Be assured of your RMO
A defence of resident medical officers and private hospitals’ reliance on them P26
Beware of gifts
How to negotiate the tricky ethics of being given a thank-you gift from a patient P30
Does paying for advice work? Why investing in a professional adviser could be crucial to your financial success P40
By Robin Stride
Plans to give patients and their doctors a faster, cheaper and less stressful experience in alleged medical negligence cases have been revealed to Independent Practitioner Today
Under the blueprint – being actively backed by some leading medical expert witnesses – both sides would have to agree to early and independent mediation.
Independent Medical Negligence Resolution (IMNR) has been launched by a private consultant entrepreneur to cut through many of the processes’ current frustrations.
Urological surgeon Mr Hugh Whitfield, said: ‘Once the case has been taken over by lawyers, the best opportunity for mediation to be successful has been lost.
‘There is no incentive for lawyers to pursue resolution by mediation. There is a very strong financial disincentive.’
He added: ‘IMNR will work with all those who want to avoid a lengthy, expensive, stressful and confrontational approach by first exploring the possibility of alternative dispute resolution.’
Injured patients, chief executives of both private and public hospitals, doctors’ defence bodies, medical negligence solicitors and NHS Resolution would all be able to access IMNR directly.
Mr Whitfield, who practises at London’s King Edward VII’s Hospital, added: ‘The present system is not achieving what must surely be the objective: to provide an apology, an explanation, reasonable compensation and rapid resolution.’
He said cases he was involved with as a medicolegal expert witness acting for both claimants and defendants ‘drag on for years and this delay often causes as much stress for the claimant as the original injury’.
Case costs were escalating at an alarming rate and caused enormous stress for doctors too. The threat of litigation led to defensive and risk averse medicine. Both were expensive and poor practice.
He said medical expert witnesses were frustrated by the current system and he had already recruited 20 highprofile doctors. ‘The motivation for us all is to improve the “patient journey”. By doing so, costs will be reduced and the other
main stakeholder, the wider NHS, will benefit.’
Expert witnesses were currently frustrated by:
Slow settlement of fees notes;
Some inefficient agencies used by solicitors;
Not being told about a case’s settlement and its outcome;
Cases being settled by an adversarial legal approach that failed to reflect the clinical picture.
Mr Whitfield said they were also required to block off dates many months and even years ahead of a trial window that had been
reserved for a court case, knowing there was less than a 1% chance of the case coming to court.
He foresaw many advantages for medical expert witnesses when instructions came through IMNR. They would avoid many frustrations and know they were contributing to improved care of the injured patient, rapid resolution of claims and a reduction of stress for claimants and for doctors involved.
IMNR has an expert adviser in each major specialty who will identify the best expert in that specialty or subspecialty and then oversee the quality of their report. They will be paid £400 per case, while those who write a report will receive £2,000.
The firm aims for all systems to be ready by the end of the year. Mr Whitfield, who is working with lawyers who are also mediators or evaluators, has funded the startup and is looking for venture or angel capital.
If you are one of our experienced medical expert witness readers and would like to know more, email him at director@imnr.org.
Next month: Mr Hugh Whitfield outlines the thinking behind his new company’s aims to be a gamechanger
How does your practice grow?
Jane braithwaite’s latest article in her series about managing your private practice puts the spotlight on the area of business development P16
Bright and beautiful
We go behind the scenes of a new private hospital about to be officially opened. the unit has been signing up leading consultants to work for it on a salaried basis P21
We can all join up independent practitioners have plenty to gain from the private practice register, says the boss of Healthcode’s new online system to streamline doctors’ recognition by insurers P22
editorial comment
‘Ello, I wish to register a complaint.’
It’s funny when it is genius comedy. A big story this month reflects the opening lines of Monty Python’s classic pet shop sketch where Michael Palin returns with a deceased parrot ‘purchased not half an hour ago’.
The disgruntled customer is continuously fobbed off by John Cleese, playing a qualified brain surgeon, who only runs a pet shop ‘because I like being my own boss’, and assures him Polly is just resting.
But it’s not so funny when complaints happen in real life and, for independent doctors and private hospitals, there continue to be more than ever – see our story on page four. Perhaps rising complaints are unsurprising considering our consumerist society and publicity given to the Independent
How our nHS came to be private doctors were unhappy 70 years ago as the nHS took shape. independent practitioner today traces the health service’s history in the first of a new series P32
do doctors trust their regulators?
Lawyer Gregory Smith examines the legal and regulatory developments following the bawa-Garba case, the doctor struck off for gross negligence manslaughter, then reinstated P36
mind the billing banana skins
Findlay Fyfe highlights some of the biggest stumling blocks for many doctors and their practices when billing patients and insurers – not least having to chase the debt P44
Healthcare Sector Complaints Adjudication Service (ISCAS).
More shocking is that, in many cases, as with the parrot’s owner, the original complaint is handled badly and sparks a further complaint
Complaints about complaints handling have rocketed from 22% mentions by complainants in January 2015, to 80% in March 2018.
Good complaints management is an integral part of quality management and next month we will give more publicity to ISCAS’s seven-step guide to good complaints handling.
Meanwhile, regarding complaints of alleged negligence, we wish consultant Mr Hugh Whitfield (page one) every success in his efforts to give patients and doctors a faster, cheaper and less stressful experience.
Business dilemmas: intimate examinations a patient refuses to have a chaperone present for a breast examination – so what do you do? P46
Start a private practice: What to do when you are new to the business accountant ian tongue lists the areas that ‘newbies’ need to tackle to ensure a smooth ride in business P48
Profits focus: an expensive year our unique benchmarking series looks at the financial fortunes of ent surgeons P52
tell US yoUr neWS Editorial director Robin Stride at robin@ip-today.co.uk Phone: 07909 997340 @robinstride to advertiSe Contact advertising manager Margaret Floate at margifloate@btinternet.com Phone: 01483 824094
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£90 independent practitioners. £90 GPs and practice managers (private & NHS). £210 organisations. Save £15 paying by direct debit: individuals £75 (organisations £180). to SUBScriBe – USe SUBScriPtion form on Page 24 or email: lisa@marketingcentre.co.uk Or phone 01752 312140 Or go to the ‘Subscribe’ page of our website www.independent-practitioner-today.co.uk chief sub-editor: Vincent Dawe Head of design: Jonathan Anstee Publisher: Gillian Nineham at gill@ip-today.co.uk Phone: 07767 353897
By edie Bourne
Independent practitioners who also have NHS consultant contracts are being alerted about a sting in the tail from their latest pay award.
Financial advisers say specialists should be aware of potential problems arising from their pay rises due this month even though the amounts have been branded ‘small and insulting’ by the BMA. This is because any pay rise, however insignificant, can trigger a tax charge on excess pensions’ savings.
Patrick Convey, technical director of specialist financial planners Cavendish Medical, explained: ‘As
IDF goes on the road to expand its membership
A roadshow over the next year will give private consultants and GPs outside London a chance to meet representatives of the Independent Doctors Federation (IDF) and hear about its work.
First stop will be on 6pm on 30 October at Guy Salmon Jaguar, Stockport, SK1 2AD.
Chief executive Sue Smith said the tour was part of its strategy to give greater engagement and opportunities for doctors outside the capital to use its services.
Non-members wishing to attend the free event, including canapés and wine, should call 020 3696 4080.
Other venues include Edinburgh/ Glasgow, Newcastle/Leeds, Liverpool/Manchester, Birmingham/Nottingham, Bristol/Cardiff, Southampton, Chelmsford/ Ipswich, and Guildford/Reading.
we know, there is an annual allowance which limits the amount of tax-free pension savings each year. The allowance varies for every consultant – the top figure is £40,000, but this may fall to just £10,000 a year for higher earners with the introduction of the tapered annual allowance.
‘Consultants should be wary of any NHS pay rises received through increments, statutory payments, new management positions or clinical excellence awards (CEAs).
‘Increased pay equals increased pension ‘growth’, which could easily force a tax breach. Note that excess pensions’ savings are taxed at up to 45%.’
In July, the Government
announced a pay rise of as low as 1.5% for consultants in England rather than the recommended increase of 2% from the Doctors’ and Dentists’ Review Body.
Mr Convey continued: ‘Not only is the pay rise less than inflation, so, in real terms, it is a pay cut, but it comes mid-way through the year and will not be backdated to April. This is effectively a 0.75% pay rise for the year – less than the 1% increases received in previous years.
‘This partial pay rise will also add another level of complexity to the already challenging pay and pension calculations for the annual allowance. To make matters worse, the pay increase does
not apply to CEAs in England, which will remain frozen for the time being.
He told Independent Practitioner Today that doctors should do all they could to ensure they were in the best possible position to protect against tax charges by ensuring all their pay and pensions figures – including any private pensions – were accurate and had been tested against the annual allowance rate applicable to them.
Said Mr Convey: ‘Remember the onus is on the individual to report any tax breaches to HM Revenue and Customs. If this all sounds like a headache you could do without, be sure to seek expert help.’
Patients at London’s Schoen Clinic, the new hospital promoting a salaried option for its consultants, will also be seen by specialists with practising privileges elsewhere in the capital.
On the day the German hospital group announced its opening to the trade press, another hospital in the Harley Street enclave announced that the two had set up a partnership agreement.
The London Clinic said it would provide a range of clinical services to Schoen to give patients access to its new 3T MRI scanner
( Independent Practitioner Today , September 2018, p9) and other diagnostic technologies.
It added: ‘In addition, patients at Schoen Clinic London will have access to The London Clinic’s extensive network of leading consultants across other medical specialties.’
The new 39-bed hospital is focusing on spinal care and orthopaedics.
Its partner hospital’s chief executive Al Russell said: ‘I believe that this partnership agreement between The London Clinic and the Schoen Clinic London will
benefit our leading specialist consultants and their patients, who will have fast access to our comprehensive range of services.
‘Both hospitals have shared values and a focus on providing excellence in healthcare outcomes.’
Schoen’s hospital director Erin Shaffer added: ‘This partnership allows Schoen Clinic to focus on providing specialised outcomebased orthopaedic and spinal treatments, while ensuring that all aspects of patient care are delivered to the highest possible standards.’
See page 21
A new treatment option is being trialled as an employee benefit across the south of England –DocHQ.
Staff can now quickly book an appointment, with the choice to opt for a private or NHS doctor, depending who is available at the most convenient time to them.
The company provides access to
secure personal medical records that can be shared with the patient’s GP, a range of medical services, pharmaceuticals and more via multiple choices of communication: phone, video, online chat or face to face.
Chief medical officer Dr Simon Chaplin-Rogers said unlike with other digital employee benefit
healthcare offerings, DocHQ formed a partnership between the employee, the healthcare system and healthcare providers.
It is planned to roll out the service across the UK over the next 18 months. It is supported by six private and NHS clinics across the region with ten doctors and five advanced nurse practioners.
The British Association of Aesthetic Plastic Surgeons (BAAPS) has decided that the results of the Brazilian buttock lift (BBL) are disturbing enough for them to dissuade all members from performing this surgery until more data can be collated.
Surgeons at their annual scientific meeting warned that the procedure had the highest death rate – thought to be as high as one in 3,000 operations – of all cosmetic surgery procedures.
This is due to the risk of injecting fat into large veins that can travel to the heart or brain and cause severe illness and death, they said.
A spokesman said: ‘This risk has galvanised the BAAPS to distribute a recommendation to all members, suggesting they refrain from performing BBLs, at least until more data is available.
‘This is going even further than the American and Australian Societies, which only alert members to reporting outcomes.’
A study presented at the international BAAPS conference analysed a single UK NHS hospital, recording a six-fold rise in cases needing urgent follow-up care
By Robin Stride
Patients’ complaints about how complaints have been handled in private practice have rocketed.
They have gone up from 22% of mentions by complainants three years ago to 80% in the year ending last March.
Figures from the Independent Healthcare Sector Complaints Adjudication Service (ISCAS), the voluntary subscription scheme representing 95% of UK independent healthcare providers, also show nearly a quarter of complainants were unhappy with their clinical outcomes.
Complaints about consultants and medical care nearly doubled, featuring in 52% of cases as the number of complainants rose from 249 to 527 in a year.
The ISCAS annual report says that, of these, 378 related to its subscribers.
Others were directed to other organisations where possible. 117 complainants were forwarded to an independent adjudicator who gave a final decision in 101 complaints, identifying 279 heads of complaint.
Most (63%) of complaint heads were either upheld or partially upheld, a 60% rise on last year.
ISCAS subscribers pay an average of nearly £3,000 for adjudications. Goodwill payments were made in 80% of cases, a decrease from the 87% of cases in the previous year.
But the average a goodwill payment rose from £630 to £813.
ISCAS director Sally Taber said the stand-out finding was complaints about complaints handling. The service was working on improving systems and processes to improve outcomes.
See Sally Taber’s feature on this subject next month
from pro cedures done abroad, since 2013.
All but one of the complications deemed ‘major’, based on cost and level of emergency care input –including intensive care, were for buttock enhancement, also known as gluteal augmentation.
These patients required an average ward stay of 20 days, costing the hospital just under £32,500.
Added to other procedures, the hospital shelled out over £63,000 to pick up the pieces of surgery botched abroad, including the removal of industrial-grade, banned PIP silicone implants.
Complications from BBL ranged from severe bacterial infections including MRSA and pseudomonas, necrosis, scarring, wound ruptures and abscesses – among others.
One patient alone, excluded from this study, had necrotising fasciitis, treatment for which cost the NHS nearly £47,000.
The number-one most cited reason for choosing to travel, unsurprisingly, was cost – 85% of respondents.
Surgeons ascribe this specific phenomenon, in part, as a possible result of aggressive marketing campaigns – particularly targeting
vulnerable people through social media.
Celebrities unashamedly pursuing the curviest of curves on their Instagram feeds, such as Kim Kardashian and rapper Cardi B, can trick the public into thinking that – just as one medical tourism website advertises – ‘Surgery is just like make-up!’ and inadvertently lead them to danger.
Hence the association has called a moratorium on the procedure in the UK, until more research is conducted.
Author of the paper, trainee in plastic and reconstructive surgery Dr Mohammed Farid, conducted this study at the Royal London Hospital.
He said: ‘As a trainee, it has been staggering to see the lengths – and the damage – these patients will go through in the quest for cheaper options. Especially for the kind of surgery which requires such specialist training.
‘I remember in one procedure, we found a piece of Latex which had been left inside the patient’s buttock. This was one of the most shocking moments in my career, and the one that inspired me to conduct the study.’
Healthcare review and booking platform Doctify has partnered with practice management software company PPM to allow patients to see real-time availability of doctors online.
PPM’s Tom Hunt said: ‘This integration will allow our doctors’ to have the best of both worlds from our relevant services, without the risk of booking issues for patients.
‘We strive to continually improve our service through innovation to benefit our doctors’ and their medical secretaries’ experience of our platform, and partnerships like these with newer health tech companies are essential in keeping our trusted and established services relevant.’
Doctify chief executive Stephanie Eltz said: ‘This integration further enables our advanced booking process for all doctors that use PPM software. Today, consumers book everything online, and we as the healthcare industry need to ensure we keep up with modern user behaviour.’
By Robin Stride
Private doctors grappling with Care Quality Commission (CQC) inspections – and their fallout –could be given fairer treatment in future.
The independent sector hopes that new research into what goes on when inspectors descend on NHS premises will bode well for operators of smaller private practices.
