HMRC has faced criticism over its planned business record checks.

From April this year, HMRC plans to spot-check 20,000 firms’ business records – inadequacies could result in fines of up to £3,000.

But the measures have been slammed by business leaders and Tory MPs, who claim that the move will cause more trouble for already struggling businesses.

Speaking to The Independent, national chairman of the Federation of Small Businesses (FSB), John Walker said: “Despite the worsening economy, HMRC is launching this scheme regardless of the consequences.

“We have spoken to HMRC and expressed our concerns about this a number of times. But as far as they and ministers are concerned it is a policy aim to make this happen.

“There is a huge difference between the rhetoric of the Government about helping small businesses and what it is doing in reality.”

The move is particularly poignant following the recent revelations of favourable tax treatment of larger firms. Priti Patel, the Conservative MP for Witham said: “The attitude of HMRC to small businesses is frankly disgraceful when they are blatantly doing deals with large firms which have allowed them to escape millions of pounds in tax liabilities. It seems as though HMRC sees small businesses as low-lying fruit to meet their targets. That kind of persecution is outrageous.”

Reacting to the criticism, an HMRC spokesman said: “HMRC recognises that the launch of the Business Records Checks pilots has caused considerable concern to the tax profession, and that the project would have benefited from more detailed consultation with tax professionals at an earlier stage. In the light of these concerns, HMRC will undertake a strategic review of the project, in consultation with the professional and representative bodies.”

The spokesman added: “The findings of the review will be shared with representative bodies in January 2012, and final decisions will be made by HMRC before the end of the current financial year.”

Thanks to PG&T

We think we know, but do we really?

Do the people who say they know what’s best ever listen?

What Patients Really Want From Health Care
AIllan S. Detsky, MD, PhD

Perhaps the most widely scrutinised sector of the economy in North America will be the health care industry. Politicians, policy analysts, academics, and the public share concerns about the state of health care in both the United States and Canada. However, each of these constituencies has a different perspective.

Most sectors of the economy are characterized by a supply side that focuses on minimizing costs, expanding sales, and maximizing profits and a demand side that considers consumer preferences, incomes, and alternative purchases. Markets use prices to link supply to demand. Health care is very different. In the mid-20th century, patients’ aversion to the risk of large health care expenses gave rise to a market for insurance, thereby separating patients from the true costs of care at the point of service delivery. This in turn greatly expanded demand for health care, resulting in cost escalation, which gave rise to government involvement in many ways (eg, tax subsidies, US Medicare, the Canada Health Care Act, and, most recently, the US Affordable Care Act).

Decades after this evolution began, the United States and Canada are struggling to contain the “beast” of health care costs by setting priorities, an important step in policy formation. Politicians, the media, and academics often focus on important issues like cost increases, waste, inefficiency, access, cost-effectiveness, evidence-based medicine, and conflicts of interest.
This Commentary focuses specifically on what people want from health care services and rates these preferences from highest to lowest. The opinions are based on my 30 years of experience, both in performing research in health economics and as a practising general internist who cares for inpatients, many of whom are elderly and very ill. Because preferences vary in health care, like preferences in every sector, the characterizations described may not apply to all.

What the Public Wants Most
Restoring Health When Ill. Patients want a health care system that responds when care is needed; that is, when they develop signs or symptoms causing pain, disability, or anxiety. What they want most is to be returned to a state of good health, however they define it. In other words, they simply want to be better. Some patients understand the concept of preventive medicine and want the health care sector to provide services such as cancer screening that will prevent illness in the future. How- ever, the majority of patients primarily focus on relieving illness and symptoms rather than disease prevention.

Timeliness. Patients desire access to services in a timely fashion. While many patients procrastinate seeking medical attention, those who do not delay seeking care want it immediately.

Kindness.  Patients want to be treated with kindness, empathy, and respect for their privacy. In the days before health insurance, patients paid for care that consisted primarily of kindness.

Hope and Certainty. Even if patients are in a health state for which cure is exceedingly unlikely, they want to have hope and be offered options that might help. Patients are uncomfortable with uncertainty about diagnoses and prognoses and often request tests to help alleviate those anxieties. As well, patients and their families feel guilty if they do not try to get better. These characteristics make patients and their families highly susceptible to accepting active test and treatment options, even when those options are unlikely to help. This occurs especially at times when patients are emotionally vulnerable, such as when death is near. Although many patients prefer not to “know” or “try,” the majority of those who seek health care prefer active strategies. An extra test or two, “just to be sure,” is often preferred to possibly missing something.

Continuity, Choice, and Coordination. Patients want continuity of care and choice. They want to build a relationship with a health care professional or team in whom they have confidence and have that same person or team care for them in each episode of a similar illness. They want the members of their health care team to communicate with each other to coordinate their care.

