolkit available on the HMRC website.
As an employee, your secretary will be entitled to employment rights such as paid sick leave, holiday pay and parental leave.
That also means that your business will have PAYE obligations, meaning you will need to deduct tax and National Insurance (NI) from their salary and pay these over to HMRC.
You will also be required to pay employers NI and pension contributions. These are often referred to as ‘on costs’.
For you to pay the tax and NI,
you will need to register for a PAYE scheme for your business and report monthly to HMRC. You may also need to operate an employer pension scheme.
In addition to a basic salary, you may also choose to pay your secretary bonuses or commission or provide benefits to them such as private health insurance.
These extra payments are taxable and also need to be reported to HMRC. There are, however, certain benefits provided to employees which fall outside the scope of tax and NI.
It is always advisable discussing the potential employment of a secretary with an accountant so that you are aware of the total cost to your business prior to offering employment.
You should also seek the advice of an employment solicitor or HR specialist to have a contract of employment drawn up.
➱ continued on page 48
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It may be that in certain cases you may need to involve another healthcare professional such as another consultant or a nurse.
When working with other healthcare professionals, it is important to establish who will be responsible for the procedure and how the parties involved will be paid.
Where you require the services of a nurse or another healthcare professional under your supervision, the arrangement will usually be on an ad-hoc basis and therefore they are likely to be paid as a self-employed person or through an agency.
If you are continually working with someone under your supervision, you may need to consider HMRC’s ‘off-payroll working’ rules and consider whether they need to be paid via a PAYE scheme.
When you work with other consultants, you need to think about where the responsibility lies and who has the relationship with the patient/insurer.
You could:
Each raise an invoice to the insurer/patient for your share of the fee;
Have one party invoicing for the full fee and paying the other party their share.
Financially, the end result is the same. However, if your business invoices for the full amount and then pays the other party, it could be exposed to potential liabilities because it has supplied the service of both clinicians.
In these cases, you should ensure you have suitable contracts of service in place with your colleague and discuss the arrangements with your indemnity provider to ensure you are suitably covered.
If you regularly work with a colleague, it may be worthwhile forming a joint, separate legal entity for this income.
As with many small businesses, the administrative duties of your business such as invoicing, bookkeeping, chasing outstanding debts and social media/website updates can often fall on your immediate family.
If this is the case, your business can employ them for the work that they do. This can often be tax advantageous where the employee does not have another job or is a lower-rate tax payer. Again, you may have to have to register a PAYE scheme for your business to pay your family members.
Using a PAYE scheme for family members can often be very taxefficient. It can also help to fill in any gaps in a NI record which can, in turn, increase the state pension to which they are entitled.
In addition to the basic salary, you may also consider a pension scheme for your family member.
You need to think about the total remuneration package paid to any employee. This should reflect the work the employee does for your private practice. In the event of a HMRC inquiry, a record of hours worked and the work done will help support a claim.
Making them a director of your limited company – if applicable –can also help with your claim because additional duties arise from being an officer of a company.
If you have a limited company,
you could be paid a salary. Historically, many consultants have chosen to not draw a salary from their company, instead choosing to receive dividends in their capacity as a shareholder.
With any rise in corporation tax and changes in NI thresholds, this is something you may wish to revisit, because it may be more taxefficient to receive a salary.
In addition to a salary, there are other ways your company could remunerate you or your family members. This could include benefits in kind such as the company providing you the use of an electric car.
This is often very tax-efficient, as the company obtains the tax relief of the purchase or lease of the car together with the maintenance costs, while the tax implications on you, as director, are very minimal.
By using company funds in this way, there is normally a corporation tax saving and also a reduction in the amount of dividends you need to draw from the company, ultimately saving personal tax.
A billing company will raise the invoices, collect payment and chase outstanding debts. For this service, it usually charges a percentage of the invoices raised or fees collected. These fees are taxdeductible.
It will also provide you with detailed reports showing the income generated and fees received, which can be used by your accountant when preparing your annual accounts.
You may wish to use a billing company to handle the invoicing side of your business. Some find this more comfortable because it takes away the need to discuss financial matters with patients and frees up time for your secretary.
While not members of your direct team, a private practice business will need some form of accounts to be drawn up in order that the relevant taxes are paid, so you will likely need an accountant. Specialist medical accountants will be able to help you in other areas too, including discussing the tax implications of the above with you. They can also reduce your administrative burdens by providing payroll and book-keeping and advise about appropriate accounting software packages.
Solicitors, independent financial advisers (IFAs), human resource support and insurance specialists would also fall into the category of the indirect team and all of these professions can also be vital to help your business continue to be successful.