Report author Ruth Robertson, senior fellow at The King’s Fund, said: ‘When CQC identifies a problem in a large hospital there is a team of people who can help the organisation respond, but for a small GP surgery or care home the situation is very different.
‘We recommend that CQC develops its approach in different ways in different parts of the health system with a focus on how it can have the biggest impact on quality.’
The report, Impact of the Care Quality Commission on provider performance, Room for Improvement? , comes as the watchdog is near to concluding the inspection of independent doctors’ services and is preparing to launch the ratings scheme for the sector next April.
Martha Walker, an independent medical management consultant who runs CQC Consultancy, said: ‘Doctors in the independent sector have constantly echoed an apparent lack of proportionality.
‘Although the report concentrates on the inspection process and its outcomes within the NHS, many parallels can be drawn between the findings from health service providers and the experience of independent doctors during the current wave of inspections.
‘The report found that providers made a wide range of improvements before, during and after inspection.
Martha Walker, of the CQC Consultancy, said the watchdog recognised its inspectors’ variable understanding of the private sector
According to the report, the watchdog’s Ofsted-style inspection and rating regime is a significant improvement on the system it replaced, but it could be made more effective.
The research, carried out by The King’s Fund and Alliance Manchester Business School between 2015 and 2018, examined how it was working in four sectors – acute hospitals, mental health, general practice and social care – in six areas of England.
It found the inspection regime’s impact came through the interactions between providers, CQC and other stakeholders, not just from an individual inspection report.
A disconnect between the sexes when it comes to staying on top of their health has been revealed in a Cleveland Clinic survey in the United States.
Eight-in-ten women said they encouraged their spouse/partner other to get their health checked annually – but 30% of men thought they were ‘healthy’ and did not need to go.
Dr Eric Klein, chairman of Cleveland’s Glickman Urological and Kidney Institute, said many male patients admitted to only seeing a doctor after their women encouraged them to go.
‘The report mirrored those concerns saying that “recruiting and training an inspection workforce with relevant skills necessary to be open and flexible whilst retaining objectivity and consistency will be key to ensuring that the process remains uniform and personal’’.’
She said the CQC had acknowledged the discrepancies in inspections and variable understanding of the independent sector among the inspectors.
The body was working with stakeholders, including the Independent Doctors Federation, to develop a more effective inspection regime to enable private doctors to show what ‘good looks like’.
Mrs Walker believed independent doctors would agree with the report’s conclusion that the general consensus was that quality regulation was a necessary function in the healthcare system but there was room for improvement on both sides of the relationship.
‘Hopefully, both the positive and negative observations in this report will be taken into consideration as the CQC prepares to rate the independent doctors,’ she said.
‘Independent doctors have long complained that the knowledge and experience of the inspectors has been variable and, in turn, that dictated how the inspections progressed.
Researchers suggest that relationships are critical, with mutual credibility, respect and trust being very important.
Their report argues that CQC should invest more in recruiting and training its workforce and calls on providers to encourage and support their staff to engage openly with inspection teams.
It also suggests the focus on inspection and rating may have crowded out other activity which might have more impact.
Researchers recommend that the CQC focus less on large, intensive but infrequent inspections and more on regular, less formal contact with providers, helping to drive improvement before, during and after inspections.
They found significant differences in how CQC’s inspection and ratings work across the four sectors it regulates. Acute providers were more likely to have the capacity to improve and had better access to external improvement support than general practice and social care providers.
Researchers recommend that CQC thinks about developing the inspection model in different ways for different sectors, taking into account differences in capability and support.
Both sexes turn to the internet as much as they do their doctor when a health concern arises. 27% of men (26% women) research symptoms online or consult a doctor when first noticing changes in their health.
‘to
Over a third of London’s hospitals are in areas where vehicle exhaust air pollution is likely to breach legal limits, according to research from air quality experts.
Of 58 hospitals analysed, 22 were in postcodes where NO2 levels are expected to breach the annual legal limit.
Christian Lickfett, managing director of Commercial Air Filtration, believes patients should quiz hospitals about how they measure internal air pollution and what purification systems they have in waiting and treatment rooms.
He said: ‘It is very unfortunate that patients are still being exposed to potentially dangerous levels of air pollution by simply travelling to, waiting for and attending hospital appointments.’
By Charles King
New figures showing a 142% rise in hospital doctors retiring early from the NHS are ‘concerning but not surprising’, according to the BMA’s seniors’ leader.
BMA consultants committee chairman Dr Rob Harwood said given the combined pressures of mounting demand, unmanageable workloads and widespread rota gaps, it was to be expected that doctors might choose to leave early.
NHS data released to the BMJ shows the number of hospital doc-
tors in England and Wales claiming their NHS pension on grounds of voluntary early retirement rose from 164 in 2008 to 397 in 2018.
Dr Harwood said the number retiring on ill health grounds – up from 12 to 79 over the same period – was most worrying, ‘clearly illustrating the effect these pressures are having on the physical and mental well-being of doctors, with many finding themselves at high risk of stress and burnout’.
He said transitional arrangements for those approaching retirement should be made more available, including better opportunities for flexible working and an end to overnight working.
The BMJ reported that, in 2008, 14% of hospital doctors claiming their NHS pension took voluntary early retirement; in 2018, 27% of doctors did so. In 2008, 1% retired on grounds of ill health; in 2018, 5% did.
you CAN Be BeTTer off By ‘reTIrINg AND reTurNINg’
A steady rise in the number of specialists choosing to retire early has brought new advice to those who also have a private practice.
Specialist financial planners Cavendish Medical has been witnessing the early exodus and, according to director Dr Benjamin Holdsworth, many are also opting to reduce their role or choosing to ‘retire and return’.
He said this enabled them to decrease professional commitments yet maintain their financial earnings by claiming pension benefits while working.
Dr Holdsworth told Independent Practitioner Today: ‘Although their base salary may be reduced, doctors will save on pension contributions. Clinical excellence awards will be lost upon retirement, but
the pension benefits received can be higher, so many find they are better off financially.’
He advised independent practitioners who also work in the NHS to weigh up their own options well ahead of time to ensure a successful transition from full-time practice to retirement in whatever guise was relevant to them.
‘There can be many issues to factor in – an exit strategy for your private practice, the tax due on your accrued pensions savings and the potential to receive a lump-sum payment from your benefits.
‘By taking a look at your entire affairs in terms of lifestyle and finances, you can make well-considered decisions which will point to the best time for you to retire while retaining your future financial security.’
Consultants, hospitals and insurers must work together to demonstrate independent healthcare’s quality and value, according to Bupa UK Insurance’s medical director.
Dr Luke James told consultants, practice staff, private hospital and clinic owners that the UK health insurance market decline meant just 6% of lives were covered by private healthcare in 2016 compared to 2007’s 12% peak.
Personal subscriptions had fallen from 3,604,000 in 2008 to 3,016,000 in 2016, he told a LaingBuisson seminar.
Dr James said Bupa shared challenges with consultants and hospitals to offer and demonstrate best quality and value.
He told the meeting the insurer was improving patients’ access so they could see a consultant without a GP referral for musculoskeletal symptoms, mental health
Negligence claims have doubled in seven years
GPs can expect to be sued four times during a 40-year career – but very few are likely to be found negligent.
The Medical Defence Union says the figures applying to all its GP members, including those practising privately, were released as it called for a solution to the compensation crisis.
Chief executive Dr Christine Tomkins told a Westminster Health Forum seminar: ‘Claims against GPs have doubled in frequency and cost over the last seven years. Claims over £10m are no longer unthinkable and GPs can now expect a claim every ten years.’
She said the rise in claims did not mean there was any deterioration in clinical standards. The cause was in the legal environment, which doctors could not control.
The Government plans to bring in a state indemnity scheme for NHS GPs next April, but Dr Tomkins said all this would do was ‘move the bill to the taxpayer. It won’t address the root cause of the rising cost of compensation claims’.
Self-pay plan will aid doctors
A new self-pay strategy at The London Clinic will support consultants to grow their businesses, the hospital said.
The Harley Street clinic now has 170 fixed-price packages for patients across all health conditions.
conditions or concerns about possible cancer.
Dr James said Bupa could work with consultants to understand unexplained variation in their practice compared to their peers.
The insurer aimed to support consultants through its online directory Finder (finder.bupa.co. uk) – key to helping patients find out more about consultants when deciding whom to see for treatment.
It told Independent Practitioner Today its strategy included improved processes, targeted digital marketing and specialist account management ‘to support consultants in attracting more patients wishing to pay for treatment themselves’.
Business development manager Georgina Bishop said: ‘We want to provide improved support for our consultants and our strategy offers a simple transparent approach.’
By Leslie Berry
Consultants’ leaders have been praised for championing the drive for greater transparency in private healthcare.
Their efforts helped the Private Healthcare Information Network (PHIN) last month to hit its initial target of publishing 1,000 specialists’ performance measures, as forecast in our last issue.
Another 4,000 consultants are now said to be working towards publication of their figures in the ‘UK’s largest clinical data validation exercise’.
The 5,000, who collectively handle an estimated half of admitted private healthcare in the UK, have been working with PHIN and hospitals to check their private practice data and improve its quality.
The data body said there was now more validated information about individual consultants available in the public domain – on its website – than ever before for people considering private healthcare.
PHIN chairman, former surgeon Dr Andrew Vallance-Owen, said: ‘Over the past few years, there has been a noticeable, positive shift
from the medical profession towards embracing transparency.
‘We would like to thank those consultants who are at the forefront of this transformation. We have had excellent support and input from the leaders of various specialty associations and, in many cases, those professional leaders are among the first consultants who have approved their data for publication.
‘We hope that this will provide strong encouragement for other senior doctors to also review and approve their data, working with the hospitals at which they prac-
tise to improve the quality of data where necessary.’
Calls for greater transparency, data quality and improved patient safety in private healthcare have come from a number of leading organisations including the Royal College of Surgeons (RCS).
Its president Prof Derek Alderson considered the response from specialists so far ‘shows the commitment the profession has to improving patient safety and reducing risk’.
He encouraged all RCS members to now follow the lead of colleagues and engage with PHIN.
of specialties with orthopaedic surgeons making up the largest number at around 30%
We reported last month on PHIN’s portal going live
Measures published by PHIN are the number of patients that each consultant treats by procedure, along with their average length of stay.
But these are the first of up to 11 measures that PHIN is required to publish under its mandate from the Competition and Markets Authority, following its long-running inquiry into private healthcare.
Information on the fees that consultants charge for common procedures in their private practice are due to be published by PHIN next year.
The data body said it recognised that it would take time for private healthcare data to mature and it aimed to continue working with consultants, hospitals and specialty associations to improve data reporting and get more consultants on its website.
Compiled by Philip Housden
Marsden breaks through £100m barrier
The Royal Marsden has recorded record private patient revenues –now exceeding £100m for the first time – achieving the stated target of the trust.
Private patient income was reported as £104.3m for the year to end of March 2018. This is an increase of £12.5m on the previous year, a rise of 13.6%.
Previous year growth was also in excess of 10% and so annual revenues have risen by over 25% in the last two years.
Private patient revenues now supply 33.3% of income, up from 31.4% the year before.
This remains by far the highest such proportion in the NHS, with Great Ormond Street and Moorfields reporting around 14%.
In fact, last year was a good year for all of the ‘Big three’: Marsden, Great Ormond Stree and Imperial, with combined revenues of £212m (last year £193m, a rise of 10%).
Great Ormond Street’s private patient revenues rose from £55.1m to £57.3m (4%) and Imperial broke through its own barrier, achieving over £50m for the first time (£50.7m, up 10% on £46m).
Together these three trusts presently deliver almost one third of the estimated £600m annual private patient revenues of the NHS. Will these encouraging results be mirrored across London and the rest of the country? NHS trust annual reports and accounts for 2017-18 are due to be made public in September-October each year.
A full summary review of the performance of trusts from across the NHS will be published in a coming issue, together with ongoing monthly focus reports broken down by region.
Philip Housden is a director of Housden Group. Read his feature article on page 42
DoN’T Be SHy – rePLy!
So what has been going on in your private practice? Independent Practitioner Today invites all those entrepreneurial consultants and private gPs out there to tell us their story. Let us share your achievements and good news.
Contact editorial director robin Stride at robin@ip-today.co.uk
oN ‘rEflECtioN’
By Olive Carterton
New guidance to help doctors with reflection has been widely welcomed by independent practitioners and medical bodies.
The advice, setting out key points and principles on being a reflective practitioner, comes after doctors called for clearer information on what reflection meantand how best to do it.
Published by the Academy of Medical Royal Colleges (AoMRC), the Conference of Postgraduate Medical Deans (COPMeD), the GMC and the Medical Schools Council, it outlines the importance of reflection for personal development, as a way of demonstrating insight, to help learning and identify opportunities to improve patient safety.
Key guidance points include:
Reflective notes do not need to capture full details of an experience, but should focus on learning;
Reflection is personal and there is no one way to reflect;
Having time to reflect on both positive and negative experiences is important;
Group reflection often leads to
By MR iAn MACKAy, Responsible Officer for the independent Doctors Federation (iDF)
ideas that can improve patient care; Tutors, appraisers and employers should support individual and group reflection.
COPMeD chairman Prof Sheona MacLeod said reflection was an important part of professional practice. It enabled doctors to assess how well they were performing, as well as identifying learning needs and enabling improvements to be made to their practice. But many doctors found it difficult.
AoMRC chairman Prof Carrie MacEwen said: ‘Being able to reflect on all aspects of clinical care is important to improve the way we look after patients.
‘This guidance and the reflective practice toolkit developed by COPMeD and the academy, which we are publishing in parallel, should reassure all doctors that it is possible to record events in a way that optimises learning and promotes active change in practice based on this learning.’
The guidance is on the GMC’s website – https://bit.ly/2OeBSaL
The reflective practice toolkit, including templates and examples to use alongside the guidance, is available at https://bit.ly/2CXhKsv
Reflective practice is ‘the process whereby an individual thinks analytically about anything relating to their professional practice with the intention of gaining insight and using the lessons learned to maintain good practice or make improvements where possible’ AoMRC and COPMeD
The guidance on reflection stresses that it is for doctors’ own development rather than as a forensic tool after a critical incident
The IDF eagerly awaited this new guidance.
There will be some who feel that it is unnecessary to provide guidance on reflection, which should be an everyday, automatic response, particularly when things go wrong.
The UMbRELLA* report, Evaluating the regulatory impact of medical revalidation , published in February, describes the process as: ‘… when you really need to reflect if someone’s made a complaint or you’ve got an event that’s happened, a significant event where somebody’s died or a near miss situation, and you automatically reflect on that at the time.’
It goes on to point out that we don’t always write it down at the time, although perhaps we should. Added to this, some doctors, particularly following recent high-profile cases, are still concerned that they may be providing self-incriminating evidence.
The report clearly states that ‘the GMC does not ask a doctor to provide their reflective notes in order to investigate a concern about them’, however ‘they can choose to offer them as evidence of insight into their practice’. We are informed that this guid-
ance has been developed in response to requests from doctors for clearer information on what is meant by reflection and for practical advice on not only how to reflect but also how to avoid the pitfalls of providing written reflective notes in the appraisal documentation.
The guidance confirms that while, at present, reflective notes can be required by a court, it is important that we should still have the opportunity to reflect and discuss events in an open and honest way.
We should concentrate on learning, reflecting on and discussing how practice will change as a con-
rEaCtioN to thE GuidaNCE
The BMA hopes the guidance and accompanying toolkit will give doctors the confidence to reflect safely, securely and effectively.
