Advicesheet

Setting up in practice

A18

Advicesheet

Setting up in practice

A18

contents
Making a success of a new business takes more than entrepreneurial flair and desire to manage your own destiny; it also takes thought, planning, management skills, determination and appropriate professional advice. This introductory guide provides ideas to help create an entirely new practice, and is structured according to the stages to go through. The information in each of the sections has been kept brief, but references are given to more detailed advice publications. Individual help is also available and we are happy to talk through your ideas on the telephone or in person by contacting the BDAs Business Advisers on 020 7535 5864. Part 1: Getting started Making the decision Choosing a location Finding the right premises Planning permission Practice design Surgery planning and design Dental equipment Part 2: Business planning Developing a business plan Setting business objectives Marketing Customer care NHS or private practice? Finance Help for small businesses Part 3: Managing the practice Recruiting and managing staff Health and safety Clinical governance Other essential legislation Practice administration Quality and best practice Opening up Avoiding the pitfalls Further information

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First of all, it is important to think very carefully about whether creating a new business is the right move for you. Starting a squat essentially means securing premises that were not previously used for dentistry, equipping and staffing them, putting up a sign or a plate, informing the local population you are there and then caring for anyone who decides they want to try you out. This option is complicated by the NHS contracting requirements in England and Wales, where you have to have a contract before seeing NHS patients. There are other options that may be more straightforward, such as buying an existing practice or buying into a partnership. These involve less commercial risk, as you buy the goodwill associated with a list of patients and will probably be guaranteed a minimum income from day one, rather than having to wait for your income to build. By buying a practice, existing problems will also be inherited, as will responsibilities for staff and premises and practice expenses may be high and not easily reduced. If you are entering into an existing arrangement between dentists, you will have limited control over business decisions as partners and/or associates will need to be consulted, and the feelings and rights of staff taken into consideration. But for many associates, avoiding the stress of starting a business from scratch, along with the support of other dentists and reduced commercial risk, is the preferred option. On the other hand, benefits from starting from scratch include: Ability to choose the exact location of your practice (subject to factors such as patient demand, whether you want to provide NHS care and availability of premises) Design and equip the practice as you wish (within budget!) Select staff and set terms and conditions Building up practice goodwill yourself, rather than paying for it Personal rewards of building a business through your own efforts and developing new skills. Before making a decision on whether or not to squat, investigate all options thoroughly, including visiting practices for sale in the locality and look at what you might be able to buy. Decide for yourself what advantages there are personally in setting up, and identify risks. Try and quantify the time involved and write a list of pros and cons. Estimate the costs of each option, and develop and compare two contrasting cashflow forecasts: one for setting up a new practice and one for buying an existing business (see page 20). Talk to local colleagues about their experience of setting up or buying an existing practice in the area. Most of all, talk to your immediate family and make sure you have their support. It might be their future financial security you are putting at risk and inevitably you will be calling on them to offer emotional and quite possibly practical help in the first few years. It is important to realise that single-handed ownership can be a lonely position where you may be the only dentist on the premises in a new environment and where you cannot ask for clinical or management opinions from colleagues. New situations will face you, and you will have to cope with many additional responsibilities which do not generally face associates, such as: Making decisions and coping with business problems and worries Hiring, training, motivating, counselling and possibly dismissing employees Leading a team of individuals who may have different ideas about how a dental practice should run Complying with a host of legal requirements Taking full responsibility for the health and safety standards of the practice and the health, safety and welfare of staff, patients and visitors

Making the decision

Why choose to squat?

Can you cope?

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Monitoring expenditure and financial planning Keeping the bank, accountant and HM Revenue & Customs (HMRC) happy Chasing bad debts Dealing and negotiating with suppliers Addressing equipment breakdowns and failures Possibly dealing with a difficult landlord Negotiating with the primary care organisation (PCO). All of these situations will have to be dealt with whilst building relationships with patients and the local NHS and providing excellent care. If you would still like to go ahead and find out more about starting your own practice, read on!
When is the best time to make the move?

Many dentists decide to become practice owners in their late twenties or early thirties. By this time, they have achieved a comfortable level of earnings as an associate and have enough financial security to take a calculated risk. Furthermore, they should have gained broad experience of situations encountered in general practice which gives the confidence required to practise alone. Dont be in a rush to go into practice ownership too young as there are many problems which an inexperienced or unsupported dentist might face and could find difficult to deal with. Dentists are required to comply with very high standards of professional practice as members of a profession and providing an acceptable standard of treatment, possibly complying with NHS regulations as well as the many ethical and legal requirements which are placed on practitioners, can be extremely tough when coupled with the pressures felt by owners of all new small businesses. The pace of change, both within the dental profession and for small businesses in general, can compound this sense of frustration. A young dentist with little professional experience or support might be tempted to compromise clinical standards or overlook the rules of professional conduct due to commercial pressures. Dentists who have spent their careers in the armed forces, hospital or salaried primary dental care may also decide to enter general practice and be unwilling to start out working for someone else. In this instance, they might be in a position where they are learning about general practice at the same time as they learn about practice ownership, which is a massive step to take at once. External factors will also affect when you go out on your own. Setting up any new business is a major financial commitment, and the uncertainty over the future of NHS dentistry in England and Wales beyond 2009 entails a level of risk that may force many dentists to delay making a move. But this risk can be mitigated by gathering and assessing detailed information about the area. If you are planning to set up a practice with a substantial NHS commitment, you should look carefully at the following information about the practice location: The oral health needs of the local population The PCOs attitude to dental services. For the purposes of this advice sheet, we will refer to PCTs, LHBs and HBs as primary care organisations (PCOs) The number of practices in the area and the percentage offering private treatments Socio-economic status of the population. The main consideration is whether the information suggests that, over the long term, the PCO will want to contract with your practice, in its particular location and with the facilities and services you intend to establish, for the provision of NHS care or whether a private dental practice will be profitable. Ultimately, only you will know when is the best time to start out on your own. Provided you spend time thinking about what you are doing at the outset, obtaining as much information as possible and talking through the options, you are unlikely to encounter problems you can not resolve.

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One of the most important factors in determining the success or failure of your new practice is the location. When setting up a squat practice, you are able to choose not only the location, but also the size and style of the premises. It is imperative to gather as much information as possible about the area in which you intend to work. Before deciding upon a location, consider carefully what type of practice you are trying to establish: Do you want to concentrate on NHS or private treatment? An area with mainly private practices shows the local population accepts private dentistry What are the treatment needs of the local population? Do you want to treat children? Are you near a school or college? What are the local orthodontic services like? Are they accepting referrals under the NHS or privately? Do you want to concentrate on private cosmetic dentistry? If so, will there be enough demand? What is the percentage of older people in the local population? Are you prepared to provide the dentures that may be needed? Is there a local practice or clinical dental technician that accepts referrals? You must ensure there is a need for your particular services in your chosen area. If you intend to set up a mainly private practice, for example, can patients afford the higher fees and are they willing to be treated outside the NHS? Look at local unemployment rates and the percentage of patients on benefit in the area. If both are high, patients may not be able to afford private fees and go instead to other dentists in the area who offer NHS treatment. When weighing up a particular location, ask yourself: What are the economic conditions locally? Is there any financial assistance available to new businesses starting up in the area? What is the socio-economic profile of the area: predominantly professionals, families with young children or older people? Are there enough potential patients in the area to make a new practice viable? What are patient attitudes to dental care? What are local attendance patterns? Is the water fluoridated? What is the local housing pattern? What is the local labour force? Will a new practice be able to recruit dentists and the required staff easily? What are local transport links like? What are the strengths and weaknesses of neighbouring practices in the area? Are there any dental services lacking in the area? If there are no other practices in the vicinity, why is this? If you wish to practise in England or Wales, then in order to provide NHS care a contract must be obtained from the local PCO. Contracts will normally be given following a tendering process and new practices will be located only where there is a need for NHS provision. Population trends, economic conditions and town plans all have a bearing on your choice of area and particular type of practice. Personal as well as professional issues should be taken into consideration, so you may decide to live in close proximity to the practice, become part of the community and not have far to travel should you be called out. Consider also the thoughts and feelings of your family: will they feel at home in the area and does the locality offer the right amenities, schools and leisure activities?

