When he turned 45 Gawande realised that his professional performance had stopped getting better. He’s a surgeon, so there are obvious performance measures; he assumed he had reached his peak. Then, at a conference, he had time for a game of tennis – he’s a keen player – and he took a lesson with a young coach. Gawande was amazed to find how much that one lesson improved his game. He went on to reflect that even Wimbledon champions have coaches, but surgeons don’t. He wondered whether a medical coach could improve his surgery. A senior surgeon agreed to observe him operating, and suggested some simple changes in his practice, such as the way he draped the patient. Gawande’s surgical performance started improving again.

Coaching, Gawande suggests, is an effective way to break entrenched habits – to teach an old dog new tricks. He quotes a study of teachers being taught new skills. After a workshop only 10% would take up a new skill. Practical demonstrations worked a little better. But when teachers had a coach watching as they tried out a new skill in the classroom, 90% of them absorbed it into their repertoire.

Students and registrars may sit in on our consultations, but as qualified GPs we are rarely observed by our peers. I recall my first two weeks of clinical training, spent in a rural GP practice sitting in with several partners. Each was incredibly curious about how the other partners consulted. They had no idea; they never saw them.

Yet there is so much to learn, both from observing and being observed. Some of the most useful ‘tricks of the trade’ I picked up from sitting in with other GPs – not ways of treating so much as ways of saying. For instance, how to divert patients from their long stories to possible action. Or finding vivid ways of illustrating risk. The oil that greases the wheels of the consultation makes the difference between a mechanical exchange and a relationship. I recall one GP giving a patient test results and saying “The results set my mind at rest; do you feel reassured?” I‘ve used his quote for years. You don’t find tips of that sort on GPnotebook. But how many GPs take part in a formal system for learning from each other in this way?

Recorded consultations are one way of observing. Trainers video consultations but I suspect that few of the rest of us do, and I’m not sure that it is the same as having someone in the room with you, experiencing the consultation first hand. It’s too easy for someone studying a video to think they would have done better, but the observer witnessing a live consultation is sharing the consulter’s dilemmas in real time. It’s the difference between watching a film and a live performance.

What might you learn from trying this out? Coaches are likely to pick up some things you are already aware of, like how much time you spend looking at the computer, but may also be able to analyse when and why you turn your attention away from patients, and to suggest ways of keeping your eyes on them. And they could contribute many new insights, things you are unaware of but which make your consultation less effective. It is hard to change entrenched behaviour patterns on your own, but having a coach watch you try out new techniques does seem to help the reprogramming process.

Appraisal and mentoring can be valuable, but appraisers and mentors don’t see us consulting. Maybe we could have a network of coaches – respected GPs nearing retirement or perhaps recently retired – who sit in on a surgery and talk with us about what we do well and where we could improve, whether it be the way we greet the patient, or how to consult more quickly, or improving our body language or ways of handling patients we find it hard to sympathise with. An extra bonus: they will be picking up tricks from you to pass on to others.

Do any NASGP members have experience of a system of this sort? If so, how does it work? Can you share your experience?

If you, or your parents, are looking to reduce eventual inheritance tax liabilities there are various simple opportunities available:

Gifts:

Small gifts: – up to £250 p.a. to as many people as you like are exempt (covers things like Christmas and birthday gifts)

Annual exemption: up to £3,000 p.a. (and the previous year’s entitlement if not already used)

Gifts in consideration of marriage/civil partnership (‘in consideration of’ not after)

Parent of party to marriage £5,000

Remote ancestor of party to the marriage £2,500

Any other person £1,000

Gifts out of income: unlimited – providing the donor retains sufficient income to maintain their standard of living and does not use capital to top up their income.

Outright gifts of capital: unlimited provided the donor lives for 7 years. (hence the term PET – it is only potentially exempt until the donor has survived the 7 years)

Business assets:

Certain business assets are entitled to 100% relief from IHT – and certain investments can make use of this rule.

Investments: There are various investment ways of reducing inheritance tax or providing for the liability, for which you should take specialist advice.