Private Room. Patients want to be hospitalized in their own room, with their own bathroom and no room-mate.

No Out-of-pocket Costs. Patients want to pay as little as possible from their own pocket at the point of service delivery. They also want to be assured that insurance or third- party coverage is always available to them.

The Best Medicine. Patients want to know that the clinicians delivering their care are highly qualified. Indeed, some seek “the best” physicians. Patients want information about clinician qualifications but they do not want it to be statistical. They prefer testimonials from other patients or clinicians they trust.

Medications and Surgery. Patients prefer treatments that they perceive will require little effort on their part. Medications and surgical procedures are preferred over clinical strategies that involve behavioral changes (eg, diet or smoking cessation) or exercise regimens.

Second-Level Priorities
Efficiency. What patients mean by efficiency is that their time is not wasted. No one likes to have an appointment with a physician scheduled for 9:00 AM only to be seen at 11:30 AM. Rapid scheduling of tests and reporting of results is also important. However, to most policy analysts, efficiency means something different. To them, efficiency is delivering the most value with the least resources. While the public shares this concern, this kind of efficiency is of lower priority to patients.

Aggregate-Level Statistics. Most patients care little about the average patient; they primarily care about themselves. As such, evidence that does or does not support the use of treatments based on large groups of people is of much less interest to patients than whether those treatments work in their specific case. Again, testimonials trump scientific evidence. This lack of appreciation for evidence-based medicine ex- plains why comparative effectiveness research is an easy target for politicians and interest groups who dislike the results of those efforts because the results may threaten their in- comes or access to currently available care.

Equity. Although everyone recognizes that health care is a “merit good” (ie, all members of society should have the right to it regardless of income), most patients put equity lower on the priority list than whether they are receiving adequate health care services. Illness, like other stresses, inherently breeds selfishness.

Conflicts of Interest. Although most patients would be disappointed to learn that some treatments are recommended partially for the purpose of increasing the income of the prescribing health care professional, most patients do not fundamentally care as long as the service helps make them better without increasing the costs they have to bear.

Lowest Priority
Real Cost. Individual patients have virtually no interest in costs they do not bear. Presenting patients with bills that are sent to insurance companies listing real costs or full charges is meaningless unless the patients face those costs.

Percent GNP Devoted to Health Care. The amount of gross national product (GNP) spent on health care is just a number and has absolutely no relevance for individual patients. Similarly, expenditure trends, international comparisons, and government debt mean little to patients.

Implications for Policy Makers
Policy makers in the United States and Canada have serious concerns about the sustainability of the health care sec- tor, especially the part funded by tax revenues. However, predictions that the health care sector will overwhelm the entire economy are likely overstated. Health care is perhaps society’s most valued service. Patients want to know that over time their chances of being restored to good health when ill are continuously improving. As a result, consumers understand that they are going to have to devote more resources to health care. Preferences for immediate care and elimination of uncertainty make excess capacity and waste tolerable to the public. It may be more rational to spend resources on interventions that are of more value, like efforts to combat obesity, but most of the public cares more about treating illness. Changing attitudes about priorities would require a public health strategy, much like the efforts to make smoking or putting children at risk while playing sports socially unacceptable.

Some may say that the consumers’ preferences described in this article are irrational and unrealistic; that may be true. In fact, I have spent most of my research career on the issues that are herein described as unimportant to patients (eg, cost-effectiveness and conflict of interest). However, the lack of rationality does not render these preferences irrelevant. What people want when they are healthy may be very different from what they want when they are sick. In addition, patient preferences before undergoing tests and treatments will clearly be different from how they perceive those choices after the fact, altered by the outcomes they experience.

This description of patients’ preferences does not render efficiency, evidence, and rational thinking in health care unimportant. Technological progress should lead to increased efficiency by developing technologies that both improve health and lower costs. Market distortions clearly interfere in the development of a health care system that offers value, and there are serious challenges ahead. However, policy makers need to truly understand and appreciate what the public really wants when they undertake efforts to reform health care. There may be no answer to what linear programmers call “a set of constraints without a solution.” But failure to consider consumer priorities will certainly lead to failure.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: I thank Robert M. Wachter, MD, University of Califor- nia, San Francisco, and Donald A. Redelmeier, MD, and Maureen Shandling, MD, University of Toronto, for their comments on an earlier draft of the manuscript. None received compensation.

REFERENCES
1. Wells DA, Ross JS, Detsky AS. What is different about the market for health care? JAMA. 2007;298(23):2785-2787.