Choosing a location
Type of practice

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Source of information

Primary care organisation You can find out how many dental practices there are in a given area and where they are by referring to the PCO, or by visiting www.nhs.uk. These references will not include practices which offer only private treatment, but those can be found by looking through local Yellow Pages or by searching on Google or Yell.co.uk. Would you want to establish a new practice in an area where the local population is already served by a large number of practices, and where you would have to compete for new patients? If there are few practices in a specific area, then this could suggest unmet need, but also low demand. Look at the global treatment patterns of dentists within the PCO and talk to the local dental practice adviser to find out whether they feel a new practice would succeed in the locality. The local council The local councils planning department can provide helpful information about the local population, for example if there is a large number of young families or older people. Is the population increasing or decreasing and are there any plans for new housing developments? It is important to get a feel for the area and to know what the local economy is like, and to ensure you are aware of local planning policies and restrictions. Personal contacts Go to local BDA meetings, and talk to colleagues in the area where you wish to set up the practice. Obviously some local dentists will be more amenable to help than others and approaches must be handled sensitively. The LDC secretary will also be able to tell you if, in their opinion, a new practice is needed or not. Local estate agents, libraries and doctors will also have detailed knowledge of the area. Dental drug and materials suppliers representatives might also provide useful information, since they visit local practices. Another useful resource is upmystreet.com, where you can find information about an area by typing in a street postcode. Check all the available statistics that allow you to compare prospects in one area with prospects in another. NHS tendering opportunities PCOs offer tendering opportunities for new NHS practices by placing advertisements in the BDJ. Some of these tenders involve starting a new practice.

Finding the right premises

Once you have decided on a particular area, the practice premises needs to be chosen. Start by contacting local estate agents and outlining your requirements. Factors to consider when looking at potential premises include: Price of the property, including business rates and bills Condition of the building. Check the building is structurally sound by having a structural survey. Furthermore, a property with a good outside appearance and well-maintained garden will reflect favourably on the practice Allow room for sufficient surgeries, reception room, reception, office, toilets, radiography room, decontamination room, staff area and space for expansion if planned for at a later date Potential risks to business continuity, such as flooding Utilities and services such as plumbing, broadband, electricity, gas, water, sewerage and telephone lines. A gas supply may not be available, whilst sewerage is sometimes provided by means of septic tanks Visibility from the street. If passers-by can clearly see the practice, it is more likely to attract patients

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Access to the building at night will it be necessary to protect windows and doors against potential vandalism or robbery? Availability of car parking and public transport. Car parking may be a significant planning obstacle Ease of access for disabled people. Practices may be situated in either residential or commercial premises. A practice in a shop unit will generally gain more attention than one of similar size in a row of houses. Whether you establish your practice in the middle of a busy high street, in a residential area or in an area which is known for dental practices, it is advisable to make sure that passers-by can see the premises is a dental surgery by putting up an external sign. If the entrance to the surgery is hidden, at the side of the building for example, you may lose out on potential new patients merely because passers-by cannot see you are there. Premises next to or near a doctors surgery, health centre and/or pharmacy may help to integrate into the local community and increase footfall. The Disability Discrimination Act 1995 (DDA) needs to be considered when setting up a squat practice with employers taking reasonable steps to accommodate disabled employees and, as providers of services to the public, taking reasonable steps to provide accessible premises for patients. The DDA means service providers must ensure their policies, procedures and premises are adjusted to provide auxiliary services and to take reasonable steps to reduce physical barriers a person with a disability might encounter. Where physical barriers make it impossible or unreasonably difficult for disabled people to use a service, the dentist will be expected to take reasonable steps to provide the service by a reasonable alternative method. It is important for the dentist to know what would be deemed reasonable and to be able to justify an inability to comply with the provisions of the DDA. Guidelines are set out in the codes of practice issued by the Disability Rights Commission. Some guidelines for reasonableness include the size and resources of the service provider, the effect non-compliance would have on the disabled person, the effectiveness and practicability of making the adjustment, the cost for making adjustments, and the fundamental nature of the service providers business. Where converting premises to a dental surgery, there will be higher expectations and this should be discussed with your architect, planner or designer. The obvious attraction in purchasing a property is that you will acquire a capital asset in addition to the practice itself. This means taking on a mortgage and the financial implications of this need to be carefully assessed with the help of an accountant. Planning permission will be required for it to be used as a dental practice, if it is not already used for this purpose. Your solicitor should check whether there are any restrictive covenants contained in the deeds for the property which might prevent its use as a dental practice. There is further information on planning permission below. A lease is an agreement whereby generally the freeholder (landlord) of a property gives exclusive use of the property, or part of the property to the leaseholder (tenant) for a defined period. The word lease, however, can be used loosely, and it is important for you to understand what rights you actually enjoy. If for example you are granted a nonexclusive licence, you will not have exclusive possession of any part of the property. Licences simply give permission to enter and use premises. It also means there is no security beyond the agreed notice period. Greater rights of security will be enjoyed under a normal business tenancy, providing protection under the Landlord and Tenant Acts. This includes a statutory right to renew the lease at its termination, unless the landlord can provide a reason defined by statute to oppose the renewal. A lease should be drawn up by a solicitor and the BDA has Advice Sheet A16 Leases and licences to help understand them. Ensure a solicitor is consulted about your own requirements, which will depend upon the nature of the property concerned.
Leasehold Freehold Access

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Whether you decide to rent or buy the premises, the building should be valued by a surveyor who will advise on the work needed to comply with legal requirements. If you are considering renting or leasing premises, ensure that structural alterations needed are permitted by the landlord. Not being allowed to make alterations may be one of the disadvantages of renting a property and the pros and cons of buying, renting and leasing need to be weighed up. Consider the existing layout of the building: are the rooms big enough for their purpose, or would you need to knock down walls or move doors or windows? Is there is sufficient electricity and water supply to the building to operate the number of surgeries you envisage?

Planning permission

Planning permission is usually required if the development of land is proposed. This includes proposals to erect, enlarge or materially change the external appearance of buildings. Permission is also needed for the change of use of a property or land. The desirable uses for every area are set out in the local authoritys development plan. More specifically the Use Classes Order, made under the Town and Country Planning Act 1990, designates the acceptable uses of individual properties. This sets out sixteen classes of land use, for instance shops (class A1), dwelling houses (class C3) or medical and dental surgeries (class D1). A change of use between classes generally requires full planning permission; a change of use within a class does not. So, converting a retail shop (A1) to a dental practice (D1) constitutes a change between classes, necessitating full planning permission. Planning permission should be granted if the proposal complies with the local development plan. Where the local plan has a policy, for instance that there should be no loss of residential accommodation, great difficulty may be encountered in getting permission to convert a house into a surgery. If the proposal does not comply with the local plan, you can still be granted permission if you can show a good reason why it should be granted, for instance that there is a demonstrable need for dental services in the area. The local planning authority may take into account the effects of the proposed development, in particular the: Character and amenity of the area Proximity of adjacent properties and possible nuisance to neighbours Production of clinical or hazardous waste Proposed level of use External appearance and signage Road safety, traffic congestion and car parking arrangements Need to retain land in agricultural or residential use, or reserve it for other purposes such as agriculture or road improvements. These considerations should be fully investigated with the local planning authority before the application is completed. If the need for planning permission is ignored, it is possible that the authority may decide the development is unacceptable, and issue an enforcement notice requiring the dentist to cease their activities, or even to demolish a new building. There are different types of planning applications: outline permission, application for approval of reserved matters, application for full planning permission and application for renewal of temporary permission or relief from conditional permission. For these purposes, the most likely application will be full planning permission, though this should be checked with the local planning authority.

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You should find out if planning permission is required at all. If it is, your application should be submitted on the authoritys standard form, and accompanied by a plan and the appropriate fee as laid down by Parliament. You must also include a certificate which states that the applicant is the sole owner or that the owners of the property have been notified. You do not need to be the owner of a property to apply for planning permission, so, if you are thinking of purchasing a property, you can make an application beforehand (but make sure the seller is willing to wait). Again, seek the advice of the local authority when preparing the application. The process for obtaining permission can be lengthy - the Secretary of State stipulates a deadline of eight weeks, but in reality it can take longer. Improve your chances of a prompt decision by getting information on the likely cycle of planning committee meetings as three or four weeks might be gained if the application is correctly timed. If a planning application is particularly complex, or has generated controversy, it can quickly become entwined in local politics, in which case it may be worth briefing a local councillor on the proposals. The local PCO may also be willing to lend support to a planning application for an NHS practice. It can be advisable to seek the help of a consultant chartered town planner. Town planners often have an insight into the local authoritys development plan and priorities, and a list of local consultants can be supplied by the Royal Town Planning Institute (www.rtpiconsultants.co.uk) who can advise whether your application warrants their engagement. If planning permission is refused, or unacceptable conditions are attached to the permission, you can appeal to the Secretary of State for the Environment. The majority of appeals are dealt with on the basis of written representations, but in cases of particular local importance the appeal will be a public inquiry. Decisions can take a long time, with four months considered a reasonable time for considering an appeal based on written representations. In the majority of cases, the Secretary of State will support the decision of the local planning authority. For these reasons, it is actually quicker if possible to negotiate and overcome any objections with the planning authority itself. BDA Advice Sheet A1 Planning permission provides further guidance.