On death:

The ‘nil rate band’ – the first £325,000 left to other than the surviving spouse is not taxable.

Unlimited amounts may be left tax free to a UK domiciled surviving spouse. (On their death, one can use any unused ‘nil rate band’ from the first spouse)

Danger areas:

Gifts out of income – make sure sufficient records are maintained of income and living costs so that the executors can prove that the gifts were genuinely made out of income.

Reservation of benefit – if the donor retains benefit from the gift, it is treated as not having been made.  For example, if the parents put their home in the name of the adult children, but continue living there rent free, the gift will be ignored for inheritance tax purposes and still treated as part of their estate.

Pre-owned assets – where an asset has been given away sufficiently to avoid the reservation of benefit rule above, but there is subsequent benefit – an example of this is where parents provide funds to children to help buy a home – and then move in with them.  This can create an income tax liability on the parents based on the rental value of the home.

Gifts by UK domiciled spouse to non-domiciled spouse: these are limited to £55,000 (plus the nil rate band)

Wills:

Have you made a Will?  The Intestacy rules will not necessarily protect your loved ones – particularly if you are co-habiting but not married, if you have stepchildren, or are married with an estate in excess of £250,000.  If you are unmarried without children, then your estate goes to your parents – which might just give them a further IHT problem.

You will need to consider both inheritance tax – and asset protection – in writing your Will – but that is an article for another day.

Liz Densley is medical specialist partner with Sussex Chartered Accountants, Honey Barrett, and is secretary of AISMA (the Association of Independent Specialist Medical Accountants). Contact her at liz.densley@honeybarrett.co.uk.

You have until the end of January to give your opinions (they have a very well laid out online Q&A questionnaire, so no enormous documents to read).

Already NASGP members are debating some issues raised in the consultation about working as a locum GP, and members can view the discussion here and are encouraged to join in.

The GMC has asked the NASGP for its advice on its new guidance, and has started a consultation here (look for The Review of Continuing Professional Development Consultation 17/10/2011 to 27/1/2012).

This is particularly important for both salaried and locum GPs who will be facing a BIG challenge once the revalidation process begins at the end of next year – the issue for us is not going to be revalidation itself, but  providing the evidence that supports revalidation. So by ensuring the GMC’s guidance fully reflects the difficulties that Sessional GPs face, we stand a much better chance of making revalidation a much easier process for us all.

Following an adverse event, being open and admitting something has gone wrong is essential to maintain a patient’s trust. Encouragingly, in a recent survey 92% of MPS members said that they felt they are open and honest with patients.1

Yet poor communication and staff attitudes remain the top reasons for complaints in the NHS, and seven out of ten claims involve poor communication.2 Dr Stephanie Bown, director of policy and communications at MPS, says: “This is a strong indicator that what patients want when things go wrong is the truth, an open and honest explanation of what happened and why, and an apology where this is due.”

What complaint?

As a sessional GP, however, this might prove to be particularly challenging. One of the biggest hurdles for sessional GPs is actually being told when a complaint has been made. Sessional GPs often have difficulties in complying with the provisions of the NHS Complaints Procedures because of the differences in their contractual and working arrangements, eg, they are unlikely to have had any input into the drafting of the practice complaints procedure.

Sessional GPs might not be in the loop when it comes to GP partner meetings, where complaints are often discussed, or in the implementation of the practice’s complaints procedure. If you are a locum, you might not be working at the same practice when the complaint comes to light, so you might not be told how the complaint is progressing. Dr David Stewart, senior medicolegal adviser at MPS, says: “Practices should make every effort to contact any locum involved in a complaint and ask for their input.

“It is not enough to just go on the patient’s notes. The doctor involved in the complaint should actively be involved in trying to resolve it.” The Department of Health’s Listening, Responding, Improving: A Guide to Better Customer Care states that the complaints manager (usually the practice manager) should have an open dialogue with both parties involved in the complaint: “Before the report is finalised everyone involved should be given the chance to give their views on what has been said.”3

The locum experience

One locum GP commented: “The main barrier I’ve come across is that practices often don’t tell the locum that they’ve had a complaint. It is so much easier to say to the patient: ‘Oh sorry, it was the locum, but don’t worry, we’ll never book them again.’ The patient is delighted – they won’t have to see the doctor again and they feel their opinion is valued.”