It has long said there is no single way to reflect effectively, so it is a ‘positive first step’ to see this guidance acknowledge that scope for reflection includes group discussions and other methods, according to Dr Jeeves Wijesuriya, its junior doctors’ leader.
He called on health education bodies and royal colleges to now ensure they are consistent in their own guidance about the requirements for trainees, including on the need for written material.
‘The guidance also reiterates assurances given to us that the GMC does not ask for reflective notes in its fitness-to-practise investigations, and while we continue to ask for their full legal protection, we are pleased there is clarification of the level of information required.
‘The focus must be on learning, rather than blame, and so clarity that specific factual details are not needed to improve care in the future is welcome’.
At the MDU, Dr Caroline Fryar
sequence, rather than focusing on the specific details of the case.
The guidance also makes it clear that reflective notes should certainly not contain any confidential patient information.
Following this advice, far from leading to self-incrimination, reflection may well provide helpful evidence of insight and remediation, therefore reducing the need to take action, should a doctor become subject to GMC scrutiny. Reflecting on positive experiences is equally important for individual well-being and devel-
said: ‘We encourage all doctors to take part in reflection, which remains an important part of clinical practice and is also an ethical duty, set out in the GMC’s guidance Good Medical Practice (2013).
‘Careful and conscientious reflection on professional practice, particularly if things go wrong, can be helpful both in terms of learning lessons and in demonstrating insight.
‘As the new guidance points out, a reflective note does not need to capture full details of an experience. It should capture learning outcomes and future plans.’
The MDU hopes the guidance will help reassure doctors over some of the misconceptions about reflection and the contents of reflective notes, particularly in connection with legal proceedings.
She added: ‘We encourage members who are completing reflective notes after something has gone wrong or those who have received a request to disclose the document to others to contact us for advice.’
Also welcoming the guidance, Dr John Holden of the MDDUS said it condenses all the key aspects of reflection into one doc-
opment and we are reminded that, while individual reflection is helpful, group reflection may play an even more important role, leading to ideas or actions that may not have been considered by any one individual on their own.
What does the IDF think of the guidance? So far, we have not received anything but positive feedback from our members.
We are particularly pleased to see that the guidance contains the simple ‘What?, So what?, Now what?’ model of reflection and we will continue to encourage our connected doctors to use it.
We note that the guidance
ument and should provide doctors with clearer direction on how to implement reflective practice.
‘Reflection is an essential part of helping a clinician’s self-development. Those who reflect on their everyday practice are considered to be insightful.
‘MDDUS has advised its members for many years to engage in reflective practice. We believe that this raises standards, ensures doctors meet their regulatory obligations and can provide a degree of protection in the event of criticism of a doctor’s actions.
‘We particularly welcome the document highlighting the importance of learning outcomes as the key aspect of reflective practice. Being able to learn through reflection is crucial to assisting doctors with education, training and development. We are reassured that the GMC will not use these reflective notes in order to investigate a concern.’
But he warned that reflection was no substitute for reporting significant events or serious incidents. Doctors should contact their defence body if faced with any incident, claim or complaint.
explains that recorded reflections are not subject to legal privilege and would be keen to see this explored further.
In broad terms, we are very supportive of the guidance and feel that one of the key issues will be to ensure it is read and understood by all doctors and becomes embedded into healthcare culture. Specifically, the IDF will ensure it is discussed fully with all our appraisers as part of their regular update training to help them develop skills in evaluating the quality of reflection.
* The Uk Medical Revalidation coLLAboration (UMbRELLA)
A look back through our journal’s archives of ten years ago reveals that although times change,
some issues are not so new
Private healthcare insurance fraud investigators were stepping up their drive against doctors and others they suspected of dishonesty.
We reported that insurance detectives were coming together for the first time for a two-day brainstorming session to consider ways of tackling fraud.
The Health Insurance CounterFraud Group also set up a website giving a phone number for the public to report suspected fraud anonymously.
AXA PPP said it had 111 investigations open against doctors.
Independent Practitioner Today in the same issue doubted many doctors were ‘at it’ at all and warned that highly reputable independent practitioners should not be made to suffer from unwarranted scrutiny and unfair allegations arising from genuine mistakes or misunderstandings.
We said: ‘Insurers want clarity in the documentation that doctors send them. Fine. But they must work harder to improve the clarity in the paperwork they send to doctors – and patients.’
AXA PPP rebuffed claims that it was unfairly derecognising consultants during the major anti-
fraud drive across the health insurance industry.
The insurer was singled out for criticism by both the BMA private practice committee and the Independent Doctors Forum (now Federation) over concerns that numerous consultants, mainly in London, were being delisted.
AXA PPP said it was not its policy to withdraw specialists’ recognition simply because of the level of fees they charged. Less than 1% of the 30,000-plus specialists it recognised had been delisted.
The growth in GPs going private was underway a decade ago. And the leader of the BMA’s GP committee, Dr Laurence Buckman, predicted ‘most of the NHS’ would, in time, become private in all but name.
He thought some existing general practices would go private, especially in wealthy areas where private general practice would become ‘quite common.’
Independent Practitioner Today warned readers to watch out they did not sign up for more than they bargained for if invited to send their details for inclusion in a physicians and therapists guide.
Several doctors had agreed to
be included in a directory without realising the small print meant they were agreeing to pay for what amounted to an advert.
When practices tried to get out of paying hundreds of pounds, a Swiss-based firm behind the venture told them they were legally obliged to pay.
New EU proposals on cross-border care could affect the private practice market, warned the BMA.
Brussels wanted patients to have the right to treatment anywhere in the EU if their own nation could not provide treatment within a reasonable time-scale.
Consultants were making hostile bids to try and take over rival private practices and increase their market share.
The London-based specialists had focused on specific practices and wanted intermediaries to fix a deal.
Target practices were reckoned to be worth up to £600,000. Half the purchase price would be paid up front and the balance linked to business sustainability.
A consultant’s adviser told Independent Practitioner Today: ‘Our client wants to grow his practice and make a bid for the other to help safeguard his future. He fears if nothing was done, it would be difficult for him to grow his practice.’
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Doctors were issued with a guide to dealing with the media after the Medical Protection Society found one-in-five consultants had been contacted by the media about patients.
Patient confidentiality was the key issue in the study of 600 doctors’ experiences of dealing with the media.
Membership of the British Association of Aesthetic Plastic Surgeons (BAAPS) should be considered a ‘kitemark’ of quality, following publication of impressive safety figures, the body claimed.
BAAPS boss Mr Rajiv Grover said: ‘All members have been audited. Many apply but don’t get membership. There’s no other organisation in this country in this field that has audited complication rates.’
Doctors sending their children to private schools faced average annual fees for day pupils of £9,069, while boarding schools cost £22,059.
The National Union of Students was estimated that it cost over £12,000 a year to attend a university outside London and over £14,000 in the capital.
very quick to answer the phone. CPS also sets up the MDT AND provides a brilliant Mohs service. Dr Dev Shah, Consultant Dermatologist & Mohs Surgeon
Creating a better patient journey
Cellular Pathology Services has been providing specialist histopathology services UK wide since 2007. Our laboratory is CQC registered, ISO 15189:2012 accredited and trainingapproved by the IBMS.
Our streamlined processes, consultant led reporting and secure electronic dispatching of results (90% of histology cases reported within 72hrs), will enable your practice to expedite the patient journey, reduce administrative burden and reinvest the saved time elsewhere.
The delivery of our histopathology service is adapted to match the exact requirements of each and every practice. Our account management team makes sure that the transition from your existing histopathology provider to CPS is a seamless and stress free process; taking the pressure of your team whilst maintaining a continuous service and improved service to your patients.
I receive an efficient, professional and very rapid turnaround from CPS which is great for patients in terms of getting results back. They add value to my private practice with no delay for specialist histology reports. The quality of the work is excellent and I know that if there is ever a problem, I will get a phone call for clinical pathological correlation. The team at CPS are very friendly and are
An extension of your team
Our specialist client services team will deal with all of your enquiries, supporting your practice, consultants and their secretaries. From ordering consumables to arranging a courier pickup, organising MDTs and liaising with our consultant pathologists; we become an extension of your team.
You’re never on your own. Our consultant pathologists are available around the clock for clinical pathological discussions and will attend MDTs personally when and if required. Our helpful and knowledgeable client services team are at hand 9am to 6pm, Monday to Friday with a dedicated out-of-hours service for any urgent requests or access to results.
I have been in Independent Practice, as a Consultant Urological Surgeon, since 2011. I have used CPS exclusively for all my histopathology. The service is excellent and timely. Clear reports with images are produced and are now available through their online service. Drs El-Jabour & Mitra are always available for telephone discussions and attend MDTs as required. Altogether an excellent service that I recommend to all my consultant colleagues. Mr George Fowlis, Consultant Urological Surgeon
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We prefer to work as a close and long term partner and collaborator, helping our clients to provide a world-class standard of care for every patient.
If you are looking to conduct a review of your current histopathology partner or are actively looking for a new provider that structures their service specifically around your practice, then call our team today on 01923 233299.
Information Network is hugely significant for consultants. Mr Ken Anson argues this is the future, so specialists must engage with it
When I fIrst saw my nhs data alongside my private practice data, I almost fell off my chair – I was stunned.
It has become apparent, very quickly, that transparency is happening in private healthcare, and the Private h ealthcare Information network (PhIn) is driving this forward following the Competition and Markets Auth ority (CMA) ruling.
Also, it came as huge surprise to me that PhIn is able to align its private outcome data with large volumes of nhs data as well.
As a result, data quality standards within both healthcare systems are being aligned at the consultant level, allowing individual practitioners visibility of their whole practice on one digital platform for the first time.
t he process of reviewing my practice data from P h I n raised some interesting questions for me.
Mr Ken Anson, reader in urology at st George’s Hospital, London, and member of London Urology Associates
for instance, why is this the first time I’m seeing my nhs data alongside my private data and, perhaps more importantly, where is the nhs data coming from?
I explore these issues a little later, but I am in no doubt that the provision of wholepractice data on PhIn’s platform represents real progress in driving transparency and improving access to information for patients.
duty of candour from the outset, it is important to note that consultants in everyday practice in the nhs live and breathe transparency; we have a duty of care and a duty of candour and are expected to inform all aspects of healthcare with patients at every opportunity.
We are now part of a process of engaging with P h I n to sign off our private healthcare outcome data for publication to allow pri
vate patients access to a similar level of information that nhs patients enjoy.
the idea of wholepractice data isn’t revolutionary to me; I know my numbers and I live the work that I do, so there were no surprises in the data that I first saw in my activity report.
h owever, it is the first time I have seen this data provided in such a clear and compact format, and what is revolutionary is private practice clinical and outcome information being made publicly available for patients and outside agencies to monitor and audit in the future.
t his is the hugely important development.
t he importance of publishing health outcomes to provide some measure of quality is likely to have a significant impact on patients and possibly on consultants’ activity.
While data alone doesn’t change one’s practice, how the data are interpreted and acted upon can drive changes in behaviour. f or example, I was somewhat surprised to see that one of the initial data points – length of stay – was slightly longer than I had thought.
to then be able to analyse and interpret that information down to the individual patient provides a fantastic level of insight and allows me to reflect on my practice and see if I can effect changes to improve my practice.
Visibility of wholepractice data will also be very beneficial for consultants for both annual appraisals and revalidation. As PhIn proceeds to explore publication of further surgical outcomes measures over time, the greater the value of this information will prove to be for surgeons and patients alike.
But I predict that this initial signoff and publication process by P h I n will prove challenging for many of my consultant colleagues.
some will question the validity of their nhs h ospital e pisode statistics (hes) data and will no doubt comment on the fact that, in most centres around the country, individuals do not have the opportunity to check or validate their data before it leaves their nhs trust.
Others will question why PhIn should be the organisation to publish whole practice data. Ultimately, it will be up to individuals whether they want to include their nhs practice alongside their private practice when approving their indicators with PhIn
But, in my opinion, hes data does provide a sufficient indication of nhs practice to justify it being included alongside PhIn’s private practice information.
P h I n is working to meet a Government mandate and is moving the sector forwards quickly. t he information published since July of this year will be just a starting point.
this will provide consultants with a fantastic opportunity to initiate a virtuous circle – the more we get involved with our data, the more accurate the data will become and the more time will therefore be saved in its validation.
All of this will ultimately and positively impact on our workload and patient safety.
My experience so far has been that engaging with PhIn has been an easy and straightforward process. there is a remarkable level of
An anonymised ‘information dashboard’ of statistics gathered on a real surgeon, showing the format that other consultants will face in the future
data being made available for sign off, and I have been pleasantly surprised by the quality of the initial private healthcare practice information being provided. Bringing both nhs and private datasets together into one place is
immensely attractive to me for the reasons outlined above. I would encourage all consultants working in private practice to get behind this initiative which may well prove to be the source of all our whole practice data in the future.
f rom June 2018, consultants with private practice have been be able to preview and approve the first performance measures for publication on P h I n ’s website. f or more information, visit PhIn’s consultant guide
The questions independent practitioners are asking their accountants – answered! If there is something about your business accounting you are unsure of, never be afraid to ask your accountant.
Susan Hutter answers some of the most frequent questions she has recently been receiving from private doctors
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I trade through a company and I have a large cash pool that I don’t need to draw on. What can I do with it?
A compAny cAn invest in stocks and shares and also property – you don’t have to draw the money out to invest.
If you did, this would give rise to dividend tax, which is expensive.
A number of my clients in the medical profession do this, but beware if you buy a property that is a residential property.
If you don’t rent it out at market value to an unconnected third party, there is a hefty tax called ATED which stands for Annual Tax on Enveloped Dwellings.
Let’s say the value of the property is between £500,000-£1,000,000. The annual tax is £3,600. For properties between £1,000,000 and £2,000,000, the charge is £7,250.
Also, if you invest large sums of money into non-trading assets –shares/property – unless you are running your letting as a holiday let, then you lose your trading company status and when you finally close your company down and distribute the assets to yourself, you are unlikely to receive Entrepreneurs Relief (ER) on the gain.
ER means the gain will be taxed at 10% as opposed to the higher rate of 20%.
It’s worth bearing in mind that a cash pool is also considered an
investment asset – so you might as well invest in something better than just leaving it lying dormant.
As always, in all the above examples, your accountant will guide you as everyone’s circumstances are different.
ThE shoRT answer is it is a good idea because the salary will reduce the practice’s profit.
The likelihood is that you are a 40% or 45% taxpayer. Assuming your children do not have their own successful business, then they will more than likely be non-taxpayers and your spouse – if they do not work or have much income – will also be either a non-tax or 20% taxpayer.
The personal allowance before you pay tax is £11,850 and a 20% taxband is £11,851-£46,350.
Be aware, any children working for your business have to be 18 or over. Also, all paid work must be commensurate with the salary.
Ideas of work that children can do could be assistance with IT. often they are better at that than their parents. or, potentially, they could do admin and personal assistant work. neither children nor spouse can be self-employed – all salaries have to go through a payroll.
I have a lowerincome spouse who isn’t even using the tax-free allowance. Can I transfer income earning assets to their name?
ThE AnswER is you can – there are no tax consequences affecting capital gains tax, inheritance or income tax, which means you can transfer.
This is considered tax neutral. however, if you transfer investment property to your spouse, then you must have a legal conveyance. Everyone has an annual capital gains tax exemption – £11,700 per person – so you may want to consider 50:50.
The other income-earning assets are bank and building savings accounts and stocks and shares.