It is important to think carefully about how the new practice will be laid out and designed. Uncomfortable and cramped surroundings, harsh lighting, dental smells and dental noise can demotivate staff and make patients irritable and edgy. A negative environment will have a negative effect on morale; a positive environment may increase goodwill. A well-planned practice will also improve the efficiency of patient throughput, improve security and reduce hazards, whilst attention to practice design at the start can prevent problems in the future, such as lack of space, poor layout and lack of flexibility. Important points to reflect on when discussing the design of the practice include: Waiting areas and seating arrangements Size and access to reception Display area for toothbrushes, toothpaste etc for sale Lighting Dcor Private areas, both for staff and for discussing matters with patients Odours Will there be a childrens play area?

Practice design

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Consider professional help with the layout and design of your practice. There are architects and design consultants who work in dentistry and a list is available from the BDA. Before talking to the consultant think about: How many surgeries do you ultimately see the practice having? This will affect the siting of services How many patients will be on the premises at any one time? How many staff will you employ? What will be the character of the practice friendly, informal, exclusive, welcoming, family-orientated? How will the lighting and colour scheme fit in with this? How can you personalise your practice? Some dentists try to make their practices feel like extensions of their own homes so patients feel welcome, relaxed and secure. When briefing the designer, provide as much information as you can about the way you want the practice to operate. A checklist Engage a professional architect/designer Consider light, colour, smell, touch, sound and space and how each can be used to create a relaxing atmosphere Look at the practice from a patients point of view Look at other businesses and store away good ideas what do they do well that can be replicated by your practice? Keep control over your budget Pay most attention to ensuring that enough space is available.

Surgery planning and design

Overview of the general practice environment

Surgery planning and installation is quite simple if planned properly. Consider the following points: The general practice environment influences the design of a particular surgery room. For example, the easy flow of patients through the building is of prime importance. A normally relaxed patient may become anxious when faced with uncertainty and the need to know where to go and what to do. Good direction from reception staff and clearly marked passageways and doors are a must. For the patient, access should be obvious and simple. For the dentist and nurse, it is beneficial if the layout places them where they face and greet patients as they enter the room, whilst having a seating area for anyone who may be accompanying a patient is a good idea. Avoid having the foot of the chair pointing directly to the door of the room, for decorum and patient comfort. The character of the room may influence your choice and style of dental equipment. The size and shape of the room, the position of doors and windows and the nature of the floor, along with the availability of electrical, plumbing and waste services, will all play a part in your decision-making. Early in the planning stage, professional advice can be well worth the investment and can make big improvements. There is a temptation to reproduce the type of surgery you are used to, but a fresh eye may spot improvements. The actual operating site The position of instruments, equipment and cabinetry will be in a direct relationship with the headrest of the chair, so determine the optimum chair position first. Both dentist and nurse should be able to reach everything required for normal procedures, without the need to over-stretch or rise from a seated position.

The surgery

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Delivery system The question of which handpiece delivery system to choose can only be answered by the individual dentist. There are several options: traditional garage or cart or an overthe-patient system such as the tray or swing-arm. Other equipment Think ahead to what your needs and requirements might be in the future. For example, if the practice is to be family orientated, consider a chair with a childs headrest. Will the practice be computerised? Can the system link into filmless radiographic equipment or intraoral cameras? Is there forthcoming health and safety legislation that would be more sensible to comply with now? Would your existing equipment be adequate if you decided to expand at a later date? Having chosen a manufacturer, discuss your plans with one of their equipment specialists and compile a realistic plan of action before committing yourself. Include in discussions the level of service, support and maintenance, availability of spare parts and how fast emergency call-out responses would be. A comprehensive maintenance contract should form part of the equipment deal. Having decided on the new equipment, cabinetry and any other items to be installed, hold a site meeting with all necessary contractors. Ensure everyone concerned is made fully aware of the work they are required to carry out and of the necessity to keep to agreed completion dates. Immediately after the site meeting and when all costs are known, address the question of raising finance. Broadly speaking, if ownership of the equipment is important to you, consider cash purchase. Alternatively you may decide that it is the use of the equipment which is important and elect for a leasing arrangement. Look at the terms of the lease carefully and, if in doubt, take advice. Whichever route you choose it is wise to cover the cost of the maintenance contract within the overall capital equipment package. When the finance is agreed and the delivery/installation dates are known, you can go ahead with any major underfloor plumbing or electrical work. The floor can go down once this has been completed, which should offer anti-static and anti-slip properties and be easily cleaned to ensure it is hygienic. The equipment can be installed after this. When the installation has finally been completed, get used to the new equipment and layout. Train surgery staff on the operation and maintenance procedures necessary to keep your investment in pristine working order, and the manufacturers representative should help in this respect.
Discuss with the equipment manufacturer

Arrange a site meeting

Discuss with finance supplier

Installation

It is essential to purchase the right equipment for your needs. Here are some points to consider when thinking about buying the equipment for your surgery: The equipment chosen must meet your needs for years to come Shop around and get detailed costings from several equipment manufacturers and suppliers If buying a whole new surgery, negotiate as discounts should be available Make sure that servicing and repair facilities are reasonable. Ask about call-out times and charges Take time to consider the options before making your final decision Ask local colleagues for recommendations. Dentists who have recently set up will be a good source of information.
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Dental equipment

Buying the most expensive, attractive equipment in a bid to impress patients will not necessarily pay off. Patients are more likely to be impressed by the general practice environment, cleanliness of the surgery and the attitudes of staff and dentists. So, when selecting equipment, be more concerned that it will do the job properly rather than what it looks like. If money is scarce, dont be afraid to buy cheaper, simpler equipment without all the latest gimmicks because, if it comes from a reliable and well-known manufacturer, it will probably function just as well.
Saving money

There is no reason why you should not buy equipment secondhand. Ask other dentists if they have equipment to sell and look for adverts in the dental press. Make sure it is in safe, good working order and that maintenance contracts and spare parts are still available. General office furniture and cabinetry can also be bought secondhand. Items such as filing cabinets, desks and chairs can be used in your office and reception area and are easily obtained from office supplies firms.

Dental equipment companies

Many companies now have modern showrooms demonstrating the latest equipment in an ideal operational environment. Services they provide include: Installation and servicing, although your own plumber and electrician will probably be able to help with the final connections Professional advice on interior design, down to the choice and selection of colour schemes A surgery design and planning service incorporating the latest furniture designs Support and training in operation and routine maintenance. Remember to get competitive quotes for the same equipment from different companies and do not be seduced by large discounts from unknown suppliers. It is always better to deal with established companies who are selling reliable and wellknown equipment at a reasonable discount.

British Dental Trade Association

The BDTA (www.bdta.org.uk) can send you a list of all the dental equipment companies currently members of their Association and can advise you where best to buy your equipment if you have particular requirements. When looking for dental equipment a visit to either the BDAs Annual Conference exhibition or the BDTAs International Dental Showcase should prove invaluable.

Developing a business plan

Objectives Market

The lender may give you a model business plan to work from, but, as a guide, your plan should cover as many of the following points as possible. Here the aims of the practice should be set out for the short, medium and longterm. Defining your market is a crucial part of the plan. This can cover geographical sources of patients and the general characteristics of your market or location. This information should have been gathered as part of your initial decision about location and premises. A potential lender will expect to see a clear marketing plan, outlining how your service will meet the needs of your target market, and how you will promote your services. For more information on how to develop this, see page 14.

Marketing

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Comment here on the adequacy of the existing or proposed premises, equipment and future requirements: The general condition of the property and estimates of anticipated adaptation, repairs and redecoration costs Capacity and layout of the premises and whether there is room for expansion Will part of the property be required for living accommodation? Is the property freehold or leasehold? (If leasehold, give the length of the lease remaining, the rent payable and when the next rent review is due) If relevant, a statement that planning permission is required or has been obtained List of equipment required, how it will be financed and an estimate of its life-span Are there expansion opportunities available within the chosen site? Have you investigated where you will obtain your supplies and included estimated costs? The earlier section on dental equipment should help you to pull this together. Comment on the staff required, the skills needed and the employment basis (full- or part-time). The lender will want assurance that you have the ability and relevant experience to make a success of the practice. This section of the plan will be similar to a standard CV. This is the core of your business plan, and you must demonstrate to the lender that careful thought has been given to the figures. Include money you are investing yourself, take into account any potential setbacks in the first year and summarise precisely the finance required. Expect to present a cashflow forecast - a monthly estimate of income and expenditure - for the first year. Think about this carefully and make your best effort, but the lender will appreciate it is an estimate and will not be surprised if the reality does not conform exactly to what you predicted. Further help in developing the business plan can be obtained from potential lenders themselves. Banks and other lending institutions generally offer a small business advice service. It may be worth arranging a meeting with one or more of these for an informal discussion when plans are at an early stage, as they can take you through their own model plans and give a good indication of how a business plan should be presented. BDA Advice Sheet C3 Business plans provides a more comprehensive guide to writing a business plan, whilst C6 Financial management for general dental practice can help with cashflow forecasts and financial planning.

