Parliament may finally be debating what to do about NHS contract reform, but for many dentists and practice owners it’s all too late.
UDA values as low as £23 (and that’s after a much heralded increase) have left even the most committed NHS practice managers and owners frantically tapping calculators and spreadsheets to work out how they can continue to operate as viable businesses.
Handing back a contract to the NHS in order to go private is, of course, a seismic decision. Aside from business risk, many clinicians wrestle with ethical considerations. Who is going to look after the patients who can’t afford to stick with them, especially when many of these patients may be families who have long standing and harmonious relationships with their dentist?
To debate these and other issues Practice Plan’s Head of Sales Zoe Close hosted a webinar whose participants had trodden the path. What their wide-ranging reflections reveal is the depths of despair each had reached with the NHS treadmill of targets, dictatorial terms and poor remuneration and the value they attach to working outside of NHS constraints.
Anthony Davies owns two practices that were contracted to deliver 54,000 UDAs. Based in Workington, West Cumbria, Davies converted in July 2022 having wrestled with the intractable problem of trying to recruit dentists to do NHS work. One of his practices ended up with no NHS dentists, leaving him to pick up the pieces and this became his main driver.
Davies worried about the sustainability of his practice if he terminated his NHS connection plus how his patients would react given that the area was not typical private territory. In the process of converting his own list to private, however, “it became apparent everybody else was having the same ideas.”
Helen Louden had worked in her practice, a small, one-clinician-practice in the village of Corbridge in Northumberland for nine years before she bought it from the previous owner in a deal concluded after the pandemic.
Going from being an Associate to Practice Owner was an eye opener for Louden who confessed to being ‘shocked’ by the finances, operating costs, staffing and the targets. Yes it was a small contract but I was like “how the heck does anybody do this and have a life without running themselves into the ground?”
Ms Lauden said that exhaustion was a whole team phenomenon. “we were all exhausted and team morale getting down and we were still not quite hitting targets. The change in team morale since going private was “so different, so much better”. She had also attracted another associate to work in her spare surgery for two days a week enabling her to spend time with her young family.
Simon Gallier did his first conversion over 30 years ago. Working in the military after dental school, he never worked as an NHS associate describing the military dental service as “more like private practice”. He bought mixed practice in 1989 in north London and within 18 months realised NHS was not for him.
He could not work in a system that dictated what kind of dentistry he was to do and how much he could charge for it so he converted to private in 1990.
Gallier said NHS dentistry constituted an abusive relationship in employment terms, but that many dentists don’t recognise this because they know no other. “If you come straight from dental school in to the NHS it’s normal for you but the relationship has just got worse in terms of what they want you to do for what they want to pay you, dramatically worse since the introduction of UDAs in 2006.”
Around four years ago Mr Gallier bought a practice that had a 24,000 UDAs contract. When he visited the practice for the first time he was “completely horrified by what I saw … it was get them in, get them out, get them in, get them out….so far removed from the private practice I’d been delivering for 25 years.”
Gallier added the original intention was to convert the previous owner, who had stayed on, and then the remainder of the practice. In an interesting twist, six months after the sale the original owner decided he did not wish to be a private dentist and, released from the burden of running the practice, wished to continue NHS work. This left Mr Gallier’s business plan in tatters culminating in him handing the whole NHS contract back.
Converting Associates
A common obstacle occurs when a Practice owner wants to converts but has difficulty persuading associates to do so. Some have grown stale, others fear change.
“If they’ve been doing NHS for 20 or 30 years then they may well be the best people to go” said Mr Gallier. “I would doubt you’ll get many younger dentists who don’t want to convert. You get it from people who are completely blinkered about NHS dentistry and you don’t want them because they will carry on doing private dentistry as if they were doing NHS dentistry and that will be the worst thing you can do in your practice.
You need to find out what the barrier is to them converting.” The older generation feel allegiance to the NHS. At the end of the day you have to think of the long term. Once that line has been crossed and you are into the private world they will suddenly see how different it is and how differently you can do dentistry. The problem is someone who has been doing it for 20 years and has difficulty changing.
Although there was a perception that in order to convert a practice needs to offer the familiar dentists but this is not the case and patients are happy to see newly recruited associates.
Confidence Booster
Having decided to convert, the process was a positive experience said Louden. “Helped me with my confidence. To be a private dentist you have to really care for your patients, enjoy what you do, do it well, take your time. The Regional Support Manager was there every step of the way.” As an owner Helen was pleased with the support her plan provider had given her team and patients.