I trade through a limited company. I am changing my car; should I get my firm to buy or lease my new/ replacement car for me?
you nEED to do the maths, but usually, depending on the car, it works out marginally better from a tax point of view for your company to buy it for you.
The decision of whether to buy or lease a car is largely a commercial one because the tax rules are similar – so make sure you get the best commercial deal.
Remember, if you are the recipient of a company car, there is a taxable benefit on you.
The benefit is calculated on the list price when new and co2 emissions. For expensive cars, with high emissions, the benefit can be up to 37% of list price; but for electric cars, the benefit is only 13% of list price.
The company will also pay employers’ national Insurance at 13.8% on the benefit. It will receive tax relief on this. But if the company buys the car, it can claim capital allowances against tax and also all running costs.
As a rule of thumb, it is advisable to pay personally for all private fuel – otherwise there is a fuel benefit as well as a benefit taxable on you. And do remember that travel from home to work is regarded by hm Revenue and customs as private, not business.
your accountant will need to file an annual p11D, which is a return of benefits in kind. There are likely to be additional fees for the p11D.
For those who either do not trade as a limited company – sole trader – or who do not want to be involved with the company administration, you can make a mileage claim of 45p a mile for the first 10,000 business miles.
Susan Hutter (right) is a partner at Blick Rothenberg and part of the team that advises medical practitioners
Jane Braithwaite’s latest article in her series about managing your private practice puts the spotlight on the broad area of business development
We often see or hear the term ‘business development’, but it is little understood and often it is confused with sales.
Well, I see business development as all the activities that lead to developing your practice or clinic in terms of growth and expansion.
Anyone who has their own private practice or medical company will understand that the healthcare landscape changes all the time.
to grow and develop, we need to change with it. one of the key reasons for business decline is a failure to spot change and exploit the new opportunities that change offers.
Business development is broadly considering what we need to do to ensure we have insight into upcoming markets, services and/or technology that could make an impact on our current businesses.
t his month, I am going to explore the various options that are open to all of us and I hope one or more of these ideas resonate with you.
Developing and growing your practice or clinic further might mean offering additional services to your existing patients or looking at new channels to appeal to a new set of patients for your existing services. It might be a mixture of both. In either case, there are numerous options.
Perhaps there is a complementary aspect of healthcare that your existing patients would appreciate. You could enable this by inviting another practitioner to make use of your facilities.
Physical consulting space is an expensive overhead and it is always wise to consider how you can make better use of the space you have in a way that might
complement your practice. Do some market research or competitor research to find out what your options might be.
You may feel there is an opportunity to grow by servicing a wider geography. Could you add another clinic at a hospital in a different location, if your schedule allows?
It might also be worthwhile considering different age groups and identifying the differing needs of each group. Consider the age range of your current population.
If the patients at your clinic tend to be 40-plus, do you need to review your marketing activities to attract potential patients below the age of 40?
A good understanding of the different requirements of differing age groups will assist you when it comes to marketing your services at a broader age group. Perhaps the message to younger patients is about preventive healthcare
rather than specific treatment plans.
technology now offers us different ways to communicate with patients and this may enable new service offerings such as telephone, email or skype consultations.
e mbracing these technologies may allow you to offer more frequent support to your current patients and allow you to reach patients who are unable to see you in person. there are several very successful companies offering only ‘virtual’ consultations. t here may well be a greater opportunity for doctors who are able to offer both face-to-face and virtual services in a complementary manner.
Regardless of how you decide you should develop and grow your practice, there are numerous ways in which you can ensure you meet your objectives.
l
l Solvent liquidations
l Consultant groups and consortia
l
l Ad hoc assistance
networking wins one of the main ways to identify and research new opportunities for business development, and to progress them, is to invest time in networking.
It’s a core part of business development, as leveraging relationships is critical to success. How do you maintain relationships with patients, staff, suppliers, organisations, the local community, hospitals and other doctors?
traditional networking is about communicating in person with patients, colleagues, suppliers and peers. there are numerous events that provide such opportunities and often provide valuable opportunities for education and reflection.
Do you arrange regular events at your practice and invite your own contacts to attend? this requires a real investment in time and effort, but can provide valuable opportunities for referrers, patients and
prospective patients to get to know you.
You will also get some valuable feedback this way – people are far more forthcoming in person than on a feedback form.
n etworking these days also includes your online network. Your practice may have several different social media channels that allow you to communicate with a wider audience. the most personal networking tool is probably LinkedIn.
It’s a valuable tool, especially for keeping in contact with your peer group. Most people check LinkedIn at least once each week to accept connection requests and check on messages, but you could maximise its power by contributing to conversations daily so that your name comes to mind at the right time.
Presenting at conferences and events only suits certain individuals, but if this type of activity
appeals to you, it is a powerful way to reach a far wider group of people. If presenting is not especially attractive to you, then perhaps publishing articles is more realistic and enjoyable.
powerful communication
Video is a very powerful way of communicating with your audience. Like presenting, you will either love it or hate it, but it is a very wise investment. Ideally, you would create regular videos, upload them on You tube and link to your website. t his is an area that is going to grow and grow in popularity.
Healthcare marketing is rapidly becoming more focused on digital, but still relies significantly on print advertising. Whether you’re handling your own marketing or outsourcing it, you must be clear on what your audience and goals are before starting.
Without an awareness of whom you want to reach and what you want to achieve, any money spent is wasted.
You also need to bear in mind the guidelines issued by the GMC and the BMA around ethics and confidentiality when it comes to marketing your services.
Below, I have highlighted some important marketing areas to keep in mind, but it’s important to get a full assessment of your marketing needs, as every business is different.
business website
I suspect that anyone reading this has a website of some description, but is it doing a good job for you?
Is your website helping you to reach your desired audience? once potential patients visit your website, do they follow through to book an appointment?
A website should not be a static tool but should evolve and change over time to better suit your purpose. f or a start, any website which isn’t enhanced for mobiles is not going to appeal to users –you may lose them before they have got past the homepage.
Does your website allow users to book an appointment online? If competitors have this option, so should you.
What capability do you have to record testimonials from your site or include reviews from other sites
such as trustpilot, f acebook or Doctify?
Patient reviews are key to build your reputation, and therefore your business.
f inally, a key way for new patients to find your website is a Google search, but this relies on your site being optimised for search engines (Seo).
Many people think that Seo is a one-off activity, but it’s best to review every six months to make sure that your brand is still appearing near the top. t his is where it does pay to hire an Seo expert, as it’s a science which relies on many factors and changes often.
o ne of the main factors which affects Seo is ‘freshness’ of content – a website which never changes will not score highly and won’t appear on the first page of results. this is one of the reasons why so many businesses embrace regular blogs.
Blogs, if marketed properly and consistently, can attract new patients. But this is if they’re written to add value for the reader, rather than simply advertise the business.
one of the most successful blogs written for my business, Designated Medical, was about the eU’s General Data Protection Regulation. It contained helpful information for our audience and brought new visitors to our website. It wasn’t about the services we offer or salesy in any way. Writing content which is valuable for your audience is key for blogs.
Don’t forget about Google My Business, which is an excellent –and free – way to boost your business online. GMB is basically your business profile on Google, where you can add your opening hours, photos and short posts.
It’s also where you can respond to Google Reviews. It’s quick work to set up your GMB profile, but well worth it to control your image on the biggest search engine.
Social media marketing is a very cost-effective marketing method, and for most private doctors it can
Look at ways to develop the range of services you offer your current patients, perhaps by collaborating with other practitioners
Broaden the range of patients you see by marketing to different age groups or serving different locations
Consider offering patients different ways of communicating with you. Your existing patients may like to review their progress by phone/Skype and new patients may like to have an introductory Skype consultation prior to booking a face-to-face consultation
Traditional networking offers valuable opportunities to connect with your patients and your peer group. it requires an investment of your time, but when viewed as a valuable way in which to develop your practice, it’s easier to justify
Online networking, using Linkedin and so on can make a significant difference and is often easier to reach a wider community than face-to-face networking
Look at opportunities to present at conferences and events. Ensure these are featured on your website, along with photos and video
Create a series of videos and start a YouTube channel. These can be marketed via social media and will bring a much wider audience to your website
Publish articles on your website as part of your blog. This will benefit your website to score high on online searches as well as provide patients with useful information
Social media can be used to network, communicate and drive more people to visit your website
Review your website to improve its performance over time. Your website should not be static, it should evolve over time
Create a blog and write a monthly article. This will attract lots of visitors to your website and improve your search engine optimisation (SEO)
Ensue you have a Google My Business page and update it from time to time. Keep on top of patient reviews, thanking each contributor and following through on any feedback if appropriate
SEO is important and needs to be reviewed every six months
be a very successful way to grow networks and attract patients.
As before, knowing your audience and goals is essential to make social media work for you. If you’re looking to establish more business connections or thinking of branching out to other markets, LinkedIn will be a key platform for you.
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facebook is ubiquitous for businesses but using its low-cost, super-targeted advertising is the key to success.
You can also get impressive reach via free facebook events listings. finally, Instagram can work very well for beauty and aesthetics clinics, with image-driven high engagement.
twitter also works very well in terms of business relationships, as it’s more conversational and ties in well with events.
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Independent Practitioner Today has been behind the doors of a new private hospital
The Schoen c linic London is about to have its official opening after beginning to admit patients in the summer.
The Wigmore Street spinal and orthopaedic hospital, in the harley Street medical area, is run by a family-run hospital group in Germany and has been signing up consultants on a salaried service option.
Patients can have outpatient consultations, diagnostic imaging, conservative therapies, surgical treatment, inpatient care and physiotherapy all under one roof.
Spread over seven floors, the new build includes 12 consultation and treatment rooms, onsite physiotherapy, imaging suite with MRI and c T, three laminar flow surgical theatres, a day-case unit and 39 ensuite inpatient bedrooms, including a VIP suite with roof terrace and private access.
Schoen clinic says the hospital’s design, emphasising natural light and using wooden furnishings and scenery, reflects its belief in the impact a positive healing environment can have.
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‘Here to help. Not to judge.’
Independent practitioners have plenty to gain from The Private Practice Register, explains Fiona Booth (above)
Our front page last month reported that over 10,000 practitioners have now joined the Healthcode project
PRIvATE PRovIdERs make a vital contribution to healthcare provision in the UK, delivering highquality care for thousands of patients and helping to alleviate pressure on the overstretched NHs
But if everyone in the independent sector is to grow and thrive, we must pass some significant tests, from achieving the level of information transparency demanded by the Competition and Markets Authority, to demonstrating that we have learned the lessons of the Paterson case.
The surest way to overcome these challenges is for practitioners, private medical insurers and hospitals to collaborate in a drive to streamline cumbersome processes, develop better lines of communication and improve governance and quality assurance.
This is where The Private Practice Register (PPR) comes in. When Healthcode launched The PPR two years ago, we wanted to make it easier for practitioners to obtain recognition and update their details with insurers.
Until then, the process would involve completing separate applications which would usually pose the same questions. Registered practitioners who changed their details would have to do so for each insurer.
The PPR eliminates this frustrating duplication. Practitioners complete only one form to set up their profile on the system and register with their chosen insurers. They can update their details once on The PPR, rather than inform each insurer separately. Each practitioner has complete control over their own profile and access to Healthcode’s electronic billing, secure messaging services and coding tools.
To date, more than 10,000 practitioners have registered with The
PPR and we are setting up new profiles at a rate of over 500 a month. We are rapidly reaching the point where The PPR becomes the definitive primary source of practitioner data, from their biography, qualifications and professional registration, to the hospitals where they have practising privileges, procedures and practice hours.
And this is why The PPR has become more than a fast-track to insurer recognition – as important
The Private Practice Register is an online portal that eliminates duplication by allowing doctors to register just once to gain recognition with all insurers and hospitals
being rolled out to private hospitals.
We are piloting the service with these users to determine their priorities, but, initially, hospitals will be able to view the PPR profiles of practitioners who have practising privileges at their organisation and see whose appraisal or indemnity is overdue.
They will also receive notifications when a practitioner joins The PPR and links to their organisation so they can cross-check this with their own records and discrepancies can be addressed.
Future functionality will include the ability to process and administer practising privilege applications and procedure credentialing. In short, it will give hospitals a clear picture of their consultant population and provide the tools to enhance their governance procedures.
Extending The PPR to hospitals is an important step towards data transparency, which will benefit the sector as a whole and it also brings practical advantages for independent practitioners.
works on a stand-alone computer. Without access to a common network, it is impossible for people to be sure whether the information they hold is accurate; administrative processes are often inefficient and duplicate effort; and there is nothing to stimulate discussion about new ideas or best practice.
The PPR is a game-changer because the technology brings together practitioners, insurers and hospitals. With access to a secure online platform, many of the transactions that take place across the private sector every day can be managed more efficiently. We can access reliable information on which to make informed choices. And looking further ahead, there is the potential for further innovations such as centralised appointment booking, which will increase our appeal to patients.
as this is. Its wider significance lies in being the technology platform that securely connects the different parts of the independent healthcare sector – practitioners, private medical insurers and hospitals – so we can work together more effectively for the common good.
To this end, Healthcode has just launched the next phase of The PPR project which will see it
For example, the detailed information on a PPR profile supports practitioners in maintaining practising privileges and, in future, it should be possible to apply to hospitals through the system.
Practitioners will be in control of their own data and will be able to securely share confidential information with their hospital contact. And it should make billing insurers for admitted patients more efficient.
For too long, the private healthcare sector has resembled an organisation where everyone
While the private sector has enormous strengths, the Paterson case left us at a crossroads. If we are to convince people of the safe, highquality care they can expect from the private sector, we need to unite and deliver meaningful change.
While the publication of performance data through the Private Healthcare Information Network is a definite sign of progress, we need to go further. The PPR provides the technology and tools to transform outdated working practices, but most importantly, it brings us together.
www.theppr.org.uk
Fiona Booth is overseeing the launch and development of The PPR at Healthcode
At CPS we tailor our pathology service to your practice. And when you need it, you’ll have access to consultant pathologists and not just in office hours.
Should the results be adverse I always receive a call to appraise me of the situation…. an extremely efficient and user friendly service that I would highly recommend to all physicians. Mrs Nitu Bajekal - Consultant Gynaecologist
Private hospital reliance on the Resident Medical Officer (RMO) system has come under attack from an independent, non-party think-tank. Dr Stephen Drotske (top) and Justyn Tollyfield hit back fighting
In november 2017, the Centre for Health and the Public Interest (CHPI) published a report entitled ‘ n o safety without liability –reforming private hospitals in e ngland after the Ian Paterson scandal’.1
The report used data from Care Quality Commission inspections at several private hospitals to set out five key recommendations designed to increase standards and, above all, patient safety within the sector.
In this article, we aim to address the third key recommendation, specifically the assertions that:
1. rmos should be employed by hospitals directly rather than by outside agencies;
2. o ne rmo should not be required to look after a significant number of beds;
3. reliance on doctors trained outside the UK presents a risk to patient safety.
our company, neS Healthcare, is the UK’s largest supplier of rmo services, currently employing more than 500 doctors within both private and nHS hospitals. So it could be argued that we have a vested interest in maintaining current rmo practices.
but, despite this, we do recognise there are areas, including some identified within the CHPI report, where improvements could and should be looked at.
After all, since 1994, ne S has been the driving force for significant changes to the conditions and professional standards for rmos.
We would therefore like to present a balanced response to recommendation three from the CHPI report, which reinforces some elements, yet challenges those that we feel are based on misconceptions.