2. Maa J. The waits that matter. N Engl J Med. 2011;364(24):2279-2281.

3. Srivastava R. The power proxy. N Engl J Med. 2010;363(19):1786-1789.

4. DetskyME,EtchellsE.Single-patientroomsforsafepatient-centeredhospitals. JAMA. 2008;300(8):954-956.

5. Bailey R. Will Comparative Effectiveness Research Kill More People Than It Helps? Consumers, Not Bureaucrats, Should Make Healthcare Decisions. May 24, 2011. http://reason.com/archives/2011/05/24/will-comparative-effectiveness. Ac- cessed October 27, 2011.

6. Dhalla I. Canada’s health care system and the sustainability paradox. CMAJ. 2007;177(1):51-53. 7. AckeryAD,DetskyAS;EditorialAdvisoryTeam.Reducinglifelongdisabilityfrom sports injuries in children. CMAJ. 2011;183(11):1235.

The trap of social media noise

If we put a number on it, people will try to make the number go up.

Now that everyone is a marketer, many people are looking for a louder megaphone, a chance to talk about their work, their career, their product… and social media looks like the ideal soapbox, a free opportunity to shout to the masses.

But first, we’re told to make that number go up. Increase the number of fans, friends and followers, so your shouts will be heard. The problem of course is that more noise is not better noise.

In Corey’s words, the conventional, broken wisdom is:

• Follow a ton of people to get people to follow back
• Focus on the # of followers, not the interests of followers or your relationship with them.
• Pump links through the social platform (take your pick, or do them all!)
• Offer nothing of value, and no context. This is a megaphone, not a telephone.
• Think you’re winning, because you’re playing video games (highest follower count wins!)

This looks like winning (the numbers are going up!), but it’s actually a double-edged form of losing. First, you’re polluting a powerful space, turning signals into noise and bringing down the level of discourse for everyone. And second, you’re wasting your time when you could be building a tribe instead, could be earning permission, could be creating a channel where your voice is actually welcomed.

Leadership (even idea leadership) scares many people, because it requires you to own your words, to do work that matters. The alternative is to be a junk dealer.

The game theory pushes us into one of two directions: either be better at pump and dump than anyone else, get your numbers into the millions, outmass those that choose to use mass and always dance at the edge of spam (in which the number of those you offend or turn off forever keep increasing), or

Relentlessly focus. Prune your message and your list and build a reputation that’s worth owning and an audience that cares.

Only one of these strategies builds an asset of value.

The usual lack of understanding about the way that Denplan works, as pointed out in one of the comments. Whoever buys it will be well advised to change very little – it’s a well managed business and an excellent brand. It’s more about insurance companies and their “strategic reviews” which frequently accomplish change for its own sake and very little else.

Axa has put its dental-insurance business, Denplan, up for sale for a mouth watering £100m, the Daily Telegraph can reveal.

The company, which covers more than 1.8m patients across the UK and 6,500 dentists, is the UK’s biggest dental insurance company.
It has enjoyed a boost over the last decade as more Brits turn to cosmetic dental treatments. Angelina Jolie, Cheryl Cole and the Duchess of Cambridge top lists for sought after smiles in the UK.
Founded in 1986, Denplan also offers loans of up to £25,000 for dental treatment. In the year to December 2010 the company had profits of £11.9m on sales of £25.4m.
The sale follows a strategic review across Axa UK. The division has already offloaded part of its UK life business to Resolution for £2.75bn last year and has put its Bluefin employee benefits arm up for sale.
Despite this, sources close to Axa say the company is not planning a wholsale exit from the UK. Instead it will focus on general insurance, wealth management and the remainder of its healthcare business.

It never fails to amaze me, but so many sellers still fail to take care of some of the most basic items before they try and bring their practice to market. I thought that I would take you through some of the biggest ‘no-no’s’ so that you won’t make the same mistakes.