He added: “On the other hand, it’s a huge hassle for the practice to work out which locum it was (if there were several locums in that day and they all had the same username and password), get the notes posted to the locum, chase the locum up, get them to drive in on their free time to talk to the staff or patient, etc.

“These barriers can be resolved by ensuring all locums have unique usernames and passwords and have doorplates and name badges. As all work is booked through the chambers, we have a strict policy that if any practice manager ever says ‘please can we have a locum, but not Dr Smith again’, we will only continue to book locum work if the surgery agrees to talk to Dr Smith about why they don’t want him anymore.”

Responding to a complaint

Locums and sessionals might not have the opportunity to contact the patient to give an open and honest explanation of what went wrong and why, or to demonstrate to the patient that lessons have been learnt to try and prevent the incident recurring.

Poorly handled explanations serve only to compound the harm, distress and loss of trust that has already been experienced, increasing the likelihood of litigation. Information cannot be provided as openly and empathically if it is second-hand. If you are asked to reattend the practice to try and resolve a complaint at the local stage, this will probably be in the form of a fact-finding interview or writing a witness statement.

You should familiarise yourself with the patient’s records and make sure that any statement is factually correct, conciliatory, empathic and (where relevant) includes an expression of regret. You should ask to see a copy of the reply the practice intends to send, to check it is factually accurate, and should not hesitate to contact MPS for advice.

Barriers to openness

There are other barriers to openness as well as not being automatically involved in the complaint process. MPS members highlight time constraints as a key factor in restricting their ability to communicate as effectively as they would wish.

Two thirds of MPS members believe that there is a pervasive blame and shame culture within the NHS – and believe this is difficult to overcome. When a mistake occurs, 70% of doctors said they received limited, or no support, from their organisation, making it difficult to resolve the complaint promptly and accurately.4

MPS believes that a cultural change is what is needed to improve openness. Meaningful, open and honest communication with patients and working in a culture that expects it is more likely to be delivered by doctors committed to transparent working at all levels, rather than doctors forced to report adverse incidents through legislation and a “top down” managerial approach.

By improving communication between GP practices and locums and sessionals, complaints resolution can focus on openness and honesty between the doctor in question and the patient, allowing complaints to be resolved locally and quickly.

Case study: Left out in the cold

Dr A was a member of GoodDoc, a locum GP agency. He was contracted to work at an inner city medical practice for one day to cover unexpected staff absences over a busy holiday period. He saw Miss C, a 35-year-old patient, who presented with severe abdominal pain. He prescribed some paracetamol and told her to come back in a few days if the pain had not subsided.

The next day, Miss C was rushed to hospital with acute pain. On arrival at the emergency department (ED), she was diagnosed with appendicitis. She was rushed to theatre and luckily the procedure was performed before the appendix ruptured.

She complained to the practice about Dr A’s failure to diagnose. The following week, Mrs W, the practice manager, received Miss C’s complaint, logged it and sent it to the GP partners for discussion at their next meeting. They drafted what they believed to be a sufficient response using the patient’s notes. Dr A was not consulted throughout the process and no attempt was made to contact him.

Miss C was invited into the surgery to discuss the response. She was thoroughly dissatisfied. She felt that the details of the consultation were sketchy and the response was very cold and impersonal. No-one was open and honest with her. No-one apologised. Miss C felt that the practice was hiding something and she decided to take the complaint against Dr A further.

Learning points:

• Practices should make sure the doctor who is the subject of the complaint is involved in responding to the patient’s concerns and drawing up steps to avoid errors in the future.
• Practices should have a complaints manager (again, usually the practice manager) who can deal with all complaints in the first instance and a responsible person (usually a GP partner) whose role (in part) it is to ensure that the correct procedure is being followed.
• The complaints manager should make every effort to contact the locum through the relevant agency, giving them adequate notification of the complaint and the right to respond to the complaint.
• It is a good idea for the practice manager to keep a log of all the locums used at the practice, along with their contact details.