A key CHPI criticism of the current system relates to the model whereby private hospitals use companies such as ours to provide their rmo s. It argued that they should employ the doctors themselves.
The rationale for this argument is broadly that devolving the responsibility for the appropriate management and governance of these doctors allows hospitals to
avoid liability and therefore presents an unacceptable risk.
What the report does not cover in detail is what this risk is.
Instead, it cites a small number of examples, such as one case where a doctor – not ours – had not been subject to ‘the relevant and legally required background checks’.
While this was a clear breach of an employment company’s responsibilities, one such case does not necessarily mean all companies are prone to similar lapses.
As a provider of rmo services, we are responsible for doing all necessary background checks, specifically references, qualifications, criminal records and occupational health.
We also ensure completion of mandatory training, a medical e nglish exam and the essential qualifications from the UK resuscitation Council that ensure a doctor can lead a resuscitation team.
As the employer, we accept full responsibility and liability for the actions of our doctors, including professional indemnity provision.
We are subject to regular audit and inspection by the relevant authorities and have a track record of consistently achieving outstanding levels of compliance. our credibility, and therefore our business, depends upon us providing a safe and reliable model for our clients and, by extension, the patients.
on average, we engage 30 new doctors each month, so we have invested to create an appropriate infrastructure, both in terms of facilities and staffing to ensure
Our credibility, and therefore our business, depends upon us providing a safe and reliable model for our clients and, by extension, the patients
this is done to the highest possible standards.
If one solution to eliminate a perceived risk is for hospitals to employ doctors directly, does that mean it is necessarily the right one? The hospital in question would be infrequently recruiting a small number of doctors on an ad hoc basis.
Is this a better arrangement than using a specialist organisation that does this on a far larger scale?
What happens when the duty doctor is sick or unable to work for any other reason, such as a family emergency? In a directemployment scenario, the obvious response would be for the hospital to turn to a locum agency to provide shortterm cover, but this introduces a whole new level of risk around availability, suitability and a significant cost increase.
ne S deals with such situations every day and has a team of standby doctors available all over the UK to respond at a moment’s notice. All of them have been recruited to the same high standards in terms of professional com
petence, language ability and background checks.
The report suggests that supervision for rmo s is ‘apt to be weak’, referencing cases where a lack of clarity existed in respect of clinical supervision. This highlights the need for a clearlydefined system.
Junior doctors in the n HS are supervised by consultants as part of their training programme. The limitations created by the structure of the private sector, including the role of the consultants and the lack of a training element within the rmo role, make this more of a challenge.
This makes it even more important that companies like ours have clear structures in place so that performance is managed and responsibilities relating to clinical supervision are clearly delineated. o ur clinical team, under the guidance of a medical director and r esponsible o fficer, is the first point of contact for any concerns relating to a doctor’s scope of practice.
Clinical mentorship for doctors while at a hospital is frequently provided by a designated consultant. This system provides clarity and support for the individual doctors.
‘The errors that occur in healthcare are rarely the fault of individuals but are usually the result of problems with the systems they work in’. 2 The CHPI report quotes research by Prof brian Jarman of Imperial College that ‘there is a strong correlation between the number of doctors employed for each bed in a hospital and the number of deaths in that hospital’.3
but this research focused on the nHS and with no data to support the same outcomes in the private sector, these assumptions are open to challenge.
It is not uncommon within a private hospital for a single rmo to be on duty, irrespective of the number of inpatient beds available for occupation.
on top of their routine duties, they play an important role in responding to emergencies.
If the number of beds is excessive, and indeed the report cites
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NES records accolades for RMOs’ appraisals – and the approval rate grows
the case of one rmo looking after 96, then common sense dictates that this doctor may struggle to maintain an effective level of patient care for all.
At first glance, to better the system and to match the research, it would therefore seem that a cap should be placed on the number of beds that a single doctor can be responsible for looking after.
This, however, may be a simplistic approach that does not take account of a private hospital’s patient acuity, bed turnover and hospital staffing.
our approach is to closely monitor the workload that our doctors face at our client hospitals and, where necessary, to make recommendations to hospital management around either the need for additional manpower or a change to the rotation structure.
one of our overriding criticisms of some sections of the CHPI report is that they are written from a viewpoint that seems to take no account of the challenges and realities faced by the healthcare sector as a whole.
Changes are recommended, yet there is a distinct lack of concrete proposals as to how these might be achieved.
one example of this is the section where it criticises the ‘reliance on doctors trained outside the UK to fulfil the rmo role’.
The reasons for highlighting this as a risk appear to be around the lack of familiarity with the UK health system and issues around english language, as referenced in the case of one doctor struggling with communication after working for just three weeks in the UK – again, not ours.
The private hospital rmo role
has never been of any particular interest to a UKtrained doctor or one with extensive working experience gained within the n HS. This is mainly because the role will not form part of their training and does not therefore contribute towards their career aspirations. It is also not typically as challenging or clinically stimulating as some alternatives.
In over 20 years of recruiting rmos for hospitals in the UK, we have received applications from only a handful of UKtrained doctors. only a fraction of these went on to start work with us.
It cannot be ignored that there is a national shortage of doctors across all areas, both geographically and by specialisation, across the UK. This is only going to worsen as brexit approaches. Already we have observed an increasing reticence from e uropean doctors to take up positions in the UK, and a bmA survey of 1,720 doctors in november 2017 found:
more than nearly half (45%) of doctors from the e uropean economic Area (eeA) surveyed are considering leaving the UK following the referendum vote. This compares to 42% of eeA doctors surveyed in February 2017; o f those considering leaving, over a third (39%) have made plans to leave, meaning almost one in five e U doctors (18%) have made plans to leave the UK.4 The UK has relied upon overseas doctors since the nHS’s creation in 1948. Another GmC report in 2017 found that nearly half of the doctors working within the nHS were trained overseas.5
Foreign doctors are essential to the UK healthcare system. What is also clearly essential is that their introduction here needs manag
ing effectively and in such a way as to minimise any risk to patients during the early days of their work. This is where companies like us can make such a sizeable contribution.
For example, we have learned that it can take anything between six months and two years to recruit a doctor.
Throughout this time, we assure ourselves that they have the knowledge and experience commensurate to the role they are being considered for.
We require them to practise the skills they will be using once they are in the UK. We take them through training programmes that are all based around the skills and protocols associated with UK healthcare.
once a doctor arrives in the UK, they are assessed again in person, covering language, clinical skills and pharmaceutical knowledge. They then spend an appropriate period on site at their designated hospital, learning the role under the supervision of an experienced colleague.
closely monitored
Thereafter, their work is closely monitored both by neS and hospital staff, with feedback sought regularly. These doctors are immediately added to our Designated body list and will begin gathering evidence for their first appraisal.
We have followed this process for over 700 new doctors in the last five years alone. most of these individuals have completed fixedterm contracts with us and gone on to establish themselves in nHS training posts or other training programmes. So we play an invaluable, and entirely unrewarded, service in nHS recruitment.
This is all very well, you may ask, but what are the outcomes?
The CHPI report notes that ‘doctors trained outside the UK have double the rate of fitnesstopractice sanctions against them compared to UKtrained graduates’. reviewing rmos’ success in the private sector reveals low levels of complaints over consecutive years. During the last five years, no doctor employed by us received GmC disciplinary sanctions and we currently have zero open cases at the regulator. Comparing this with any n HS
trust of similar size shows these statistics are an accolade.
neS has experienced a continual improvement in quality standards and a reduction in levels of complaints at the same time as seeing a significant increase in accolades, which doctors will use as part of their medical appraisal. This is the result of the hard work we put into recruiting the right people and making sure they are fully prepared.
There is far more in the CHPI report with which to agree than to disagree. Here we have simply focused on the third recommendation, as this is where we feel we are most qualified to comment. but it is our belief that, in this area, the report has identified risks of thirdparty involvement without properly assessing these third parties. There is also an assumption that direct hospital employment of doctors would solve some of the issues the report identified.
Yes, we agree there is a case for many private hospitals to review their rmo requirements, either in terms of numbers or rotation pattern, especially if one doctor is routinely responsible for a large number of beds.
What is difficult to support, however, is the contention that the use of overseas doctors poses an unacceptable risk to patients in the UK.
These skilled immigrants are a fundamental part of our health system and, if they are recruited and introduced safely by wellregulated and competent companies, they will go on to make a massive and safe contribution to the UK health system.
References
1. https://chpi.org.uk/wp-content/ uploads/2017/10/CHPIPatientSafetyPaterson-Nov29.pdf
2. NHS England: About Patient Safety. https://bit.ly/2zXVStJ
3. www.bbc.co.uk/news/health-39204681
4. BMA (Nov 2017) EU Doctor Survey
5. www.gmc-uk.org/static/documents/ content/SoMEP-2017-final-full.pdf
Dr Stephen Drotske is the medical director and Responsible Officer, and Justyn Tollyfield is operations director at NES Healthcare
The apparently simple act of a patient giving a gift to a doctor to thank them for their care can have unexpected repercussions for the doctor-patient relationship.
Dr Gabrielle Pendlebury (right) explores the ethical arguments and looks at how a busy practitioner can negotiate this act without causing embarrassment or prompting a loss of trust
Gifts may not always be as straightforward as flowers, wine or a piece of jewellery. they can also come disguised as a discount on a new car, or the offer of a weekend stay in a Cotswolds cottage.
One side of the argument is that doctors should never accept gifts because they can influence the standard of care and weaken the fiduciary relationship.
t his view is supported by the case of Dr Peter Rowan, a psychiatrist who accepted a £1.2m legacy and £150,000 in cheques from a patient.
i n the course of treatment, he had prescribed excessive doses of benzodiazepines and not communicated with other doctors involved in the patient’s care.
t he G m C’s f itness to Practise panel erased Dr Rowan from the medical Register in 2011, saying his judgement had been clouded by accepting substantial amounts of money, and expressed concern that he had not appreciated or considered the inappropriateness of accepting such gifts.
But many doctors believe accepting gifts in certain circumstances allows the patient to express gratitude and can strengthen the doctorpatient relationship.
Dr Paquita de Zulueta, a GP and lecturer in ethics, describes several reasons for giving gifts, which should be taken into consideration when weighing up whether accepting is appropriate:
to show genuine gratitude;
to redress the balance in terms of power sharing;
Out of affection;
to attract attention;
to manipulate the practitioner to carry out preferential treatment or some other treatment they would not normally give;
to expiate guilt for burdening the practitioner.
in terms of the doctor’s professional obligations, the G m C’s Good Medical Practice is clear and this is a good starting point for practitioners when considering this matter. it says: ‘you must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you.
‘ you may accept unsolicited gifts from patients or their relatives provided:
‘ a ) t his does not affect, or appear to affect, the way you prescribe for, advise, treat, refer or commission services for patients;
‘B) you have not used your influence to pressurise or persuade patients or their relatives to offer you gifts.
‘However, if you receive a gift or bequest from a patient or their relative, you should consider the potential damage this could cause to your patients’ trust in you and the public’s trust in the profession. you should refuse gifts or bequests where they could be perceived as an abuse of trust.
‘you must not put pressure on patients or their families to make donations to other people or organisations.
‘you must not ask for or accept –from patients, colleagues or others – any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients. you must not offer these inducements.’
Here are some case scenarios that demonstrate situations where doctors should consider the nature of the gift, how it may affect the care provided and the patient’s state of mind, before accepting.
1The expensive watch the parents of a child with an inoperable brain tumour believe there are treatments abroad that will help their child. t hey want your support. t hey buy you a very expensive watch. t he first point to consider is that the family may be vulnerable to exploitation; the treatments that they believe are available may not be evidence based or appropriate for their child. a gift of this nature could leave you pressurised to agree to inappropriate care plans. it may be an attempt, out of desperation, to manipulate the relationship. you must ensure this gift does not affect, or appear to affect, the way you prescribe for, advise, treat, refer or commission services for the patient.
the value of the gift is another factor; the clinician must consider how this could be perceived. in this scenario, it would be sen
You must ensure this gift does not affect, or appear to affect, the way you prescribe for, advise, treat, refer or commission services for the patient
sible to decline the watch but also explain your reasoning to the family. you would wish to support them at this time, but would not want your judgement clouded by an extravagant gift.
2 The BMW discount a businessman who owns a BmW dealership offers you a discount on a new car. the patient has a history of bipolar affective disorder and is grateful for the treatment he received. in this instance, the appropri
ateness of the gift may be in question. the patient may not see any difficulty, given that he owns the dealership.
But others may interpret such a gift negatively. Depending on the patient’s reasoning, it may betray an overfamiliarity that is related to his diagnosis. so it would be sensible to decline the gift, consider if further evaluation of the patient’s mental state is required. i f the patient remains keen to show his appreciation, perhaps indicate that a card would be valued.
3
christmas champagne i t is Christmas time; a patient who was treated successfully for breast cancer is very grateful. she has two young children at home and believes your intervention was lifesaving. she expresses her gratitude by buying you a bottle of champagne. in this scenario, it would be up
to the clinician to evaluate the situation from his or her knowledge of the patient. Would declining the gift cause upset? is this a simple expression of gratitude? the clinician needs to weigh up the situation and if he believes that declining would cause unnecessary distress, then acceptance may be the sensible approach, perhaps with a caveat that he would share it with the clinic staff at the Christmas party, if this was appropriate or possible. t hese are fictional cases compiled from actual cases from the m edical Protection’s files, used here to aid reflection on the matter. However, many factors can be at play when you are offered a gift and if the complexity does not allow for easy resolution, you should contact your defence body for advice.
Dr Gabrielle Pendlebury is a medicolegal adviser at Medical Protection
Private doctors were unhappy 70 years ago as the NHS took shape.
Today traces the history of the health service in the first of a new series adapted from a new book by Dr Ellen Welch (left)
Hospitals 70 years ago were in a poor condition following wartime bombing. Most had been built in the late 1800s and were beginning to crumble even before the Blitz of World War ii. there was no sort of health system at the time and hospitals had been established over the years in a haphazard fashion.
Most relied on Gps and unpaid consultants, who worked for free in exchange for a secure base for private practice.
t he relationship between the medical profession and the state has always been guarded. Many doctors were opposed to the establishment of the NHs, as they disliked the idea of becoming
employees of the state, and the BM a led a vigorous campaign against it; some even comparing Health Minister aneurin Bevan’s autocratic proposals to Nazi Germany.
Hospital doctors relied on private patients to boost their income and were wary of a new system that would endanger this.
Bevan was famously reported as ‘stuffing their mouths with gold’ by allowing consultants to work within the NHs on a salaried basis – plus merit awards – but able to continue to do some lucrative private work within NHs hospitals. proposals to make Gps salaried were declined and instead they reached a compromise in which they worked for the NH s as private contractors and were paid on a capitation basis, based on the number of patients they had on their list.
t he NH s was born on 5 July 1948. Doctors, nurses, dentists, opticians, pharmacists and hospitals came together for the first time as one colossal UK organisation with the unveiling of a hugely ambitious plan to provide free healthcare for all.
aneurin ‘Nye’ Bevan, the health secretary recognised as its creator, formally launched the service at trafford General Hospital – known at the time as park Hospital – in Manchester.
t he first NH s patient to be treated was 13-year old s ylvia Diggory, who recalls shaking Bevan’s hand, saying, ‘Mr Bevan asked me if i understood the significance of the occasion and told
➱ p34
me that it was a milestone in history – the most civilised step any country had ever taken and a day i would remember for the rest of my life – and, of course, he was right.’