Children
A big worry for many dentists is the challenge of ‘if’ and ‘when’ to charge children for something that (subject to access) is free on the NHS. Children, after all, can’t fund their dental care and need it most.
Anthony Davies wanted to keep children on the NHS but NHS England’s ‘all or nothing’ approach was a barrier. He now offers payment plans for children with discount tiers and sees the under sixes without charge where their parents attend .
Simon Gallier was forceful about this issue. “It’s not our job, as single practice owners, to deal with the country’s problems. That’s the governments problem…they’ve abused us for so long, they’re not going to pay us to see children, in a way what we need to do, we need to get NHS system to fail completely then they’re going to have to rebuild it.
Social Media Trolling
Anthony Davies said lows were difficult to pinpoint. “I’d already hit a low point when we were having to contemplate potentially closing a site so going through the (conversion) process it was a bit of a rebuild. Clawback, not great, that’s a hefty one to be having to stare down the barrel with a big contract like mine.
There was point during the sending of letters to patients that Mr Davies confessed he did waiver and this concerned social media backlash.
Somebody had posted rather caustic comments about how bad it was for someone who supposedly cares about patients leaving disabled people and other without access.
But on closer examination it transpired that many of the people who were ‘trolling’ the site with negative comments were not patients of the practice. People even used fake accounts to post comments. Practice Plan’s Zoe Close said social media was increasingly a worry but what is key is how a practice reacts to it.
Davies concluded - “The system isn’t our fault: the fact that it’s failing patients and isn’t providing for them isn’t on us, as the people trying our best to care for our patients, and it kind of reinforced it for me when I realised it wasn’t even a patient”
Simon Gallier too seized on the emotional tie some dentists feel to the NHS “Some people have got to provide NHS for people who can’t afford it, and that is fine, but that needs to be properly funded and done properly and its not our job as general practitioners who are running a business to do that. We need to be paid a decent amount of money.”
‘Plan Only’ Or Pay-As-You-Go?
Some practices are ‘plan only’ and have withdrawn pay-as-you-go. Davies said he is moving towards plan only and won’t take on new patients unless they join a plan.
Helen Lauder is 85 -90% plan, pay-as-you-go patients normally go over to plan. Some patients just don’t want another DD whilst some patients have insurance through work, but this won’t cover their plan memberships so she has maintained a pay-as-you-go option.
Highs
Lauder said “it all feels much calmer.” We have more time, it’s more relaxed, the staff are happier and patients are. Team building workshops great morale./
Davies spoke of the dentists he’d attracted who want to do dentistry in a similar way to him. They want to develop and improve themselves and grow. I would say it feels more stable now and no more clawback which fuels feelings of instability.
Simon Gallier said he has never met a dentist who has gone private and regrets it. He spoke of all the “NHS admin bollocks that you can just throw away.” The amount of e-mails and paperwork had been unbelievable he added.
When
To practice owners and staff contemplating a conversion Davies says do it “as soon as possible.
I delayed for too long …. You put lots of false reasons in the way of it, whether it’s talking to NHS England to try and keep kids or vulnerable adults… it always ends with them having to take it back to someone else all of which is delay ….while they mess around and decide they are not going to give you what you’re seeking. Do it now – clawback only gets worse as the year goes on.
Plan providers will do a full breakdown and projections for practices contemplating conversion. “It’s not going to be for everybody” said Davies “…you have to be behind it yourself you have to stick with your decision and you want your associates on board.
If they don’t want to do it and they come along come along they won’t last very long or you’ll start to become fed up with what they they’re doing if they’re still trying to do NHS dentistry under your new private regime or protocols. The sooner you put things in place to work these things out the sooner you can have these conversations” Mr Davies advised.
Patient Reactions
Helen Launder acknowledged that there were a few “I can’t believe you’re doing this” but added “I was so pleasantly surprised how supportive most patients were”
Anthony Davies also said there was positivity, “one came in to say I got my letter and said thank God for that. I’ve got friends who are with a private dentist and they can always get to see their dentist when they want to!” Most people are silent, they don’t voice an opinion one way or the other,.
And finally
Not surprisingly, all the dentists who took part in the webinar were ambassadors for private dentistry having totally lost their mojo with NHS dentistry under its failed contract.
Simon Gallier summed up, confessing that in all his years he hadn’t encountered one dentist who has converted and who regrets it. “I’ve not heard one say ‘let me back in the NHS I miss it so much” and to those practices struggling to recruit he assured them that “as soon as you become a private practice the CVs come flooding through the door and people want to work for you”.