Premises and equipment

Supplies

staff

Personal details

Finance

Deciding on a philosophy can be helpful as it will underpin the care you provide. It will focus your employees minds and shape your customers expectations. Here are some possible examples: In our practice we will: - put our customers first - provide patients with full information on treatments provided and their costs - use our imagination and skill to make dental visits a positive experience - provide painless, comfortable procedures. Any philosophy must be shared by everyone in the practice, so involve the whole team in drafting it. Consider why customers might want to visit your practice. What are your goals? What promises are you going to make? Are they realistic within the constraints that you will be under?

Setting business objectives

Practice philosophy

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Business objectives

Your objectives for the practice will form an important part of your business plan. You need to devise short, medium and long-term objectives, which should be SMART: Specific address a specific target or area of the practices operation Measurable quantifiable wherever possible Achievable possible to achieve Realistic bearing in mind the resources (time and financial) available Time-bound set within a defined time limit. Short-term objectives will shape your business plans for the first twelve months from startup, for example: Build up a solid patient base of x NHS and y private patients Develop clear policies and procedures to guide staff in practice administration matters Achieve practice turnover of Xk in the first year. Medium-term should describe the intentions over one to three years, for example: Increase patient base to x NHS and y private patients Recruit an oral health educator and offer twice-weekly OHE sessions Work towards and achieve membership of the BDAs Good Practice Scheme Promote the practice and raise the profile through involvement in local events. Long-term objectives will map out your plans over three to ten years. It may seem impossible to plan this far ahead, but these will be high-level strategic objectives, such as: Expand the practice through the addition of a new surgery Bring in a partner Consistently increase the value of the goodwill in preparation for retirement. If you find it difficult to see where objectives might fit within this time-based framework, an alternative way to structure them is under the headings Finance, People, and Quality. Again your lenders small business adviser should be able to give further help.

Marketing

There are two key stages in marketing a new practice. The first is to discover what potential patients actually want from a dental practice; what are their needs, demands and expectations? The second is to tailor your service; ideally, in such a way that these criteria are exceeded. You need to consider primarily the type of patients you want to attract; do you want to treat the whole community from children to pensioners, or would you prefer to try to develop a niche market whereby you concentrate on one segment of the market, for instance young professionals? Once this question has been answered, the needs and expectations of your intended patients have to be identified. Although you may find it easy to formulate your own list of what potential patients want from the practice, your understanding will be far more accurate if you actually ask them. Conduct research into the potential market by sending out surveys, talking to local shopkeepers, health professionals, and public/patient involvement groups about their ideas of a good dental practice. Get copies of patient information leaflets of other practices, and have a look around. What do the practices have in common? There may be merit in identifying these common services and making sure you offer these alongside additional ones to create a unique selling point to differentiate your practice.

What do patients want?

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Look for niches within the marketplace. Do any of the practices offer something which you are able to provide, for example hypnosis, a crche or computer imaging? Concentrate on a few unique selling points, but do not tackle too much at once at the beginning. Adding new services in the future and continuously improving can create publicity opportunities and keep new patients coming in. The next step is to tailor all aspects of your service so that it fits the needs in the best possible way. A marketing plan is the basis for how you will do so. The model of the marketing mix presents the four Ps, which need to be addressed by any marketing plan: Price at what price? Product what services do you propose to provide? Place where? Promotion how will you promote this service to customers? In addition to the standard Ps, the BDA recommends you also consider an additional two Ps: people and process. For more detailed information, see the BDA Advice Sheet A6 Marketing in dentistry. Price If you are going to operate under the NHS, then your patient charges are set centrally and you have no scope for altering them. But, if you are practising privately, then you are free to set your fees as you see fit. Naturally you need to cover your expenses and make a profit for yourself. The basic way of setting fees will be to divide the total predicted expenses for the year by the total chairside hours to be worked, to get an hourly rate to charge patients. A more detailed explanation of setting private fees is in BDA Advice Sheet C8 Fee setting. Product In considering the product element, the key questions to ask are what services will the practice provide and how will these services be customised to meet the needs of patients? For example, market research might indicate that local residents would like a dental practice which: Provides NHS treatment Has good communication between dentist, team and patients Has high clinical standards Has minimal waiting time. In response you decide to: Offer NHS care to everyone at the beginning Spend time explaining costs and what you are doing to each patient Have a time-specific appointment scheduling system Recruit experienced staff Have staff name badges and a clear uniform policy. As the example illustrates, in addition to the clinical aspects of the dental care product, for example any specialist services you will offer, you also need to address the overall service experience. So, the quality of customer care, attitudes of staff and pleasantness of surroundings are all components of your product requiring due consideration.
Developing a marketing plan

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Place Within the context of the marketing mix, place equates to where you intend to deliver your products and services. Is the surgery up to scratch with the latest equipment and does it look clean, tidy and well maintained. Does the practice look professional, welcoming and where you personally would want to undergo medical treatment? This will have an effect on how patients form opinions on the quality of service offered and their general overall picture of the practice, and therefore is an integral part of marketing. Promotion Once you have decided on the services you will offer, you need to come up with a plan for how you will promote them. Again, you should choose a promotion method that fits with the type of patients you wish to attract; so if your services are targeted towards young children then it makes sense to focus promotion on local parents groups, nurseries and schools. Make a realistic budget for the pre-launch promotional activity and dont overspend at the beginning. During the first year you will need to promote the practice regularly to build up a patient base. This promotional activity may be enough to bring several hundred new patients into the practice. These patients will be the ones who will be the source of your patient base and who will promote you to their friends, neighbours and acquaintances. Building up a good professional relationship with your patients will encourage them to discuss with you first any problems they may have with the practice, rather than going away and telling everyone else about it. The later section on customer care gives more guidance on this area. Remember, promotion goes beyond traditional advertising methods like leaflets and adverts taken out in a local newspaper or Yellow Pages. Anything that raises awareness of your practice and services is a form of promotion, such as: A clear, bright exterior sign (obtain planning permission for this) An opening party with a local celebrity to which the press is invited A new patient welcome procedure: welcome pack, introductory tour and so on Offering all new patients a discount on their first account A recommend a friend scheme Offering a family discount where whole families attend regularly Participating in local events, such as running an oral health stall at the village fte. People A dental practice relies heavily on the quality of the people working for it and the rapport built between patients and staff for successful delivery of services. It is therefore worth developing your people, both in their clinical skills (if necessary) as well as the softer people skills, so they are able effectively to handle patients in the best manner. The practice staff are the human face of the practice imagine them as walking, talking billboards for your practice, and ensure that they give the right impression in order to be able to market the practice. If they give efficient, polite service, then this is going to have a positive impact on how patients perceive the practice. On the other hand, if the phone is left to ring for a long time and there is a grumpy, illinformed receptionist answering calls when the call eventually is picked up, this will have a negative impact on the patients perception of the practice. Thus, it is important not only to attract and retain quality individuals to the practice, but also to develop them and ensure they are valued and content within their jobs.
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Process Process looks at the way in which services are delivered to patients right from the time they first have contact with the practice, until the time they step out the door at the end of their treatment in other words, the patients journey within the practice and how efficiently it is managed. Consider aspects of the patient journey and how it can be managed are reminders for appointments sent out? Are patients kept waiting around for a long time? Can they get appointments when they want them? Is there a smooth transition from reception to dental chair to hygienist? The smoother this patient journey, the better the impression for the patient and the happier the patient. A happy patient should mean a repeat patient; an unhappy patient means not only that they may not return, but also adverse publicity for the practice through negative word of mouth. One well known marketing statistic is that consumers who have a bad experience tell on average nine people, whilst one study has shown that 13 per cent of people will tell twenty or more friends and colleagues. So it is imperative to manage expectations and to ensure that patients are happy with the service they are receiving - that the patient has been placed at the centre of the practice. When considering the above points, always try to look to see how the practice would be viewed through patients point of view.

Customer care is a key element in running a successful practice, especially with regard to retaining patients. One approach that is becoming increasingly widespread is customer relationship management (CRM), centring on two concepts: A businesss customer base is as varied as the number of customers it has. In other words, your service should be customised to the level of individual patients, moving away from market segmentation, whereby you assess and serve the needs of groups of patients who share similar attributes, and towards the idea of a market of one, whereby each individual patients expectations are identified and exceeded Customers are not all equally valuable, and a business should devote most effort and resources to its high-value customers. That is certainly not to say that lower value patients are neglected; indeed, this would present ethical concerns (for example if you were to start to neglect fee-exempt patients). Instead, it is concerned with providing a very personal, attentive service which exceeds the expectations of every patient. This may seem complicated, so how might you go about adopting a customer relationship management approach? There are several key activities involved: Profile your patient base: This means tracking their activity through all the channels you have available. How often do they proactively book routine appointments/ recommend another patient to the surgery/fail to attend an appointment, for example? What types of treatment do they have and how often? Are they a nervous patient? Have they shown any interest in cosmetic treatments? These sorts of questions can be used to build a scorecard reflecting the value of any particular patient. Evidently, you will be relying on a level of information to make this assessment and this highlights the supporting role of technology in CRM.A patient database is extremely valuable in providing a basic level of data, from which you can form an insight into a patients historic activity and thereby their potential future behaviours. Patient surveys or questionnaires can be useful in determining patients views of the service you provide to them and where it can be improved.