Early 20th century
the NHs was clearly not formed from thin air, but from an amalgamation of the healthcare services that already existed which, pre1948, were messy and did not coordinate well together.
t he state had gradually taken responsibility for the health of the nation since the p oor l aw reforms were implemented in Victorian Britain – leading to improved public health measures such as compulsory vaccination and surveillance of disease.
e vents such as the Boer War (1899-1902) demonstrated that many people were unfit for active service.
the dawn of the 20th century welcomed a liberal government which tried to reduce poverty and improve people’s health by introducing reforms such as school medical inspections and free school meals.
t hey introduced state-funded pensions, initiated infant and maternal welfare clinics and developed the health visitor system.
l loyd George’s National Health i nsurance scheme in 1911 provided basic medical care to working men who paid their compulsory contributions to the scheme, which provided the assurance of medical care should they become sick and a limited income during periods of unemployment.
Many resented giving up their hard-earned wages to such a scheme and there remained glaring deficiencies to this system –such as a lack of access to hospital care and an absence of universal cover for wives and children, who often continued to pay into private health insurance schemes.
t he Ministry of Health was established in 1918, strengthening the philosophy that healthcare was the inherent responsibility of the state. t he Ministry took control of the administration of the poor law, National insurance, local government, planning, housing and environmental health.
there were rumblings of discon-
It was the 1942 Beveridge Report that advocated the idea that all working people should pay a contribution to a state fund that could be used for a comprehensive health service
tent among the medical profession at the time of this slow expansion of state-funded health services, and many saw it as a threat to their freedom to control their own incomes.
Lord Dawson’s Report
i n 1919, s ir Bertrand Dawson, a military doctor and physician at the l ondon Hospital, was commissioned by the newly formed Ministry of Health to chair a council to advise on the systemised provision of health services to link the hospitals into a single institution.
His 1920 report outlined a model that would be adopted by the NHs 30 years later, based on primary healthcare centres, –staffed by G p s – and secondary health centres – hospitals staffed by consultant specialists.
t he committee’s proposal was backed by a report eight years later from the r oyal Commission on National Health insurance, which advocated for medical services to be divorced entirely from the insurance system in the same way as public health services – and funded by the general public’s purse.
But the years following this saw a period of depression and economy cuts, which destroyed any chance of significant reform.
By the 1930s, many of the voluntary hospitals faced closure due to financial crises and many were pleading for state support.
t he charitable donations on which they depended reduced significantly over the years. i n the 1890s, 88% of their income came from gifting, and this had dropped to a mere 35% by the 1930s, and many could not keep up with the costs of medical treatment.
Furthermore, a national survey of hospitals was conducted in 1938 which indicated that the whole country needed an upgrade.
the major problems identified were a shortage of beds due to poor hospital buildings, a shortage of consultants and poor patient access to both. lack of a structured system meant that the distribution of specialists around the country was haphazard.
Complicated cases were cared for in hospitals without the necessary resources, and those hospitals that could deal with such cases had beds full of more simple cases.
l ong-stay wards were lacking; some reported to have a ratio of 60 patients to one trained nurse, accommodating a mix of elderly patients with dementia on the same ward as young children.
Furthermore, the cost of being
sick was beyond the reach of the average person. a patient diagnosed with tuberculosis, undergoing operative treatment and several months bedrest would be expected to pay more than £1,000.
the BMa had proposed in 1930 that health insurance coverage should be given to the whole population and that a co-ordinated regional hospital service should be instituted.
t he s ocialist Medical a ssociation went a step further and proposed that healthcare should be provided to all, free at the point of use, through a government-led scheme.
this policy for a state medical service was adopted by the labour party at its 1934 conference.
Wartime healthcare
the threat of another war halted parliamentary discussions on the future of the health service and the Ministry turned its attention to co-ordinating all hospitals to join together to form an emergency Medical s ervice ( e M s ) in preparation for the mass casualties of war.
Bed numbers in some hospitals were increased and temporary buildings were erected. Many of the former poor law institutions were upgraded and many specialist centres, such as plastic surgery, neurosurgery and rehabilitation units, were created in preparation for war.
the Ministry dictated what the functions of the existing hospital should be on a regional basis –which laid the foundation for a united health service when the war was over.
t he state had controlled most aspects of people’s lives during the second Wold War – with good effects. r ationing improved the health of the poor, and the eMs response to treating the casualties of air raids had given citizens access to healthcare that they had never experienced before – so the prospect of the government looking after healthcare did not seem outlandish.
t he major political parties largely agreed on the country’s main priorities and generally cooperated to achieve them: namely
post-war recovery and the welfare of the people – and the first twinklings of the NHs were kindled.
The Beveridge Report the Beveridge report of 1942 set out plans for the future of postwar Britain and paved the way for the modern welfare state.
senior civil servant sir William Beveridge chaired the committee tasked with reviewing social insurance schemes and the resulting work ‘report on social insurance and allied services’ became more succinctly known as the Beveridge report.
it put forward a scheme of ideas to tackle what he described as the ‘five giant evils’ that blighted the lives of British people:
Want;
Disease;
ignorance;
squalor;
idleness.
i t advocated a compulsory
A national survey of hospitals was conducted in 1938 which indicated that the whole country needed an upgrade
social security scheme that would provide benefits without meanstesting.
and it proposed that all working people should pay a contribution to a state fund that could be used for a comprehensive health service, the avoidance of mass unemployment and a system of children’s allowances.
t he report had piqued media curiosity and was published for public consumption, selling over 600,000 copies.
t he white paper ‘ a National Health service’ was published in 1944 outlining the wartime coalition government’s vision for a free, unified health service.
it proposed central government management, with responsibility for its provision lying with the minister for health. the minister appointed to this position was aneurin Bevan, whose proposals for the service went further than what had been discussed before,
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making him the almost singlehanded architect of the NHs in keeping with labour’s commitment to a programme of public ownership, he wanted nationalisation of municipal and voluntary hospitals, with funding to come primarily from taxation rather than National insurance. this regional hospital scheme to replace the local authority boundaries was a shrewd plan, as it meant the control of the hospitals would no longer be so insular, and executive control of all the hospitals would allow for service planning. in 1946, the National Health service act received royal assent.
Next month: GPs, consultants and how their relationship changed
☛ Adapted from The NHS At 70 – A Living History, by Dr Ellen Welch, a cruise ship doctor and GP in West London. £12.99 from www.pen-and-sword.co.uk
ThE DR BAwA-GARBA cAsE
Most Independent p ractitioner today readers will be familiar with the case of Dr Hadiza Bawa-Garba, the junior doctor who recently successfully appealed a decision by the GMC to strike her off the Medical Register following an earlier conviction for gross negligence manslaughter.
s ome may even have contributed to Dr Bawa-Garba’s defence fund, which reached approximately £366,000.
others may have refused to pay their GMC subscriptions or reported themselves for minor clinical errors in direct protest, and others may have started to
anonymise their reflections as a defensive measure.
In short, the response from practitioners was unprecedented.
Her circumstances have clearly touched a collective nerve among doctors and thrown a focus on the legal and regulatory frameworks. sensitive to the outcry precipitated by the initial decision to strike Dr Bawa-Garba off the medical register, both the Department of Health and the GMC launched reviews of the offence of gross negligence manslaughter as it applies in healthcare contexts.
the former – the Williams Review – was completed in June 2018. the latter was formerly known as the ‘Marx Review’, after its chairman Dame Clare Marx. But she has now been appointed chairman of the GMC from January 2019 and the council has appointed cardiac surgeon Mr Leslie Hamilton to head its gross negligence manslaughter review, which is expected to report early next year.
Although the Williams review shied away from considering the merits of the underlying criminal legislation, both have, or will, address its application. there are also broader legal and
regulatory changes which have been mooted – some from unexpected quarters – and which could have far-reaching consequences if enacted.
While not commenting on the conceptual merits or otherwise of gross negligence manslaughter as an offence, the Williams Review recommended clearer guidance for its application on the basis that only a minority of investigated cases result in a conviction. t he numbers speak for themselves. over a five-year period from
2013-18, the Crown Prosecution service has investigated 151 cases of gross negligence manslaughter involving health professionals, resulting in 15 prosecutions and six convictions, two of which have been overturned on appeal.
t he Williams Review had an unexpected sting in its tail, arguing that it had to consider the broader regulatory framework to do justice to its purpose – and recommended legal changes to prevent the GMC from having the power to appeal a decision of the Medical Practitioners tribunal service (MPts).
Unsurprisingly, this did not go down well with the GMC – especially as the Health s ecretary announced his support for the recommendations, albeit vaguely.
But this recommendation may well reflect the source of doctors’ unhappiness about this case –namely, that the GMC appealed the decision of the MPts tribunal
that suspended Dr Bawa-Garba, leading to her erasure.
The GMc’s response to the williams Review
In the GMC’s formal response to the Williams Review, it argued that the number of healthcarerelated gross negligence manslaughter prosecutions was too high and hinted at support for a shift from individual to organisational responsibility, where there is the offence of ‘corporate manslaughter’.
But the GMC also surprisingly suggested that reflective writings should be given ‘legal privilege’ to prevent them from being admissible in court proceedings.
this would be a significant legal change. But it should be noted that the Williams Review concluded that this would be excessive, instead recommending that the GMC and General o ptical Council should lose the powers
that they alone among regulatory bodies have to compel registrants to hand over reflections – in the context of regulatory rather than criminal proceedings.
The ‘hamilton’ Review
In the absence of a final or even interim report, it is obviously difficult to comment on the GMC’s forthcoming Hamilton Review. t he working group has issued a call for written evidence and Independent p ractitioner today readers may wish to contribute.
If the GMC does indeed lose some of its powers, then the BawaGarba case will have had legal and regulatory consequences unrelated to the actual offence of gross negligence manslaughter, which was the original focal point of attention and which will perhaps ironically remain untouched–better guidance notwithstanding.
there are, however, further possibilities which could arise.
Does the conviction of Dr BawaGarba – a professional – by a lay jury pose questions about the applicability of jury trials to complex matters involving environments, judgments and skill sets which jurors will be utterly unfamiliar with?
Might the Government piggyback on the backlash against the GMC to reduce the number of regulatory bodies – an intention that it spelled out as recently as late 2017?
Even in the absence of any changes to gross negligence manslaughter on a legal or practical level or to the GMC’s legal powers, one uncomfortable development of the Bawa-Garba case is perhaps this question: what happens when a regulator tasked with maintaining public confidence in a profession loses the confidence of the professionals that it regulates?
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Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.
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In February 2011, Jack Adcock, a six-year-old with Down’s syndrome and a history of heart surgery and bowel abnormality, was admitted to Leicester Royal Infirmary, where Dr BawaGarba was working as a registrar.
Following a series of systematic and individual errors – the latter on the parts of both Dr Bawa-Garba and a nurse, Isabel Amaro – Jack died from sepsis.
Dr Bawa-Garba was charged with gross negligence manslaughter in December 2014 and found guilty in November 2015. She received a two-year suspended sentence.
In December 2016, she was denied permission to appeal. Dr Bawa-Garba’s supporters have pointed in mitigation to her previously impeccable record, computer system failures, the fact that she had just returned from maternity leave and this being her first experience of such an acute setting. Others, on the other hand, have pointed to the number and nature of the mistakes that
she made, such as missing what a medical expert described as ‘barn-door obvious’ signs of sepsis in arguing that the conviction was reasonable.
Following an investigation by the GMC, in June 2017 an MPTS Tribunal suspended Dr Bawa-Garba for 12 months. The tribunal explained that erasure would be disproportionate in the circumstances, when the mitigating and aggravating factors were weighed together.
In January 2018, the GMC successfully appealed the tribunal’s decision in the High Court. Dr Bawa-Garba was erased from the Medical Register, with Lord Justice Ouseley noting that the tribunal had not respected the jury’s verdict of gross negligence manslaughter.
The then Health Secretary, Jeremy Hunt, expressed his ‘deep concerns’ about the decision and launched a review of gross negligence manslaughter in healthcare
settings. The GMC also announced its own review shortly afterwards.
Dr Bawa-Garba was granted leave to appeal against the decision to erase her from the Medical Register in March 2018. Her appeal was heard in July 2018, and the judgment in her favour was handed down in August 2018.
This reinstated the original MPTS Tribunal’s sanction of a 12-month suspension, subject to review.
The Court of Appeal emphasised the high bar which needs to be met before a court should interfere with a Tribunal’s verdict –given that the panel will possess considerable expertise – and concurred that suspension was a reasonable sanction in the circumstances.
Gregory Smith (right) is a trainee solicitor in the regulatory team at Hempsons, under the supervision of partner and solicitor dr tania Francis
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you buy financial advice? Simon Bruce shows why investing in a professional adviser could be crucial to your financial success
AT TH e start of your career, you probably found your finances fairly manageable and easy to track.
The difficulties begin as the professional pace picks up, clinics overrun, income streams become more complex and you acquire more assets, liabilities and possibly family members.
This is usually allied with increasing complexity of tax reporting and payments in advance through HM Revenue and Customs’ ‘payments on account’ in January and July, as well as navigating NHS and private pension rules.
and you are entirely frustrated, as you don’t feel well organised and you aren’t making the progress that you would like in your life.
Where do you turn for help?
A good financial planner takes the time to really listen to you, help give an objective and empathetic appraisal of your unique situation and challenge you where this is merited.
This can take the emotion out of money choices, make the complex simple to understand and create a structure that encourages action.
The main question we get asked by new doctor clients is: ‘Will I have enough?’
The NHS pension provides a good level of income in later life compared to other schemes, but without additional investment, it is unlikely to provide a similar standard of living to high-achieving doctors still in practice.
Your planner should set your investment portfolio at an appropriate level of risk for you and your loved ones while being mindful of the relationship between risk and reward.
Once you reach retirement, there are yet more decisions to take and an experienced hand could save you tens of thousands of pounds on poor withdrawal decisions – taking money at the wrong time or in the wrong order of your other assets could cost you dearly.
You know you need to do something, but you just don’t have the time to put yourself first. Deadlines then get missed, decisions are delayed and, before you know it, much time has passed
This means taking a long-term view, making some well-considered decisions and creating a plan to reflect this.
In doing so, your adviser may discover financial needs you have not even considered, or indeed potential problems that have not yet come to light.
Calculating how to supplement this retirement income with further pensions, savings and investments can be challenging. There are a number of strict pensions’ savings caps and tax implications that make the support of an adviser invaluable.
can you diY?
A key concept to ascertain is your attitude to risk and how this should impact your financial decisions in future, particularly as you get older and your viewpoint changes.
The research sets out several key areas where advisers can add value and reports that the support of an adviser gives clients an extra 3% net return each year on their investments
There is an abundance of online information available and the weekend newspaper supplements are adept at making it sound easy to pick the stocks which will earn a substantial return.
Sadly, vast amounts of empiri-
cal, independent research shows that the reality is rather different.
Remaining disciplined at times of market volatility is easier than it sounds. Few investors can stay calm when the market noise is at its loudest. They may chop and change investment strategy, trade shares in online accounts, chase hot funds or star managers or badly time their entry into or exit from markets.
Since 1994, American market research company Dalbar has produced an annual quantitative study into investor behaviour –measuring the effects of buying and selling in the short and long term.
In fact, the figures reveal that over a 30-year period, no matter the state of the economy at the time – recession or recovery –investment results are always more dependent on investor behaviour than fund performance.