As you build your successful team, it is important your relationships with them are formalised to ensure the risk of getting things wrong is minimised.
As always, make sure you discuss your circumstances with a specialist medical accountant and make them aware of any new arrangements and opportunities that come along.
Next month’s article: Financial housekeeping
Alec James is a partner with Sandison Easson specialist medical accountants
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Check out this good buy for doctors with a family who do not want to spend the high price demanded by other brands for electric vehicles (EVs) with decent range capability, says Dr Tony Rimmer
There is a useful under-boot compartment to store the charging cables – most welcome in any EV
TO RUN a successful medical practice, we need to, as in any other business, watch our costs and look out for good value for money.
Medical equipment is notoriously expensive and if we find a product that does the job with acceptable quality and reliability then we would need a particularly good reason not to go with it. With all-electric cars also being particularly expensive, it is refreshing to find a challenger that, on paper, seems like really fair value and re-invigorates a famous British brand: MG.
Although MG is now owned by a Chinese company, its new cars are designed and developed in the UK and plans are afoot to release an electric two-seater sports car in due course.
This would appeal to all us MG fans who owned or certainly remember the classic MGB and Midget from the 1970s and the MGF from the 1990s. It looks as though the sporting heritage could finally relive and flourish.
In the meantime, the company needs to produce cars that make a decent profit – and that means tapping into the family SUV market to appeal to a wider audience.
The recently revitalised ZS EV is such a car. It has created quite a stir in the motoring community because, at a starting price of £31,995 for the 73kWh long-range model, it undercuts class leaders such as Volkswagen iD3 – with a smaller 58 kWh battery – by £5,000.
MG is also due to release a ZS EV with a smaller 51kWh battery and that will be priced even lower. But is the car any good? Can it compete at a level that we medical buyers will accept? Are there any compromises to live with?
To find out, I have been testing the long-range model in well specified Trophy Connect mode, but even the base SE model has an excellent standard equipment list.
Although restricted by the usual small SUV profile, the ZS has benefited from some external design improvements and looks smart and almost good looking.
The electric charging port is in the middle of the front grille, so it is easy to drive forwards into a charging bay instead of having to reverse in like so many competitors.
I was expecting to find some cheap trim materials inside the cabin, but the interior is a pleasant surprise.
Of course, there is some hard plastic and fake leather to be found, but it is minimal and the new bigger infotainment screen and solid controls raise the perceived quality.
It is a shame the steering wheel is not adjustable for reach, but I did find a comfortable driving position.
There is plenty of space for passengers front and rear and the 470litre boot is on par with other rivals such as the VW iD3. There is even a useful under-boot compart-
ment to store the charging cables – most welcome in any EV.
Out on the road, it becomes apparent that MG has tuned the chassis and suspension for comfort rather than dynamism. The big battery’s weight helps keep the ride smooth, but potholes still cause a thump.
The steering is light, but not as sharp as the keen driver would like. It is better to drive the ZS as it was designed to be – a practical small SUV for urban family duties.
To aid this role, it has great visibility and performance has typical instant EV zip. The regenerative braking strength can be altered very easily to suit any driver preference.
So the ZS does what it says on the tin. It is a good value, easy-to-drive family SUV that has all the equipment you need.
However, its trump card is the bigger battery and enhanced range – up to 273 miles – at a price that will only buy competitors’ products with smaller batteries and shorter range.
Quality is better than I expected; in fact, in my higher-specified Trophy Connect test car with leather trim and a full glass sunroof felt almost luxurious.
MG deserves to do well with the ZS EV and it would be a great buy for any medic family who do not want to spend the significant extra money that is demanded by other brands for EVs with decent range capability.
It is great to see the MG badge back on our roads and I, like other keen drivers, look forward to its new sporty models.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
Body: Five-seat hatchback SUV
Its trump card is the bigger battery and enhanced range –up to 273 miles
Engine: Single electric motor. Front-wheel drive
Power: 154bhp
Torque: 280Nm
Top speed: 108mph
Acceleration: 0-62 mph in 8.4 secs
Claimed range (WLTP): 273 miles
Real world range: 250 miles
CO2 emissions: 0g/km
On-the-road price: £31,995
It was almost a complete case of déjà vu for our latest specialty to come under the accountants’ microscope. Ray Stanbridge reports
OUR HEADLINE observation is that ‘general surgeons’ pretty much stood still in 2020.
We have found that the private practice gross incomes for consultants in this specialty surgeons barely changed between 2019 and 2020.
They dropped by £1,000, falling from £157,000 to £156,000.