Customer care

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Identify and flag high-value customers: Having reviewed the activity of your patient base, it should be possible to identify the patients who are of the most value to you, whether they be regular attendees, people who opt for high-margin treatments, or people who introduce a lot of new patients to the practice. These are the patients whom you must absolutely ensure you do not fail. As such, it is important to identify these patients clearly whether on a paper or electronic patient record so the whole team is aware that this is a patient whom the practice cannot afford to lose. Adapt your service: Always show respect for all patients at all times, but devote the most time and effort to your highest-value customers. For example, contact them after major treatment to check they are all right, telephone before a surgical procedure to check they are feeling relaxed, or send Christmas cards. In addition, CRM would suggest that, instead of fining patients who fail to show for appointments, you might encourage less regular attendees by proactively sending email or SMS text message reminders to book an appointment or remind them of an existing appointment. The point is to try and gradually increase the value of all patients, so low-value, poor attendees ultimately become regular attendees who are happy to recommend the practice.

NHS or private practice?

Benefits and drawbacks of each type of practice

The majority of dentists now operate in mixed practice, offering both NHS and private treatment. A new practice may wish initially to offer NHS care to build up a patient base and then increase the number of private patients after a few years. When deciding what type of practice you want to establish, it is useful to draw up a list of the benefits and drawbacks of each. You may feel the NHS does not allow you to provide the quality of care you aspire to, you cannot get the required budget from the PCO or the /UDA value is too low and you will not earn enough to repay debts incurred by starting the practice. On the other hand, you may wish to accept all patients, concentrate on treating children or set up in an area where patients are on low incomes and cannot afford private treatment.

NHS treatment

In order to offer NHS treatment within a new practice in England and Wales, the PCO has to award a contract for NHS work. When deciding whether to contract with you, they will take various factors into account, such as the location of the practice, their budget and the dental needs of the population for which they are responsible. More information on tendering for contracts can be found in the BDAs Advice Note and detail on working within the NHS in Advice Sheet E11. In Scotland and Northern Ireland you will be able to set up a new NHS practice fairly easily. The new practice will have to be inspected by the local PCO to check it meets health and safety standards.

A private practice

There is a variety of reasons for wanting to set up a totally private practice, including freedom of choice, the feeling of being unable to provide the best service within NHS constraints and starting out privately is easier than converting later on, and wanting more time for your patients and your family. When building up a purely private practice you should be aware that patients will expect more personal attention, to see more up-to-date techniques and equipment and a better result than they would expect from the NHS. It is also worth remembering that a patient receiving private treatment can still make formal complaints through the courts or the Dental Complaints Service instead of through the PCO. You may wish to refer to our Advice Sheet B11 Handling private patient complaints. One of the most common complaints made by patients is that the cost of private treatment was not made absolutely clear in advance, and it is important to display or

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make readily available your schedule of private fees. To reduce the likelihood of a patient complaining about treatment costs, always give a written estimate at the outset, together with a full explanation of what the treatment will entail. Setting realistic fee levels is also important and BDA Advice Sheet C8 Fee setting in private practice explains this topic. When setting up a brand new private practice, consider: Marketing: patients paying private charges will expect high standards of quality across all elements of the service you provide. Consider how patients are greeted, flexibility of surgery hours, ease of booking appointments, professionalism of staff, as well as high standards of hygiene, decor, furniture and clinical care Fee setting: set your fees at a level which will cover your expenses and investment and give you a reasonable income Explanation: make sure treatment costs are explained fully to patients Training: staff teamwork is all the more important in a private practice Private care plans: there is a number of plans available to enable patients to spread the cost of their dental care.
Setting up a private practice

One of the first issues to tackle when considering setting up in practice is securing the necessary finance. This will involve a number of stages: Finding the right practice location Drawing up a business plan Producing a realistic cashflow forecast Choosing the most appropriate and affordable means of borrowing Approaching suitable lenders with plans and forecasts Making the repayments. Preparing a business plan and cashflow forecast is essential to securing finance and is also important to the future health of the business. No new business can survive without financial plans and control systems. This section deals with the basic aspects of resourcing your new business. Further information is also available in BDAs Advice Sheet C6 Financial management for general dental practice. You will probably need to borrow money in order to set up a new practice. As with borrowing money to buy a home, it is best to shop around to get the best possible deal. Your own bank is a sensible starting point, but consult other lending institutions too. Find out if a bank has any branches which have a large number of dentists as clients, as they are likely to have a greater understanding of your needs and a better idea of how sound your plans are. Ensure that you prepare well before approaching a potential lender. A lender will want as much information as possible to satisfy itself that you are a reasonable risk. This is where a business plan will be useful to you it will demonstrate that you have carefully thought through your proposals. Anticipate the criteria the lender will use to assess your application, such as: A lender will certainly try to evaluate you individually, including your current financial health and the track record of your personal finances Whether you have taken the trouble to prepare a good business plan

Finance

Securing finance

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The amount being asking for, and if it is realistic: dont assume that asking for as little as possible improves your chances! Banks would rather see a realistic amount of money being asked for, rather than someone going back to them cap-in-hand for more a few months after a loan has already been granted Contingency planning to take account of potential setbacks in the early days Personal finances are also an issue. If you have not made suitable provision in the proposals for your own day-to-day expenses you will reveal a poorly-prepared case.
Cashflow forecasting

As mentioned above, your first cashflow forecast will only be a rough estimate. Once set up, your cashflow forecast will be a vital management tool and indicator of what is happening in your practice. It should estimate how much cash you will have available at particular points in time (usually on a monthly basis), telling you whether you are likely to have a surplus or a deficit, and allowing you to plan what to do in each case. A deficit may mean certain bills may not get paid. Preparing for this possibility and knowing when it is likely to occur is very important, otherwise your business reputation will suffer. More businesses go into receivership because they fail to control cashflow rather than not producing a profit. There are three aspects to effective cashflow management: Measurement Control Projection and monitoring. Cashflow measurement is the recording of the flow of funds in and out of the business over a given period. For most businesses, weekly measurement is preferable since corrections can be quickly made. If there is insufficient money in the bank account to meet withdrawals for a given period, then the funds will have to be found from a bank loan, overdraft or an injection of more capital. It may be worth establishing a separate contingency fund for this kind of eventuality. Cashflow control/projection and monitoring involve the effective control of both income and expenditure. Income can be maximised by: Asking patients for all or some of their payment on the first visit Having an effective system for dealing with debtors and recovery of bad debts. Expenditure control gives you the opportunity to be creative. If data on the cashflow measurement is accurate, then expenditure can be planned to cope with periods when there is little or no projected surplus. The actual month-by-month cashflow can be measured against a projection for the year, so action can be taken when necessary. Again, your first cashflow forecast might not be very sophisticated, but it is worth acknowledging the importance of the forecast as a management tool in your business plan, for example by describing what system you will have for dealing with debtors. As a result of the Late payment of commercial debts regulations 2002, all businesses, irrespective of size, can charge all other business and public sector bodies interest on late payment. Make sure you take full advantage of these regulations by establishing and following a clear credit control procedure. Further information on cashflow and financial management generally is available in BDA Advice Sheet C6 Financial management in general dental practice.

Taxation

The profits generated by your new practice will be subject to taxation, as will the individuals you employ - use the professional services of an accountant to help you in this and other aspects of the practices finance. There is no need for you to become an expert on tax, but it will be helpful for you to understand the basic principles and know the right questions to ask. Look at the BDAs advice notes on the different taxes.