As investors, psychology can hold us back. Information overload or media biases can sway our decision-making ability.
We also tend to be over-confident in our ability to run our investments, believing past victories are entirely our own doing rather than a by-product of normal market behaviour. We might focus on the short term, looking for quick gains rather than longterm growth.
Becoming an effective ‘behavioural coach’ is one area where advisers add extra value to their clients. They help investors to avoid knee-jerk reactions and to maintain a long-term perspective.
Vanguard, one of the largest investment companies in the world, has produced a study into what it terms ‘Adviser Alpha’ –defined as the difference between the return that investors might achieve with guidance and the return that might be achieved by ‘going it alone’.
The research sets out several key areas where advisers can add value and reports that the support of an adviser gives clients an extra 3% net return each year on their investments.
As a specialist advice firm, we look after more than 400 medical families. This means we have the experience of navigating the NHS pension; the mix of NHS, private and academic income; and the various trading structures of successful doctors.
cost financial products not available to mainstream markets.
They will also be up to date with every financial regulatory change and have time to monitor, review and rebalance portfolios that high-achieving medical professionals do not – particularly when coupled with estate and tax planning.
You should ensure that you have agreed your adviser’s fees up front and that ongoing charges are transparent. By using regulated financial advice, you also have the protection of the Financial Ombudsman Service.
With the knowledge that you have a well-qualified helping hand, you should be able to enjoy complete peace of mind that your finances are in order and set to meet your future requirements.
You should feel satisfied that your loved ones will be well sup-
ported in the coming years and that you can now concentrate on more pleasurable pursuits.
Simon Bruce is chief executive of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS
The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.
Levels, bases of and reliefs from taxation may be subject to change and their value depends on the individual circumstances of the investor. The value of investments and the income from them can fluctuate and investors may get back less than the amount invested.
And when the to-do list seems challenging, such as creating a solid financial plan, we are inclined to put it off until another date.
If you are going it alone, each of these areas can prove to be a minefield of financial difficulties just waiting to explode. With a busy career as well, few will have the time or inclination to deal with significant frustrations.
You could also face some practical disadvantages without the support of a reputable firm. Your adviser should have access to the very best data and research available, as well as specialist and low-
Independent Practitioner Today’s series reviewing the NHS private patient unit (PPU) sector shifts its gaze to the West Midlands. Philip Housden analyses private patient revenue growth for 15 NHS acute trusts across Warwickshire, Worcestershire, Herefordshire, Shropshire, Staffordshire and the cities of the West Midlands conurbation
For this group of trusts, the accounts show that total private patient revenues declined in 2016-17 after a period of growth. total revenues were £17.95m in 2016-17, up 4.1% from £17.2m in 2014-15, but a drop of £0.4m and 2.2% on the previous year (Figure 1).*
t his now represents 0.32% of these trusts’ total revenues, with an accelerating declining trend over the last few years, down from 0.37% four years ago. t his is below the combined national average outside of London of 0.5%.
these 15 acute trusts vary significantly by turnover and private patient revenues (Figure 2).
i n the city of Birmingham, there has been substantial consolidation of providers. University h ospitals Birmingham recently merged with heart of England to form a £1.3bn turnover trust. taken together, private patient income for 2018-19 should be well in excess of £5m, with a significant contribution from t he Mindelsohn Unit, a private radiotherapy service incorporating the regional CyberKnife unit plus multispecialty use of Ward 519, the 12-bed PPU.
the trust is now partnering with hCA to build a £65m 138-bed spe-
cialist hospital facility offering both Nhs and private care on the Queen Elizabeth hospital Birmingham campus.
Planned for 2020, this will treat patients over the age of 18 and will increase capacity for N hs patients providing 72 new beds, a new radiotherapy unit and access to new state-of-the-art operating theatres.
Better than private t he 14,000m 2 hospital will also include 66 private beds, owned and run by hCA healthcare UK, which will deliver private care for the most complex surgical and medical procedures, a level of acute private healthcare not currently available to the 500,000
people in the region who have private health insurance or who want to self-pay for their care.
Birmingham Women’s and Chil dren’s h ospital is also a merged trust and includes private maternity and paediatric services. t he combined revenues of the new trust should exceed £2.5m in 2018-19 and be a platform for further growth.
the region boasts two specialist orthopaedic hospitals in the royal orthopaedic in Birmingham and r obert Jones and Agnes h unt (rJAh) at oswestry, shropshire.
Both have dedicated private beds, although the reported returns from private services differ significantly. in the city, the royal o rthopaedic h ospital delivers
£500k revenues a year at 0.7% of turnover from the seven-bed Woodlands suite.
By contrast, rJAh Private healthcare has access to 16 beds in the Ludlow Unit, used by 36 surgeons, including a children’s service, increasingly difficult to deliver in the independent sector. the trust’s PPU presently delivers over £4.3m revenues at 4.6% of trust turnover, the highest in the region.
Wholly-owned subsidiary
south Warwickshire delivers private healthcare services through a wholly-owned subsidiary company, s WF t Clinical s ervices, formed in 2011 and becoming a social enterprise in 2014. t hat year sWFt acquired the stratford Clinic, formerly owned by Circle. in 2016, the trust commenced private fertility services and opened 15 predominantly amenity beds in the Beauchamp Wing at Warwick hospital. this model is understood to be attracting interest from other trusts keen to find a partnership approach that provides commercial freedom with arms-length control and a potential vehicle for investment in private capacity. t he trust is also in a strategic partnership with Wye Valley Nhs trust, where in hereford private
patient revenues are £0.5m a year, and this tie-up also presents a further opportunity for sWFt.
t he neighbouring University h ospitals of Coventry and Warwickshire report private patient revenues of £942k (0.17% of total revenues) in their recently published 2017-18 annual accounts, representing a gradually declining trend. the trust has no in-house PPU but is understood to work closely with the onsite 52-bed BMi Meriden hospital.
University h ospitals of North Midlands is growing private patient incomes through outpatient and ambulatory services, reaching over £1.6m in 2016-17, up from £1m in three years. the royal stoke campus is reported to be short of around 75 beds and last year experienced significant demand pressures through the winter. the market is a relatively strong one for private healthcare and local independent sector providers have relative weaknesses, particularly for the complex surgery where the trust is strongest. s ome of this N hs demand is therefore from insured patients not able to receive treatment elsewhere. i t remains to be seen whether long-standing local market analysis that has recom -
mended the development of an entry-level PPU will be incorporated within any bed capacity increases and demand management planning.
shrewsbury and telford earned £1.3m private patient income in 2016-17 (0.42% of total trust revenues) with onsite outpatients and diagnostic and ambulatory procedures accessed through the Apley Clinic.
the trust’s earnings are showing a long-term declining trend from £2.3m and 0.84% in 2011-12, when the trust made use of a tenbed private patient ward. the local Nhs is working through a strategic review and considering an urgent care and elective care split between shrewsbury and telford supported by £312m capital investment. there will remain opportunities to develop private patient income on both sites, whichever the outcome, as the patients with highest complexity of need will gravitate towards the critical care-backed infrastructure of the Nhs the royal Wolverhampton presently earns £1.1m a year private patient income – only 0.25%, but this is a rising trend.
As a regional services centre, the
patient safety focus should drive more high-complexity private activity out of the local independent sector towards the trust. the appetite of the trust to ‘market make’ is interesting: the trust leads the Nhs in vertical integration of primary with secondary care. the trust has, over the past two years, become the operator of 17 out of 42 of the GP practices in its city.
Unparalleled opportunity
this offers an unparalleled opportunity to engage with GPs to ask if their patients have medical insurance and even to put the option of ‘going private’ before patients when referring.
t he ‘Black Country’ trusts –Walsall h ealthcare, t he Dudley Group Nhs Foundation trust, the royal Wolverhampton Nhs trust and sandwell and West Birmingham h ospitals N hs trust – are presently working together to create a single pathology service. this potentially is a model that could be extended to linking up their individually small private patient activity under a single brand and leadership team, which together would have viability.
t hese three trusts, s andwell, Dudley and Walsall, deliver presently very little revenues between
them, reporting an aggregate of less than £250k a year.
Neither of the two remaining trusts, Worcestershire h ospitals report and George Eliot in Nuneaton, have any dedicated private patient beds at present. the former reports £0.5m PPU earnings (0.15% of total revenues), while the latter has none.
West Midlands trusts presently split between the city of Birmingham and elsewhere, with the exception being rJAh and south Warwicks.
t here remain several trusts where the absence of private patient capability results in insured patients falling back on the Nhs for most complex treatments.
With the region-wide capacity pressures experienced in recent times, this private patient demand pressure could be alleviated in these geographies by a small entry-level PPU, likely to pay for itself within three years or so.
Next month: Yorkshire
Philip Housden is a director of Housden Group
* The figures used here are predominantly from the 201617 annual accounts as only half have published the updated 201718 accounts at the time of writing
There are many variables to be considered when taking on practice billing – not least having enough focused time to concentrate on both raising the invoices and chasing the debt. Findlay Fyfe highlights some of the biggest stumbling blocks for many doctors and their practices
OOps! It Is all too easy for practices to slip up badly when they lose control of their debt. Banana skins abound – so watch out. When we at Medical Billing and Collection take over a practice, it has an average bad debt rate of 6%-12% compared to 0.5% for our more than 1,000 consultant customers.
On average, we are finding our methods can help raise fees by between 7%-20%.
Beware of these banana skins:
1 not understanding what you should be charging insured patients there are many different insurers each with their own payment threshold. Charging the highest agreed price to each insurer will maximise your earnings.
2 not understanding what you should be charging self-funding patients
this is the fastest-growing sector in the market. so think about the Goldilocks rule. It is key to setting your fees just right. too high and you run the risk of scaring patients away. too low and you restrict your earnings. Just right is where you need to be.
Remember that self-funding patients require the most time and effort to clear payments.
3 Failing to deal with shortfalls and excesses properly t his is always a surprise for patients who wrongly assume that their insurance policy is a cover-all document.
Do not allow invoices to continue to remain unpaid while they are being disputed.
4 misunderstanding Clinical Coding and Schedule Development (CCSD) group coding t his is something that requires some time every month. Codes change monthly and new unbundling rules come into force. Beware billing the wrong code, because you will not be paid for your work or, worse, you will be deregistered.
It is your responsibility to keep abreast of this – not the insurers to let you know.
5 having an unclear patient registration form
Make sure your patient registration form is designed to take all the data you need.
If you think that you may want to contact the patient in the future with a mailshot, include a very clear question to be signed ‘yes’ or ‘no’ on your registration form. You have much more chance of getting approval at this stage. this is a requirement under the EU’s Gen eral Data p rotection Regulation.
6 letting invoices slip Raise those invoices daily. Late billing simply equals late payments – and restricted cash flow. But it is wise to know when to write something off and claim the tax back.
7
Considering only the UK
t hink about how you bill those international patients. It is hard to collect money from a patient when they are 5,000 miles away on another continent.
8 ignoring the opposition t hink about what your peers charge. Make sure you get the most for your expertise. Look at this every year to ensure you get paid the best rate for your specialty.
9 having no policy for embassy patients
With lower fees for your work with embassy patients and payment times longer, is this really acceptable to your practice? should you think about filling your time with different patients? You need to look carefully at whether the restricted cash flow is something you can work with.
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10 Delaying reconciliation
Reconcile your payments daily. Ensure you know what is coming into your account.
t here is no silver bullet. You must make sure you put enough time aside to bill correctly and accurately.
Following this, the real work comes in. Be prepared to set aside time for your practice to start picking up the phone. this is very time-consuming, but this is what gets results.
We can all ignore emails. But it is hard to ignore someone when you are talking to them.
Findlay Fyfe (pictured right) is managing director at Medical Billing and Collection
A patient refuses to have a chaperone present for a breast examination – so what do you do? Dr Sally Old investigates
QI am a male consultant who recently met a new patient for the first time. During the consultation, she informed me that she recently discovered a lump in her breast which she would like examined.
I offered a nurse chaperone but she declined, saying she was very embarrassed about baring her breast and consequently, would prefer just to have the doctor there.
However, I felt extremely uneasy about undertaking this examination without a chaperone present.
What would you advise?
AAs an independent observer present during an intimate examination of a patient, a chaperone is usually a health professional who is familiar with the procedures involved in the examination. The chaperone will usually, but not always, be the same sex as the patient.
This is in line with current GMC guidance which states that doctors should offer the patient the option of a chaperone wherever possible before conducting an intimate examination, whether or not they are the same gender as the patient.
Although, a chaperone should be a trained health professional, doctors should comply with ‘a reasonable request’ to have a family member or friend present alongside the chaperone.
A chaperone should usually be offered before conducting an intimate examination, but sometimes, patients may require a chaperone for other examinations too.
For example, vulnerable patients or those who have suffered abuse may need a chaperone for examinations where it is necessary to touch or be close to them. In these circumstances, it is important to use your professional judgement about whether to offer a chaperone, depending on the patient’s views and level of anxiety.
Patients do have the right to refuse a chaperone, but if you are uncomfortable with undertaking an intimate examination without a chaperone, you should explain to the patient why you would prefer to have one present.
You may need to offer an alternative appointment or an alternative doctor, but only if the patient’s clinical needs allow this.
You may ask the patient to return another time, if the patient is unhappy with the chaperone offered or if no chaperone is available and this is not against their clinical needs.
Be careful, that this doesn’t pressure the patient to continue without a chaperone, causing them anxiety or to feel that they are inconveniencing you.
The GMC also recommends that you ‘record any discussion about chaperones and the outcome in the patient’s medical record. If a chaperone is present, you should record that fact and make a note of their identity. If the patient does not want a chaperone, you should record that the offer was made and declined’.
It would be worth publishing a chaperone policy which clearly defines what happens when a patient refuses a chaperone. Doing this helps to manage patients’ expectations and encourages them to make their wishes known at an early stage.
Reference
www.gmc-uk.org/ethical-guidance/ ethical-guidance-for-doctors/intimateexaminations-and-chaperones/intimateexaminations-andchaperones #paragraph-8
Dr Sally Old (right) is an MDU medicolegal adviser
A paediatrician with concerns about an unmarried father’s parental responsibility asks for advice. Dr Kathryn Leask responds
I am a private paediatrician. The father of one of my patients has requested a copy of his four-year old son’s medical records. The parents are going through an acrimonious separation and the custody of the children is to be decided in court.
At the moment, the child is living with his mother. I am aware that the parents have never been married and therefore asked the father for proof that he had parental responsibility for the child. He said his name was not on the birth certificate but he has given me a copy of a Child Arrangement Order, which refers to who will take the child to school, and told me that this confirms that he has parental responsibility. Can I accept this as proof?
AMothers will generally always have parental responsibility for their child. A father will have parental responsibility if he is or was married to the mother or if his name is on the birth certificate.
Where a father requests copies of their child’s records, the first
thing to consider is the child’s age and whether they have the capacity to decide for themselves whether they are happy for their records to be disclosed. In this case, the child is too young to make this decision.
Where a father has not been married to the mother, you should request to see the child’s birth certificate as proof of their status with respect to parental responsibility.
A Child Arrangement Order regulates the child’s arrangements about where the child will live –previously called a Residence Order – and with whom they may have other forms of contact – previously called a Contact Order.
Where the order states that a child will live with a person, that person will have parental responsibility until the order ceases. But some orders will relate to specific arrangements for the child; for example, about contact with other family members and where this contact will take place.
