Groups Questionnaire

As part of AXA Health’s strategy of engaging with clinical group practice, we are sending you this questionnaire to gather information about your group. This information will be held in confidence.

The purpose of this questionnaire is to:

Gather some insight into the legal status of specialist groups with whom AXA Health may want to have closer engagement.
Commence the process of due diligence on specialist groups

Name of group (Required)

Trading name (if different)

Are you registered as an LLP or Limited Company? (Required) Yes No

Company Name (Required)

Company Number(s)

Registered Address (Required)

When were you first formed/incorporated?

Have you taken appropriate advice to ensure compliance with competition law? Yes No

Lead partner or Managing Director's name (required)

List members/directors/shareholders (names and GMC numbers)

Please provide a copy of your last filed annual accounts (Required)

Are any other clinicians included in the group not listed above?

Do you own or rent premises, if so, is this on a permanent or occasional basis? Please also provide the premises address.

Are you in a business relationship with other entity(s)? (Required) Yes No

If yes please list

Please confirm that no members/directors/shareholders have had disciplinary proceedings in the last 5 years (Required) No, none of our members/directors/shareholders have had disciplinary proceedings in the last 5 years Yes, some of our members/directors/shareholders have had disciplinary proceedings in the last 5 years

Please confirm if any of your members/directors/shareholders have any potential conflict of interest? (Required) No, none of our members/directors/shareholders have had any potential conflicts of interest Yes, at least one of our members/directors/shareholders has had any potential conflicts of interest

Please confirm if any of your members/directors/shareholders have a solely private practice.? If so which members (Required) No, none of our members/directors/shareholders have a solely private practice Yes, at least one of our members/directors/shareholders has a solely private practice

If so, which members

Practice details

Specialisms and sub specialisms for each group member

Treating locations for each group member/director/shareholder – consulting and operating

Which is the preferred location for operating? Please indicate if this is the view for all group members/directors/shareholders (Required)

Why is this the preferred location? (Required)

Do you offer remote consultations? (Required) Yes No

What % of your consulting as a group is delivered remotely?

If so, what platform do you use?

What practice management software do you use?

Is the software capable of API with other cloud based software? (Required) Yes No

Clinical Governance

Do you have a clinical governance policy? (Required) Yes No

Who is responsible for clinical governance? Please provide name and contact details

Do you have an MDT? Yes No

If yes, please confirm which circumstances

If yes please can you list who attends the MDT

Do you collect any outcome data if so, what?

Do you enter data into any registries if so, which?

Do you collect NPS data? (Required) Yes No

Do you collect any other patient satisfaction data, if so, which?

Do you have a process for capturing and reporting on complaints?

Administration

Do you have a single contact point for administration? (e.g. central email address) (Required) Yes No

Do you have a central booking function? (Required) Yes No

Are online appointments available for direct booking? (Required) Yes No

Are the outpatient clinics for all group members/directors/shareholders available on hospital diaries. If so which one(s)?

Do you invoice via Healthcode? (Required) Yes No

Are you represented on any specialist feedback sites e.g. PHIN, iwantgreatcare, Doctify, Trust Pilot? (Required) Yes No

Do all group members/directors/shareholders invoice via the group for all patients they see? If no, would you in the future? Yes No, and no intention to change No, but we would in future

Please provide copies of your group indemnity/other insurances (Required)

Do you have any additional liability cover over and above individual group member indemnity cover? (Required) Yes No

If so, please provide copies of said documents.

Do you generate income from insurers and patients as a practice or as individuals (i.e. do you pool income in some way)? (Required) Yes No

Provider Information Centre

Funding safe & effective care

Group Questionnaire

Practice details

Clinical Governance

Administration