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Information is also available from the HMRCs Business Support service, available free of charge to small businesses. Regional support offices can book you onto a workshop, arrange a personal visit to your home (or business premises) and put you in touch with a business adviser. All these services are free of charge and telephone numbers for the Business Support Team regional support offices are: Central England London West Midlands & Northern England Northern Ireland Scotland Southern England Wales 01332 724410 020 7667 4827/28/29/30 0151 242 8380 02890 532755 01355 275551 01233 653673 02920 326854
Insurances

There are different types of insurance available, offering varying levels of protection. The level of insurance you take is really a matter of personal choice, largely dictated by the level of risk you are comfortable with. Professional indemnity You must have adequate professional indemnity insurance to provide cover against professional negligence or claims for damages. Furthermore, you must also have adequate funds to ensure that you can cover the costs of compensation arising from claims of professional negligence. Sickness and accident insurance If you are not insured against sickness, you will only receive basic social security benefits in the event of a prolonged absence from work. You should protect yourself against this possibility through sickness insurance. How much you pay in monthly premiums depends on the level of cover you want (with reference to your normal income) and whether or not there is a period of delay before benefit is payable. Policies can also be taken out to meet your overheads during periods of sickness. Personal accident insurance/income replacement These policies will provide a lump sum and permanent income in the event of an accident which prevents you resuming your career as a dentist. Beware here of proportionate benefit provisions in such policies which would restrict the benefit payable if you are also receiving benefits under other policies. The main purpose of this kind of provision, which is now quite common, is to prevent people over-insuring themselves so they are, in effect, better off not working than in work. Seek advice on the maximum number of insurance policies you can take out to avoid wasting money on too many. Life assurance If you are married, have a partner, a family or a mortgage, you should consider a life assurance policy that meets your commitments in the event of your death. Surgery insurance Floods, fires and break-ins can occur at any time, even the day the practice opens so adequate surgery insurance and loss of earnings cover is essential.

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Employers Liability (Compulsory Insurance) Act 1969 Employers must take out adequate insurance to cover for liabilities for injury or disease caused to their employees as a result of their employment. A liability insurance certificate must be displayed at the practice premises. BDA Plus The BDA has special insurance deals for members on car, home contents, surgery and private health insurance. For further information, contact BDA Plus on 0845 130 1366.

Help for small businesses

England

Help, support and advice is available to small business people, including dentists, from a number of organisations both locally and centrally in the UK. The Business Link network (www.businesslink.gov.uk) provides impartial business advice and information in England to existing small firms and those just starting up, via a network of 45 local Business Link operators. Assistance for small firms is also available from a network of over 160 independent, privately run Local Enterprise Agencies (www.nfea.com). All offer business advice and counselling and, in many cases, additional services such as access to loan funds and information services.

Wales

Business Eye (www.businesseye.org.uk) offices are a source of local help and advice for new businesses in Wales. Business Eye has 28 regional offices which offer free advice and can direct to other sources of financial and business help and support. Scotlands former Business Shops were re-launched as The Scottish Enterprise, comprising regional Enterprise Offices and Small Business Gateway Units (SBGUs). They are a useful source of advice and information as well as offering practical help with business start-up and expansion. Telephone 0845 6096611 or visit www.scottish-enterprise.com. The Highlands and Islands Enterprise (www.hie.co.uk) provides business support services, training and learning programmes through ten Local Enterprise Companies (LECs) to the highlands and islands of northern Scotland.

Scotland

Northern Ireland

Invest Northern Ireland (www.investni.com) provides business start up assistance, grants and funding opportunities, as well as a package of financial incentives, recruitment and training support. The Business Information Services arm offers access to business and commercial information. Many local authorities offer services to small firms in their area such as business advice and information, help with marketing, premises, training and raising money. Search for your local councils website via a search engine to find their website to contact your city, district or county council to find out about the assistance they can provide. These can offer a wide range of advice and services to local member businesses. Look in your local phone book for details or visit www.britishchambers.org.uk. The BDA can help members who are setting up dental practices through a variety of formats: Seminars, such as the Setting up in practice seminars are run on a regular basis BDA MasterClass A range of advice sheets and notes Advisers available for discussions on legal, business and health and safety matters Products such as the BDA Practice Compendium which contains a wide range of model policies and forms needed in running a dental practice.

Local authorities

Chambers of Commerce

BDA

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Employing other people carries tremendous responsibility. Staff have to be motivated to work well, counselled if they have problems and disciplined if they fail to perform properly, as well as being paid! Some dentists perform these functions naturally and have happy, motivated teams whilst others have more difficulty, perhaps not feeling it is a priority, resulting in low staff morale and high staff turnover. Management training can help here it wont solve all the problems but it can equip you with skills to provide the right environment for staff to function effectively. Think about participating in BDA MasterClass go to www.bda.org for details. Take time to recruit the team. The calibre of person that you recruit to assist you will have a significant effect on the success of your business. Do not be too hasty and take on the first presentable person who comes along. If you are looking at a receptionist for example, their behaviour, efficiency and attitude to the practice and its patients will shape its reputation, regardless of your clinical skills. BDA Advice Sheet D12 Staff recruitment provides detailed guidance, but in general you should: Plan your staffing requirements carefully Analyse the job Produce a job description, person specification and brief practice profile Find suitable candidates by the most effective methods Send information to the candidates prior to the interview Not interview more than six people Plan the format of the interview and ask all candidates the same questions Ask open questions Do not talk too much Make the atmosphere as non-threatening as possible Assess candidates in a logical way Be careful with references Make the new employees introduction to the practice as smooth as possible and have a formal induction programme Provide a written statement of main terms and conditions of employment Give a probationary period Dont be afraid to dismiss at the end of the probationary period, if the employee is not satisfactory Be aware of your responsibilities regarding PAYE, statutory sick pay and statutory maternity pay Keep proper records of the process for at least six months Do not discriminate at any stage of the process. Although staff costs can amount up to 33 per cent of practice expenses, making sure there is adequate (but not excessive) cover is important. One person to act as nurse and receptionist is not sufficient. Dentists should be chaperoned at all times by dental nurses, which is impossible if one has to cover reception. Dental nurses must either be registered with the General Dental Council or in a GDC-approved course of training. It is therefore essential to ensure that dental nurses that you recruit meet these conditions. You might start with one dental nurse and one receptionist who can swap roles when necessary. Employing a number of part-timers can also work well, as long as there is continuity. You may start your practice on a part-time basis and want to give employees flexible contracts whereby they are contracted to work only when required and paid on an hourly basis. You may initially be quiet as you build up your patient base, and prefer not to have to pay staff when there is no work. But there should always be someone on the premises during opening hours to answer the telephone and deal with personal enquiries.

Recruiting and managing staff

Recruitment

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Conditions of service

You must give your employees written statements of their main terms and conditions: It is a legal requirement to provide this within two months of their starting work, though it is good idea to supply it as soon as possible It provides a permanent record of when the employee started work for you and the terms and conditions of that work A good contract should outline how to deal with most of the circumstances that you will meet as an employer and ensure you know where you stand It will allow you to build in reasonable flexibility if you wish to change an employees duties, hours of work or work location Disputes will be minimised, as employees will know what is expected of them from the beginning. BDA Advice Sheet D1 Contracts of employment explains the requirements in detail and there is a model contract in the BDA Practice Compendium.

Pay and benefits

Deciding on rates of pay can be difficult when you start out. Incremental scales reward loyalty but you will need to set the increments carefully to ensure that salary increases do not greatly exceed the level of inflation. Incremental scales also take no account of individual performance. Other pay systems you might consider are: Performance-related pay (PRP) Bonuses for good performance and/or attendance Christmas bonuses Linking pay to the practice, rather than to individual performance. Find out from local colleagues how much they are paying their staff. Talk to local Chambers of Commerce who will have an idea about the local job market, although bear in mind the dental job market has special characteristics. BDA Advice Sheet D2 Rewarding staff provides further information on payment systems.

Sick pay and holiday pay

Every employee who pays NI contributions (in 2008/9, those earning 90 or more per week) is entitled to receive statutory sick pay from the fourth day of illness. Small employers can reclaim a percentage of the SSP paid. Control employee absence by implementing a policy whereby employees must explain absences and any suspected abuse is dealt with at an early stage. Some practices will also give their employees a certain amount of occupational sick pay whereby the employee receives full or half pay during periods of illness up to a yearly maximum. The BDAs recommendations for paid sick leave and holiday entitlements are given below: Sick pay Length of service Less than 6 months 6 months less than 2 years 2 years less than 4 years 4 or more years Holiday pay Employees are legally entitled to 4.8 weeks annual paid holiday (including bank holiday). This will to rise to 5.6 weeks annual paid holiday in April 2009. 4.8 weeks holiday is equivalent to 24 days holiday for staff working 5 days a week. 5.6 weeks holiday is equivalent to 28 days holiday (or four weeks + bank holiday) for staff working five days a week. It may be easier to give holiday entitlement in terms of weeks rather than days because you can then use the same entitlements for part-time and full-time staff. If, say, Full pay SSP only 2 weeks 3 weeks 3 weeks Half pay SSP only 2 weeks 3 weeks 5 weeks