1. DON’T discuss the potential sale with the PCT. Of course when you do this the PCT will be as nice as pie and full of good intentions. However, this may come back to bite you further down the line – do not do it!
2. DON’T sell to anyone who gives you a call! If you were selling your house, would you sell it to someone who phoned up and claimed they were the only people looking?! I suspect not. In which case, don’t do it with your business. Corporates will call and try and offer a knock down price – make sure you promote to the entire market.
3. DON’T spend a small fortune on the internal decor. Interesting one this. I think with the plethora of property programmes on television offering good advice on house sales e.g. neutral colours, new paint, new carpet etc., many feel that the same is true of a practice. In our experience this isn’t the case. It must be presentable but it is less of an issue when buying a business rather than a residence.
4. DON’T be concerned about a slightly below average level of profit. In our experience, buyers often believe they can do better than the current owner and like to feel that there is room for improvement when they place their ‘stamp’ on the practice.
5. DON’T try and inflate the figures! Many purchasers will be wary about BIG changes in income and profit – especially big increases in income and profit the year before sale without good reason.
6. DON’T leave equipment that doesn’t work or redundant on display. Pretty straightforward – if it isn’t of any use, pack it away or get rid of it.
7. DON’T fail to plan in advance. A typical sale will currently take around 9-12 months. If you plan ahead and have 2-3 years you can make any relevant changes to the practice. Any less than this is unrealistic.
8. DON’T ignore contracts. Perhaps when you took your associate on it was done with a friendly chat in the lounge bar of the Dog & Duck! When it comes to selling a business, this will no longer do. A full legal document needs to be in place – they are an ‘asset’ of the business.
9. DON’T talk to the world and his wife. Whilst it is often useful to case opinion far and wide, the sale of a dental practice is generally not in this category. You tend to find that you will get 5 different opinions many of which will be misinformed.
10. DON’T be unco-operative with potential buyers. As long as you have used an independent agent to ‘weed out’ timewasters anonymously, you should be as open as possible with serious potential buyers and communicate with them fully.
11. DON’T try and keep back certain items e.g. practice website. This can come up quite a lot and the simple answer is that the sale of a business includes everything. It doesn’t matter that your friend designed the website and you really like it; it is an asset of the business and included in the sale.
12. ALWAYS use specialists. Whether you’re talking about finance, solicitors or the agents who sell the practice, it is absolutely vital that you work with people who understand the potential pitfalls and how to avoid them.

Selling a business is a big undertaking and as the vendor you need to maximise your return on investment. Make sure that you don’t make any of these mistakes!

Performance reviews tell you whether someone is doing an adequate job, but they fail to reveal whether people are doing the right jobs. This is especially problematic for average performers—those not good enough to be high potentials, but not bad enough to be fired.

Don’t let these folks limp along in roles that are not right for them. Instead, perform “fit tests” at regular intervals that compare people’s strengths and interests with their current job descriptions. For example, is someone in product development, but better suited for a position as an industry researcher?

Trust your instinct if you sense there’s a mismatch, and be honest. You might help average employees become stars.

As good a justification for using Kolbe Wisdom in selecting and building your teams as I could write.

Doctors and dentists are the latest targets of HMRC’s campaign to recover unpaid tax.

A final warning has been issued to more than 2500 health professionals that HM Revenue and Customs (HMRC) suspects are not up to date with their tax affairs.

The move is the latest in a raft of HMRC targets, which have so far included restaurant owners, plumbers, private tutors and scrap metal dealers. People selling on internet market places and electricians are next on the list to be targeted in early 2012.

The letters warn that if medics fail to come forward within 21 days, they may end up incurring significant charges, or be referred to the Criminal Investigations department.

Gary Ashford, who represents the CIOT on HMRC’s Compliance Reform Forum, and is National Head of Tax Investigations and Dispute Resolution at RSM Tenon, commented:

“These are 2,500 health professionals who HMRC are not giving a clean bill of tax health to.

“HMRC made clear at the launch of the Tax Health Plan in January 2010 that they would be adopting a carrot and stick approach. They have offered the carrot of a relatively low penalty rate for doctors to get their affairs in order and 1500 health professionals took it up, bringing in £10 million for the Exchequer. Now they are wielding the stick at those who have not come forward.

“People should not underestimate the amount of data that HMRC is holding. They have been talking to medical insurance companies, pharmaceutical companies and locum agencies. What we are now seeing is HMRC starting to use that information, to identify who has not notified HMRC of all their tax liabilities. ”

Warning of HMRC’s sophisticated approach, Mr Ashford adds: “Anyone who is worried that they have been underpaying tax – whether deliberately or in error, and whether they are doctors or anyone else – should get professional advice without delay. Penalties will generally be less severe for taxpayers who come forward voluntarily to put their affairs in order with HMRC.”

• Walk the talk
• T.E.A.M.
• There’s no “I” in team
• Elephant in the room
• Thought leadership
• Going forward
• Roadmap
• Outcomes
• Toolbox
• Push the envelope
• Go the extra mile
• Head up
• Flag up
• I don’t have a good optic on that
• Circle up with you
• Disestablish long haul positions
• Insufficient optionality
• Never lose sight of the bigger picture
• Dig deep
• Find another gear

Here is not the place to deal with my lack of personal flag waving so….

I’M IN PRINT!!

A promo. for the new collection “Messages from Dental Masters”.

Compiled by Stephen Hudson with 30 contributors (and yes, I’m one), 40% of profits will be split between the BDA Benevolent Fund and Dentists Health Support Group.

A really good read for anyone in Dentistry – order it now from Stephen’s website gdpresources.com website.

Alan Suggett from accountants UNW has produced an excellent flow chart which I have tried to reproduce here. For the full version go to their website here.