Useful links

• MPS, A Culture of Openness – An MPS Perspective (2011)
• MPS, Complaints factsheets (June 2011)

References

1. MPS/ComRes Survey, An online poll of 541 MPS members in March 2011, which involved GPs, consultants and non-consultant hospital doctors (2011)
2. Sir Liam Donaldson, World Health Organisation’s “World alliance for patient safety” conference (2004)
3. Department of Health, Listening, Responding, Improving: A Guide to Better Customer Care (2009)
4. Ibid 1

The original article can be found in MPS’s October 2011 edition of Sessional GP.

Some years afterwards, I read that the cell line came from a patient called Helen Lane. But it turns out that wasn’t her name. The Immortal Life of Henrietta Lacks is a fascinating portrait of a woman and her time and place, a scientific investigation, and a moral tale.

Henrietta Lacks was born in Virginia, the great-granddaughter of slaves on a tobacco plantation. Her education was cut short when she became pregnant by her cousin at the age of 14. In 1951, aged 31, with five children and syphilis, she felt a “knot” in her stomach. She went to Johns Hopkins, the only good hospital in Baltimore open to black patients. She had cervical cancer.

A tissue sample was taken before she started radium treatment. But the cells proved uniquely aggressive, both in vivo and in vitro. Even before Henrietta died nine months later, overwhelmed by metastatic cancer, the immortal cell line which bears her name was being used in labs around the world. HeLa cultures made it possible to test Salk vaccine and within a year to launch mass immunisation against polio.

Her family knew nothing of this until 1973. When they found out about the cells, they thought that in some way she was still alive. They struggled to make sense of it. The barrier between the family and the scientific community was great, the distrust deep. It took the author of the book, an educated white woman, years to gain their trust, and to help them try to come to terms with what seemed to them yet another exploitation.

They had good reason to be suspicious. In 1932 the US Public Health Service had enrolled poor black sharecroppers from Tuskegee, Alabama in a research study, in exchange for free medical care and food. The study was the natural history of untreated syphilis.  Participants were not told that, and even after the discovery of penicillin they weren’t offered treatment. By the time someone blew the whistle in 1972, many had tertiary syphilis, wives had been infected and children born with hereditary syphilis, all preventable since 1947. No surprise that many black US citizens still distrust medical research and are leery of preventive medicine.

Are things different now? The Nuremberg code, drawn up in 1947 to prevent anyone using fellow human beings for experiments the way the Nazis had, didn’t stop Tuskegee. And how much research is exported to poor countries where ethical codes are looser?

Henrietta’s treatment was standard for 1951. Then, doctors did what doctors wanted to do and patients didn’t question. As late as 1973 a postdoctoral research fellow was instructed to phone Henrietta’s widower David to ask permission to take blood samples from Henrietta’s relatives. The researcher – recently arrived from China – explained in poor English that they wanted to look for genetic markers. David spoke equally non-standard English. She thought he understood. He said yes because that was what you did when a doctor asked you something. The family thought they were being tested to see if they had cancer, and they waited anxiously for results which never came. The genetic marker study was published, with the family’s names, but no-one thought of contacting them.

Are things different now? We know informed consent is important, but how well do we check that our patients really have understood us, and we them?

Henrietta’s daughter Deborah never ceased to be troubled by the thought that her mother was still suffering somehow when her cells were blasted into space, or irradiated, or injected into prisoners, or fused with non-human cells –  to Deborah ‘cloning’ meant making replicas of her mother.

Henrietta lived in a society where racial segregation was legal. Education, health services and prospects were limited and criminality, violence and sexual exploitation were common for those on the wrong side of the colour bar.

Are things different now? Henrietta’s descendants have received no financial benefit from HeLa (and indeed cannot afford health insurance), but they are inching their way out of deprivation. And HeLa may have played a part. Traditional gospel ‘soul cleansing’ helped Deborah bear the burden of her mother’s perceived suffering, but she realised that to understand HeLa, she needed some education. And through education Henrietta’s family have come to feel proud of what HeLa has made possible – including treating the disease from which Henrietta died. Henrietta’s great-granddaughter is the first Lacks to go to university.