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you give 5.6 weeks holiday to all staff, then someone working five days a week will receive 5 x 5.6 = 28 days holiday (four weeks plus bank holiday). Someone working two days a week will receive 2 x 5.6 = 11.2 (or round up to 11.5) days holiday (including bank holiday). Part-time staff working on a Monday may complain that they have to use a disproportionate amount of their holiday entitlement on bank holiday. However, they still receive the same proportion of paid holiday as everyone else and you could agree that they can take additional unpaid holiday. When staff take leave, staffing requirements and cover must be considered, although it is possible for the practice to close and for everyone to take leave at the same time. As the employer, you can request this, as long as you give sufficient notice, though take into account employees wishes as far as possible. You must check whether closing is within the terms of your NHS contract with your PCO. Many practices buy Christmas and birthday presents for staff or give Christmas bonuses. Some practices offer private health insurance and provide dental treatment at no cost to the employee, whilst others organise outings away from the practice, giving staff a chance to bond away from work. Stakeholder schemes were introduced by the Government in an attempt to increase pension coverage for the UK working population, intended to be low cost personal pension schemes. In many cases an employer must offer access to a stakeholder pension scheme, known as the Employer Access Requirement, although employers do not have to contribute on behalf of their employees. The employer has to select a stakeholder pension scheme employees can join, should they wish, but employee membership of the scheme is not compulsory. There are exemptions to employers joining the scheme, which include: The employer already offers an occupational pension scheme that all staff are eligible to join, within one year of commencing work for the employer The employer employs less than five people. In determining this, all employees must be counted, which may include company directors but not self-employed persons. If the employer has five or more employees, but fewer than five meet the conditions to have access, then these employees must be given access to the scheme If the employer already offers to make contributions to a personal pension scheme in respect of that employee providing the scheme: Receives a contribution from the employer of at least three per cent of the employees basic pay Does not penalise members for ceasing contributions or transferring their entitlements Is offered to every employee who would in law have access to a stakeholder scheme, ignoring anyone under age 18. Many dental practices employ part-time staff who work less than the practices standard working week. Part-timers: Enjoy exactly the same statutory employment rights as full-timers, which include compensation for unfair dismissal, maternity leave and redundancy payments Are entitled to statutory sick pay and statutory maternity pay if they pay Class 1 NIC (National Insurance Contributions) Must not suffer discrimination compared with full-time colleagues, which means they must receive the same pro-rata holiday and sick pay entitlements. For example, if a member of staff working 40 hours per week receives 24 days holiday per year, then a colleague working 20 hours per week should receive 12 days holiday Should not be selected for redundancy because they are part-time
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Other benefits

Stakeholder pension

Part-timers

Should receive the same benefits as other employees, such as promotion opportunities, training opportunities, perks, pension provisions and overtime payments Can be given standard BDA employment contracts. Simply state the hours and days worked and that in the contract one week means X hours.
Personnel records

You should keep the following personnel records for each employee: A copy of the employment contract/written statement of main terms and conditions of employment Job description Person specification and a copy of the offer letter References received and/or notes of references given by telephone Induction and training records A holiday and sickness chart giving details of the days on which the employee was sick or on leave Any sickness certificates received Appraisal forms Contact name, address and telephone number in case of emergencies Home address and telephone number Notes of any counselling sessions Disciplinary record (if appropriate) Copies of warning letters Notes of interviews. Keep all of these records in a secure place and retain them for at least three years after an employee leaves. The BDA Practice Compendium contains standard forms and staff policies, including: Maternity Sickness Absence Equal opportunities Prevention of violence and aggression towards staff Confidentiality Redundancy Dismissal.

Management style

As an assistant or associate you will have developed your own way of managing your dental nurse. As you will know from your own experience, effective managers have hard-working, committed and motivated employees with low absenteeism and staff turnover and high quality of service. It therefore makes sense to put some thought into your own leadership style and perhaps undertake some management development coaching as part of your preparation for setting up your practice, such as BDA MasterClass. In a new practice, experienced, competent staff are essential. You will be seeing patients on approval and they may be highly critical at their first few visits. For example, a new patient might say to a friend I went to that new dentist in the health centre - you know the one who is offering free toothbrushes. The service was terrible - the receptionist was really unhelpful. First I was kept waiting for five minutes while she finished a phone call, and then she kept sighing because I couldnt make any of the appointments she suggested. In the end I just turned around and walked straight back out the door. I wont be going back there again. You are responsible for your staff. Their attitudes, actions and behaviour reflect how you treat them, how they have been trained and how they are managed.

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Employment law provides employees with the following rights: To a written statement of main terms and conditions within two months of starting work If pregnant, to paid time off for antenatal care or parentcraft classes To receive an itemised pay slip Not to be unfairly dismissed after one years service To receive a written statement of reasons for dismissal after one years service (except in the case of pregnancy when a statement must be supplied within two weeks of dismissal) Depending on the circumstances, to recover certain losses in the case of an employers insolvency Not to have deductions made from pay unless authorised or it is provided for in the contract (for example, deductions from final pay if inadequate notice of leaving given) To continuity of employment on transfer of the business Not to be dismissed because of pregnancy or any reason connected with it Depending on level of earnings, to receive statutory maternity pay, statutory paternity pay or statutory adoption pay 52 weeks maternity leave or two weeks paternity leave To return to work after absence due to maternity For consideration to be given to part-time working because of childcare/family responsibilities To redundancy payments after two years service To have time off with pay to seek alternative work or to arrange training in a redundancy situation, after two years service To receive equal pay for work of equal value Not to be discriminated against on the grounds of race, sex or disability where this affects employment Not to be dismissed for attempting to assert a legitimate statutory employment right Not to be dismissed if they bring a legitimate health and safety concern to the attention of the employer/other authorities To a minimum period of notice, depending on length of service: Length of service 1 month 2 years 2 years 3 years 4 years 12 years Notice 1 week 2 weeks 3 weeks 4 weeks and so on, up to a maximum of: 12 weeks.

Employment law

As an employer you are responsible for the acts and omissions of your staff. What does this mean in practice? What responsibility does it place on you to provide proper training? The following are examples of when the actions of staff could cause problems: A receptionist who: Discusses with a friend that a mutual acquaintance who came in for an appointment is pregnant Tells a school (without the parents permission) that a pupil is not booked in for an appointment on that day Tries to persuade a patient to accept a private bridge by stating that it is not available on the NHS Makes private appointments for a new patient without informing the patient of the cost of a private consultation at the time the appointment is booked
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Staff training

Sends an overdue account to a debt collector without pursuing the debt in writing with the patient first Forges a patients signature on the NHS form because they have forgotten to ask the patient to sign it. A dental nurse who: Forgets to sterilise an instrument. Rather than admit the mistake they wipe it over with alcohol without realising the potential consequences Does not report a mercury spillage which results in a short-term release of vapour into the surgery Advises a mother to give her child inappropriate fluoride supplements which results in discolouration Disposes of clinical waste with office rubbish.
Training

Some of these actions are the result of staff being unaware of the importance of proper patient care, of the many regulations that dentists must observe and not appreciating the consequences of their actions. Others are the result of the staff member fearing (perhaps with justification) that they will be dismissed or disciplined for making a mistake. All could be prevented by enabling your team: giving them adequate training and information, as well as providing a culture in which staff can admit mistakes without fear of being unfairly treated. If staff are aware of their and the dentists professional responsibilities, they will be more supportive and less likely inadvertently to cause more serious problems.

Access to information

Help prevent staff making avoidable mistakes by sharing information with them. For instance, give staff BDA advice sheets to read and refer to and have a copy of the GDCs guidance in the practice. Encourage staff to read BDA News, BDJ and other dental journals and use practice meetings to discuss a relevant article or update. Membership of a professional organisation (the British Association of Dental Nurses, the British Society for Dental Hygiene and Therapy, the British Association of Dental Therapists, the British Dental Receptionists Association or the British Dental Practice Managers Association) will help to keep staff up-to-date through journals, written advice, national and local clinical meetings. These organisations can also provide information about recognised vocational training courses. Some dentists prefer not to devote resources to training staff, feeling the investment in explaining or providing information is not worthwhile. But aware staff are interested and committed staff can contribute so much more to making the management of a practice smoother.

Creating a supportive enviornment

It is important staff understand the need to report mistakes to the dentist or practice manager. Breaches of confidentiality or serious breaches of health and safety rules may result in dismissal, but any mistake will only be compounded if it is hidden, so staff should be encouraged to admit mistakes: from simple things like the till not balancing at the end of the day or a receipt not being issued, to the mercury spillage discussed above. If you need help or advice about any aspect of your new role as an employer or manager contact BDA Practice Support on 020 7563 4574 for advice. They can advise on contracts of employment, policies and procedures. A list of relevant advice sheets is on page 39.