Costs fell, too, by £2,000 on aver-
age, going down from £67,000 to £65,000. As a result, taxable profits actually rose, going up £1,000 from £90,000 to £91,000. There was a modest fall for some in the costs of defence cover or indemnity insurance. This is the result in some cases of aggressive shopping around and taking advantage of new players in the market.
Last year . . . we felt there would be a significant growth in groups. But that has not yet happened
Most other costs remained pretty constant, so there is very little more to report. What then of the future? Obviously, the financial year 2020-21 was, for many, not a good year as a result of the Covid outbreak and resulting restrictions. This factor was compounded by the fact that some general surgeons do undertake non-essential surgery where demand was hit hard.
However, the Covid outbreak has generated considerable built-up demand and, from early indications, I am pleased to report the financial year 2021-22 appears to have been prosperous for many consultant general surgeons.
Expenditure
We have reported in recent years on the increasing difficulty of affecting realistic year-on-year comparisons because of changes in the way they run their business.
For example, general surgeons, like many other private consultants, now trade in a variety of ways through limited liability companies and limited liability partner-
ships in addition to the sole trader model.
Others have chosen not to set up in private practice, but to negotiate a second employment with a private hospital or clinic.
Others have decided to specialise in a particular area, commonly breast surgery, rather than do a variety of procedures.
indicators through regulators such as the Private Healthcare Information Network.
This increased specialisation has been encouraged by the process of revalidation and also the increasing publication of performance
For these and other reasons, our survey is not in any way statistically significant. Rather, we hope it is a reasonable representation of what an average general surgeon earns and spends in their private practice.
Note that none of the accounts studied for this report were for those who work full-time in private practice.
To be eligible to participate in our survey, consultants:
Hold either an old-style or a new-style NHS contract.
May or may not have incorporated their business;
May or may not work in a groups;
Have a keen interest in developing a private practice;
Have been engaged in private practice for at least five years;
Earn at least £10,000 a year gross from private practice.
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates Ltd.
Gynaecologists
Ophthalmologists
Cardiologists
Coming in our October issue, published on 11 October.
Get sorted! In Start A Private Practice, Sandison Easson accountant
Richard Norbury puts the spotlight on financial housekeeping. He highlights some important and often forgotten dates and compliance obligations throughout the year for individuals and corporate entities
In a new series, Troubleshooter Jane Braithwaite tackles issues surrounding consultants’ groups. This month she considers the burning question: ‘I’ve been happy as a solo independent practitioner, but with pressure on costs and other factors am thinking of setting up a group. What advice would you give me?’
Also on the subject of groups, Medical Billing & Collection’s Simon Brignall presents part two of his analysis of group problems – and gives a helpful check list for group members and managers to work through
This will also feature a check list for the group you are considering joining, examining each of these key areas
Calling investors – Short-term performance analysis can be dangerous to your wealth. Dr Benjamin Holdsworth, of Cavendish Medical, explains why disciplined exposure to risk will reap rewards
Inquest conclusions and what they mean – Hempsons’ solicitors
Thorrun Govind rounds off our legal series on inquests, while Dr Kathryn Leask answers a consultant surgeon’s query about what an Article 2 inquest is and advises how to prepare for one
In our Business Dilemmas series, Dr Ellie Mein, medico-legal adviser at the Medical Defence Union, discusses the importance of interpreters during the consent process
Published by The Independent Practitioner Ltd. Independent Practitioner Today is editorially independent and thanks Bupa for its assistance with distribution. 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 2022 Registered office: 7 Lindum Terrace, Lincoln LN2 5RP
There are some things that healthcare insurers and providers need to consider as part of the digital healthcare revolution if we’re to keep up the momentum, writes Dr Leah Jones, Bupa’s head of behavioural insights
The quest for supermodel looks: Bevan Brittan LLP solicitor Deborah Pyzer has some important advice for aesthetic and cosmetic practitioners arising from a recent case
It should be mandatory for medical expert reports to consider the role that systems issues may have played in an adverse patient outcome, argues Dr Lucy Hanington of the Medical Protection Society
Patients in private patient units need to be able to make complaints to the health service ombudsman. Sally Taber, director of the Independent Sector Complaints Adjudication Service, argues the case
Accountants Clinic: Julia Burn presents some useful tips for the upcoming tax season
Independent Practitioner Today motoring correspondent Dr Tony Rimmer takes to the road in the Alpine A110
A decade on – what was making the news for ten years ago
Nuffield Health at St Bartholomew’s Hospital has found that a proactive approach to heart health – including focusing on prevention as well as rehab – improves patient outcomes by avoiding re-admittance. It says it is essential that a connected approach is taken, because cardiac issues also impact a patient’s mental state
And don’t forget to check out our additional news updates every week online
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