Where a father does not have parental responsibility and the order refers to the child spending time with him, but not actually naming him as the resident parent, the court must decide whether or not it is appropriate for the father to also have parental responsibility. If the court feels this is appro-
priate, it will also grant a Parental Responsibility Order.
In this case, there is no evidence that the father has parental responsibility because he has never been married to the mother and his name is not on the child’s birth certificate.
The Child Arrangement Order does not refer to the father as being the resident parent and therefore it would be appropriate to ask the father for evidence that the court has also given him parental responsibility for the child.
If it transpires that the father does not have parental responsibility for the child, the mother’s consent should be sought before disclosing the records to the father.
Dr Kathryn Leask (right) is an MDU medico-legal adviser
Starting out in private practice can be daunting, but for those prepared to put in the time in advance, it will result in a smoother ride to building that successful business.
Every practice has its nuances and the allimportant work-life balance will play a big part, but considering the areas discussed here should get you off to a flying start.
Without doubt, a secretary can make or break a private practice, so choose wisely.
‘How much are you going to earn in the next year?’
If you are happy with your NHS secretary, then why not see if they are interested in helping; many do. It is important that you define roles with regards to secretarial support and understand if they can produce the necessary accounting function for billing and, importantly, chasing debts.
It is common for secretaries to perform work for several private practices and use practice management software, which can bring significant benefits to a practice.
➲
My key message here is that you are running a business and while the work performed mirrors the NHS, there are various legal obligations when running a business that you must understand.
The tax system can be complicated and it is different whether you are a self-employed individual or trade in partnership or a limited company.
Whichever route you take, it is important to spend the time going through things with an accountant, more than once if needed, to ensure the basics are understood and you know how much to save to ensure your tax obligations are met when they fall due.
➲
We are not all the same, so as with the secretary, choose wisely. The medical sector is specialised and having an accountant with detailed knowledge of the medical sector should ensure you are best placed in the everchanging world of medicine.
Many new consultants will not have needed an accountant in the past, so meet up and discuss things face to face.
I meet many new consultants every year and I never expect them to have detailed knowledge, so I go through the aspects I know they are thinking about and the ones they don’t.
One question that you will need to bring out the crystal ball to answer is the insurer’s inquiry:
The higher the number, the higher the premium, but it is clearly a false economy to understate the figures and could leave you with significant financial risk.
Just be realistic and contact them again if the figure you gave is under- or overstated. They don’t expect you to be spot on, but do expect you to pay a retrospective premium if the work performed was higher than declared.
You are allowed to deduct the defence premium against your income for tax purposes, along with any addition premium that may be levied.
Certain specialties carry substantial premiums – for example, neurosurgery and obstetrics – so alternative avenues for private work such as medico-legal work are often considered which carry much lower indemnity premiums.
Before you start trading, you will incur set-up costs, so having an accounting system early on is essential to ensure all expenses incurred are claimed as expenses.
Simple spreadsheets are fine initially, but bespoke practice management packages can provide significant efficiencies and pay for themselves pretty quickly, so these are highly recommended. Your chosen secretary may have experience and can hit this running.
As reported in Independent Practitioner Today in a number of articles, including mine last month, changes to the reporting of information to HM Revenue and Customs are on the horizon, which will make pretty much all businesses use accounting software and, no doubt, these practice management packages will be a key part of this process.
You may be asked to work with other colleagues, which can help share costs and risk and perhaps income as well.
If you are asked to join an established group or form a new one, professional advice is really important to understand your obligations and the financial risks and rewards of being part of the arrangement.
Again, having an accountant who has knowledge in this area can be invaluable.
➲ Trading structure
When you commence your private practice and thereafter, it is important that your chosen tax structure to trade meets your needs and is tax-efficient.
This may be the more simple self-employed structure or perhaps a partnership with your spouse, but commonly this involves trading as a limited company.
Trading as a company does have more responsibilities and administration but can be a more taxefficient and flexible structure. The choice of structure is not a one-size-fits-all approach and so you should discuss your individual circumstances with your accountant and take their advice. It may be that you start with one structure and transition to another later on.
Over the last decade or so, there have been big changes to public sector pensions and in particular the NHS Pension scheme.
We now have a situation where there are three different NHS Pension schemes: the 1995, 2008 and 2015 schemes. Each one has their own rules regarding how much your pension grows by each year, which affects the ultimate pension award as well as the expected retirement age.
For newly appointed consultants, they will almost certainly be in the 2015 pension scheme, but also have benefits in either the
1995 or 2008 schemes for their membership up to 31 March 2015. Running alongside these changes to the NHS pension rules has been much tinkering by the Government around how large your pension can be before additional tax charges are payable and also on how fast it can grow each year before a tax charge arises.
It is the latter of these that has become the most important area of taxation for a consultant, whether newly in post or established, due to the very real possibility of having to pay a tax charge because of your pension growing too quickly.
This is a particularly unfair tax in my view, as it is largely a penalty for working hard and achieving.
All this is a very complex area and if your accountant cannot advise you fully in this area, you need to look elsewhere.
As with medicine, accounting and tax can change regularly, so it is important that you have regular contact with your accountant to ensure that you are best placed and not reacting to circumstances after they have happened. Starting out in private practice is a great opportunity to earn extra income and run your own business. Ensuring that you plan in advance will make sure it runs smoothly and you maximise the financial benefits of your hard efforts.
Next month: VAT considerations for private practice
Ian Tongue is a partner with Sandison Easson accountants
The Micra is a small car with a big car feel and with a new lease of life it is one of the most improved cars around, finds our motoring correspondent Dr Tony Rimmer (below)
WHEN THINGs are going well at your private medical practice, time can pass with an almost imperceptible swiftness.
Months and even years can go by in status quo before it becomes apparent that serious changes need to occur.
A fall-off of client base, staff changes or the deterioration of practice premises may be what it takes to shake us out of a complacency that our competitors may be taking advantage of. Big transformations need to take place.
This is what happened to Nissan and their supermini, the Micra. since the original car’s launch in 1982, it had always been a favourite with first-time drivers and the elderly alike.
Its appeal included ease of use, relative cheapness and excellent Japanese reliability. This Ford Fiesta competitor is now in its fifth generation and, after seriously declined demand for the
previous fourth-generation model, has had a complete redesign.
Built in France and sharing content with some Renault models, the new Micra is physically a bit bigger and its styling is bang up to date.
Attract young buyers Nissan is deliberately trying to attract young buyers and also buyers who are downsizing from Golf-sized hatchbacks. We medics who might be considering a VW Polo or a new Fiesta as a second car may be interested too.
There are five trim options ranging from the basic £12,750 Visia (no air-con), the Visia +, Acenta, N-Connecta and £18,090 Tekna. Although my test car was a top-ofthe-range Tekna model, the midrange £14,900 Acenta is likely to represent best value.
Having said that, the options on my car gave it a real premium feel.
Leather seats and trim, LED ambient lighting, rear-view camera, keyless entry and powerful Bose audio system with clever headrest speakers for the driver made it feel more like an Audi.
Three engine options include a base 1.0 litre four-cylinder 70bhp engine capable of up to 61.4mpg, a three-cylinder 0.9 litre turbopetrol 90bhp unit capable of 64.2mpg and a 1.5 litre four-cylinder 90bhp diesel engine capable of 88.3mpg but better suited to those of you doing high mileages and lots of motorway trips.
The engine that fits best for use in the urban environment that is the real home of the Micra is the eager 0.9 litre turbo-petrol unit.
As already mentioned, the new car looks a lot better than the previous models. A longer wheelbase and coupé-like roofline helped by the rear door handles incorporated in the doorframes give it a smart and sporty look.
longer wheelbase and coupé-like
easy-to-use
With lots of choice of exterior colour combinations for personalisation, the Micra now competes on level ground with competitors.
For front-seat passengers, the interior is a revelation and it is a really nice place to be. There is a clear seven-inch touchscreen, easy-to-use controls and highquality plastic trim. However, rear seat passengers do not fare so well.
The coupé-like styling reduces headroom and the narrow windows give a slightly claustrophobic feel; a bit like the Range Rover Evoque.
Also, the rear windows have manual winders, even in the top Tekna model. The boot is roomy enough but suffers from the lack of an adjustable floor and, with
Built in France and sharing content with some Renault models, the new Micra is physically a bit bigger and its styling is bang up to date
the seats folded, the loading bay is not flat.
This new Micra’s chassis was developed in the UK and this is reflected in the driving experience. The comfort-handling compromise is just right for our potholed UK roads.
Unfortunately, you could not describe it being a fun car to drive like Ford’s Fiesta, but it does a great job in everyday use.
The experience is enhanced if you choose the lively three-cylinder petrol engine which, aided by the nicely direct gearbox, gives the car some verve.
Motorway journeys pose no problems for the new car and on a trip I took to the north of England,
it was quiet, smooth and had that big-car feel. An automatic gearbox will be available in the future for you city-dwelling practitioners.
so should you be giving this latest Nissan some serious consideration? Well, the Micra has been given a new lease of life and I reckon that it is one of the most improved cars around. It should appeal to any city or urban independent practitioner who already has the new VW Polo, the Ford Fiesta and even the Audi A1 on their potential shopping list. That’s not something I’ve been able to say for several years.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
Body: Five-door hatchback. engine: 0.9 litre three-cylinder turbo-petrol
Power: 90bhp
Torque: 140nm
Top speed: 109mph
acceleration: 0-62mph in 12.1 seconds
claimed economy: combined 64.2mpg
cO2 emissions: 100g/km
On-the-road price: £18,090
All you need to know about accountancy for private practitioners
A
double-digit rise in expenses has hit the profits of ENT surgeons in Independent Practitioner Today’s latest benchmarking survey. Ray Stanbridge reports
Private Practice gross income for e N t surgeons rose by 3.7% from £162,000 to £168,000 between 2015 and 2016.
But rising expenses took their toll. costs rose by a surprisingly large 10%, going up from £68,000 to £75,000. a s a result, taxable profits fell from £94,000 to £93,000, a drop of around 1%.
Some of these changes, which seem to be different from other specialties, deserve explanation. i ncome growth turned out roughly as expected. Many consultants experienced a small fall in
the number of insured patients and an increase in the number of self-pay and c hoose and Book patients.
For some consultants who are not ‘fee assured’ by insurers, the reliance on insurers and any reduction in income is quite significant.
Significant differences
Yet, as they tend to have had more experience, they tend to benefit from the growth in self-pay. there are significant differences in income mix, depending on the
aveRage INCOMe aND eXPeNDITURe OF a CONSULTaNT eNT SURgeON WITH aN eSTaBLISHeD PRIvaTe PRaCTICe
Expenditure
age and experience of an individual consultant.
What are the significant cost increases?
Staff costs have risen from £19,000 on average to £22,000. this reflects an element of salary increase where there are employees and additional charges where hospitals/consulting rooms provide services – probably the consequence of c ompetition and Markets a uthority ( c M a ) rulings.
room hire costs have risen from about £9,000 to £10,000 on average. this increase reflects the obligations put on private hospitals by the cMa to charge at ‘fair market value’.
Medical defence costs have shown a slight increase from £12,000 to £13,000 on average. the picture here is very mixed.
Some consultants have reduced their defence costs by ‘shopping around’ to the newer providers who have been marketing strongly.
Other costs have broadly remained the same. included in ‘other costs’ is the cost of medical billing and collection agents. an increasing number of e N t consultants are now looking to use
Some consultants have reduced their defence costs by ‘shopping around’ to the newer providers who have been marketing strongly
agents to bill for them and to collect their money.
Many changes in the market have made comparisons from year to year increasingly difficult and we do not claim our survey to be statistically significant, although it is a useful benchmarking tool for consultants who are not fulltime in private practice.
Some consultants have incorporated, others have formed groups, yet others have changed the nature of their practice by focusing on NHS c hoose and Book work as opposed to traditional private practice. t he impact of the c M a rulings have also inflated costs significantly for a number of consultants.
Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)
Source: Stanbridge Associates Ltd.
Healthcare 2019, the ideal event for you.
Future Healthcare 2019 is the UK’s leading healthcare Exhibition and Conference taking place at Olympia London from 18 to 19 March 2019. The event will provide a unique gathering of global healthcare buyers and leaders across government, associations and industry.
Future Healthcare 2019 will connect you with global VIP Buyers, Senior Procurement Officers, Governments, and Distributors across the public and private sector. It will present you with a vital opportunity to demonstrate your products, services and capabilities to the senior decision-making audience who will attend.
Can your business afford to miss this unique opportunity?
Dawn Barclay-Ross, Event Director +44 (0) 203 740 4666 dawn@futurehealthcareuk.com
Note that our sample of e N t consultants are those who:
Have at least five years’ private practice experience;
Hold either a maximum part-
time or a new consultant NHS contract; are seriously interested in pursuing private practice as a business; May or may not have been
incorporated, or be a member of a group;
a re earning at least £5,000 a year in the private sector.
Where are we in the future?
Looking at a sample of 2017 figures, gross incomes have continued to rise with healthy growth in self-pay. this view is also taken by LaingBuisson for the sector as a whole in its market reviews.
there are signs that costs have stabilised following the impact of the cMa rulings. as a result, we would expect profits to at least be stable – or at best show a slight improvement from 2016 levels in 2017-18.
Last October, i commented in this report: ‘Most eNt surgeons who are serious about conducting private practice should continue to exhibit growth, despite a marked increase in costs.’ My predictions have been broadly correct.
next month: orthopaedic surgeons
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates
Radiologists
orthopaedic
years ending 5 april Source:
Make sure you don’t miss our next issue, published on 22 November. you may not receive every issue if you have not yet subscribed to the journal. Don’t risk missing out on vital topics we tackle next time:
Many consultants are hesitant about the increasing number of healthcare data initiatives. There are genuine concerns around process and implementation, but former eNT Uk president Prof antony Narula argues there is also real potential with robust healthcare data to better understand and improve care
How would you respond to inappropriate advances from a patient?
Our Business Dilemmas feature gives advice on this and the issues surrounding a non-co-operative teenage patient
So just when is the time right to step back or bale out? Detailed financial modelling makes the decision-making process much clearer and will point to the very best time economically, says financial adviser Dr Benjamin Holdsworth of Cavendish Medical
Doctor expert witnesses and patients are hugely frustrated with the current costly and over-long procedures in alleged negligence cases. Private consultant entrepreneur Mr Hugh Whitfield outlines the thinking behind his new company’s aims to be a game-changer
an a-Z guide to help you make the most of your billing and collection
tODaY The
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eDITORIaL INqUIRIeS
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Leasing your premises? a lawyer gives tips on the key issues you should be considering and warns of the traps to watch out for
Tracing our roots: gPs and consultants and how their relationship changed after the launch of the NHS
Profits Focus turns the earnings spotlight on orthopaedic surgeons
Invoicing and credit control is a time-consuming but essential task in private practice, but it is the area of practice management that is most often overlooked. Jane Braithwaite has more top tips for busy doctors
The London Clinic is a charity in Harley Street – so what does it do with its money?
Improving systems and processes to support good handling of complaints in the independent sector
vaT considerations in private practice
Private Patient Units across the Uk – our series visits yorkshire
If you are looking for a new small car that is great around town but practical and fun, then the volkswagen Up gTI ticks all the boxes, says our motoring correspondent Dr Tony Rimmer
accountant’s Clinic answers more of the big questions consultants ask
Ten years ago
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Electronic Billing
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Payment Tracking
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Financial Reporting
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Complimentary App
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Appointments and Diary
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Real-time online checks for patient membership number
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