Still, Henrietta’s family remain distressed that the cells were taken and used without her knowledge.

Are things different now? It is not just in the Deep South of the 1950s that there is a gap between professionals and the public on medical ethics. Doctors at Alder Hey didn’t feel that it was necessary to ask permission to remove organs at post-mortem, or even live organs if they were considered to have no value to the owner. (The thymus glands of children undergoing heart surgery were removed and sold to a pharmaceutical company.) When these practices came to light in 1999, it was clear the public felt very differently, and the result was the Human Tissue Act of 2004 and the creation of the Human Tissue Authority. Consent is now required for the removal of human tissues and their use is legally controlled. But the removal of Henrietta’s cells would still be legal in the USA, and in the UK samples taken for biopsy can subsequently be stored without further consent. Maybe, in 50 years time, we will look askance at the cavalier way we now treat the ownership of patients’ cells.

The Immortal Life of Henrietta Lacks, Rebecca Skloot, Macmillan (2010) ISBN-10: 9780230748699

P.S. In 1972, when HeLa came to the notice of the general public, Henrietta’s name was not revealed. Who was HeLa? The popular press speculated. The film star, Hedy Lamarr, perhaps? They settled on ‘Helen Lane’.

I’ve been on PAYE up to now, so there’s no need to look at anything before I start self employment

Unfortunately PAYE does not always deduct the right amount of tax.  Doctors in training rotations are always at risk of their P45 not following them properly, or having overlapping employments – which can give rise to material under and overpayments of tax.

In addition, many doctors have not claimed for professional subscriptions and other costs.  In this respect we have recently been able to agree some training costs with the Revenue.  The contract of employment needs to be a training contract and you need to have a training number – with these, if the wording is right, we may be successful in a claim for training costs.

What do I do with my P45? 

Nothing at the moment.  Just retain it for your tax return to 5^th April 2012

When will the Revenue confirm self employed status – my out of hours organisation needs it?

The Revenue does not confirm self employed status as such.  However, It will issue you with a UTR (unique tax reference), once you have registered for self employment, which the out of hours organisation might accept.

What are the pros and cons of forming a limited company?

In simple terms you can save national insurance, you may save tax (if you leave money in the company or if you have a low earning spouse) but you are not permitted to pension the income through the NHS scheme.  The loss of the 14% contributed by the PCT and the inability to pay your own contributions will generally outweigh the other benefits.  Each case needs to be looked at on its own merits.

What do I do with forms Locum A and B? How much money do I send?

These are sent to your local Primary Care support office.  You would normally agree your tier rate with them (usually starts at 6.5% – but will be amended depending on income levels).  You calculate your pension contributions by following the instructions on the form and send them with your cheque.  If you get stuck, your accountant can do it for you (for a fee) – but it’s not difficult to do yourself.

I have overseas rental income – surely you don’t need to know about that?

Yes – you are taxable on world income in nearly all cases.

If you can argue that you are not UK domiciled, then there are very complex rules for the taxation of overseas income not brought into the UK.  If the amount is more than £2,000, then you could choose to pay £30,000 of tax for the privilege of not declaring your world income – this won’t apply to many people!

My mortgage payment is greater than my rental income – so I don’t need to put that on my tax return.

You do still need to make a return of your rental income.  If you make a loss, then that loss can be carried forward against future rental income.  Note that capital repayments on your mortgage do not count – it is only the interest element that is eligible for tax relief.

Can I claim for smart clothes for work?

Sorry, no.  There are tax cases that confirm that clothing is partly for personal decency and thus not claimable.  Protective clothing would be deductible – but you don’t see too many white coats in general practice.

Liz Densley is medical specialist partner with Sussex Chartered Accountants, Honey Barrett, and is secretary of AISMA (the Association of Independent Specialist Medical Accountants). Contact her at liz.densley@honeybarrett.co.uk.