Further information

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Health and safety covers every aspect of dentistry, from making sure you provide adequate facilities and arrangements for the welfare of your staff to performing an assessment of all the hazardous substances in the practice. The 1974 Health and Safety at Work Act (HASAWA) makes it the responsibility of the employer to ensure the health and safety of all employees, patients, and members of the public are addressed. The Health and Safety Executive (HSE) may inspect your premises at any time and has the power to dismantle your facilities and even shut down the practice. You should therefore make sure that you understand all the legal obligations expected of you as an employer. For a comprehensive guide to health and safety law, see BDA Advice Sheet A3 Health and safety law for dental practice. Under the HASAW Act, employers have a general responsibility to provide adequate facilities and arrangements for welfare at work. The Workplace (Health, Safety and Welfare) Regulations 1992 set the general requirements of employers into four broad areas: the working environment, safety, facilities and housekeeping. These regulations affect all workplaces and are relevant to dental practices in the following ways: Lighting: There should be sufficient lighting to enable people to work safely and without experiencing eye-strain. Temperature: The workplace should be reasonably comfortable without the need for special clothing. The temperature should normally be at least 16C. Ventilation: Windows will generally provide sufficient ventilation. Where necessary, mechanical ventilation systems should be provided for parts or all of the workplace, as appropriate. Recycling air conditioning systems are not recommended. Room dimensions: Workrooms should have enough free space to allow people to move around with ease. As a guide, the total volume of the room, when empty, divided by the number of people working in it should be at least 11m. This may still be insufficient if much of the room is taken up by furniture. Workstations: Should be arranged so each task can be carried out safely and comfortably. Seating should provide support to the lower back and be appropriate for the task. Floor surfaces: Should be free from holes or unevenness that could cause a person to trip, slip or fall, or to drop anything being carried. Windows and skylights: It should be possible to open, close and clean these in a safe manner from the inside. Glazed doors and partitions should be made of a safety material or be protected against breakage, for example by obvious marking. Doors and gates should have a transparent panel unless they are low enough to see over. Toilets and washing facilities: Should be sufficient to allow everyone in the practice to use them without delay. There is a minimum number of toilets and washing facilities which should be provided - one for up to five members of staff, two for six or more. Changing and storing clothing: A changing room should be provided for staff to change into uniforms. Work clothing and personal clothing should be stored in a well-ventilated place where it can dry out if necessary. Effective measures should be taken to provide security of clothing. Rest areas: Where staff can relax and eat their meals at work should be provided. Maintenance of workplace and equipment:The workplace and equipment should be maintained in efficient working order and good repair. Equipment should be regularly serviced and maintained, and records should be kept to demonstrate this has been done.

Health and safety

Premises

Working environment

Safety

Facilites

Housekeeping

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Cleanliness: The standards of cleanliness required depend on the use of the workplace: a surgery would be expected to have a high level of cleanliness. This includes floors, walls and ceilings. Cleaning should be carried out by an effective and suitable method and should not present a health or safety risk.
General surgery safety

Dentists as employers are required to maintain the practice premises in a safe condition and without risk to health. This includes providing suitable floor coverings and adequate and suitable lighting, temperature and ventilation. An approved poster entitled Health and safety law what you should know (ISBN 0-11-7014 24-9) is available and must be displayed in every workplace. Staff must: Make and keep a record of all reported injuries sustained at work. An accident book that complies with data protection requirements can be obtained from the HSE (www.hse.gov.uk) Be familiar with the whereabouts of a first aid box which should always be adequately stocked Be familiar with the fire regulations including knowing where the nearest fire alarm is and knowing how to use a fire extinguisher effectively. Written fire procedure notices must be displayed and brought to the attention of all employees. Your local fire protection officer will be able to advise on this Notify the HSE (Incident Contact Centre) of accidents causing death, major injury or dangerous occurrences. Tel: 0845 300 9923. Practices with five or more employees must draw up a written safety policy. A suggested format can be found in the BDA Practice Compendium. The employing dentist will also need to have a risk assessment carried out and documented to include the significant hazards in their practice. Comprehensive information on this can be found in BDA Advice Sheet A5 Risk assessment in dentistry.

In the surgery

Electrical equipment should be in safe working order at all times. All appliances must be correctly wired and fused and must be checked and tested by an appropriately qualified person, usually an electrician. Records should be kept to demonstrate that this has been done Staff using laser equipment must be appropriately trained. A Laser Protection Adviser (LPA) should be appointed. If you use a class 4 laser or intense pulse light sources in your practice in England, you must also register with the Healthcare Commission You should notify the local HSE of the use of radiation in the practice and all practitioners should be thoroughly familiar with the regulations for the safe use of radiographic equipment. A Radiation Protection Adviser (RPA) also needs to be appointed. BDA Advice Sheet A11 Radiation in dentistry provides advice on complying with the Ionising Radiations Regulations 1999 and the Ionising Radiation (Medical Exposure) Regulations 2000.

Safety of pressure system (autoclaves, compressors)

All clinical staff should be trained in the use of autoclaves and compressors. The inspection of pressure vessels should be carried out at intervals recommended in the written scheme of examination for each vessel, with records of all inspections being kept. The practice must comply with the Water Supply (Water Fittings) 1999 regulations. Dental equipment such as the handpiece cooling system, ultrasonic scalers, three-inone syringes, wet line suction units and automatic radiographic processors should be isolated from the main water supply by the relevant air gap. This eliminates the possibility of back siphonage of contaminated water from the surgery to the mains supply. Further information on this is available from BDA Advice Sheet A3 Health and safety law for dental practice.

Water supplies

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Dentists have a duty to take appropriate precautions to protect patients and staff from the risk of infection. Failure to provide and use adequate sterilisation facilities may lead to proceedings for serious professional misconduct before the GDC. BDA Advice Sheet A12 Infection control in dentistry contains guidance and detailed information for dentists about implementing an infection control policy to minimise the risk of transmission between patients and between patients and clinical dental staff. This includes advice on: Acceptance of patients Instrument sterilisation Ethical and legal considerations Disposal of waste Immunisation Personal protection Ventilation. The Control of Substances Hazardous to Health Regulations 2002 (COSHH) require employers to assess all work which is liable to expose any employee to hazardous substances. The BDA Advice Sheet A5 Risk assessment in dentistry contains information on how these assessments are carried out and provides help on how to do this. If working within the NHS, PCOs make routine practice visits to the practice premises of dentists on their lists. Each PCO will have its own programme for such visits, normally based on a three-year cycle and a practice visit will generally occur when either a new practice is opened or when a practice relocates to new premises. A PCO may wish to visit new practice premises before the dentist is admitted to their list. If, following the visit, it is considered the premises do not meet requirements, it may defer the dentists admittance until the premises are brought up to a satisfactory standard. The inspection may assess: Premises: situation, access, reception/waiting room, surgeries, toilets, heating, maintenance, decoration and cleanliness Equipment: unit/aspirator, light, chair, cabinets, compressor, GA/sedation apparatus, aspirator, sterilizer and radiographic equipment Instruments: hand, LA syringe and disposable needles, rotary/handpieces/forceps/ excavators/scalpel/sutures, Endodontics and 3-in-1 syringe Infection control/safety: gloves, sharps and clinical materials, emergency equipment and drugs, maintenance, compliance with regulations, radiographic equipment, steriliser, compressor, surgery hygiene, disinfection procedures, instrument cleaning, disinfection and sterilisation, appropriate patient protection, electrical wiring and plugs, mercury hygiene and GA/conscious sedation Miscellaneous: records storage and radiographic development facilities. If you have prepared properly for your new practice, the inspection will be a formality and the inspector may be able to offer useful advice on your practising arrangements. See BDA Advice Sheet B7 Practice visits (Scotland and Northern Ireland) or Advice Note on DRO visits (England and Wales). Is the health and safety law poster on display? Does the practice have a written health and safety policy? Has a practice risk assessment been carried out and made available to staff? Has a fire risk assessment been carried out? Have you got the necessary fire extinguishers or fire escape?

Infection control

Hazardous substances

Practice visits

Health and safety checklist

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Do staff know regulations covering the use of radiographic equipment? Who is the Radiation Protection Supervisor? Has a Radiation Protection Adviser been appointed? Has your radiographic equipment been assessed for safety by the National Radiological Protection Board or another competent authority during the last three years? Have you informed the HSE that radiological equipment is in use at the premises? What arrangements are there for disposal of clinical and hazardous waste? Does the water supply in and out of the practice comply with current regulations? Has the autoclave and compressor been inspected do you have a written scheme of examination for these and certificate or report to demonstrate this has been done? Have portable electrical appliances been recently checked and tested by an electrician? Do you have a laboratory? Have you identified all the hazards? Do all clinical staff use the necessary protective clothing? Are official guidelines on infection control followed? Who looks after the first aid box? Is there an accident report book that complies with current data protection legislation? Do you have adequate employers liability insurance to cover your premises? Is the insurance certificate displayed? Have you got a record of all clinical staff hepatitis B vaccinations? Do you know which hazardous substances are in the practice, and how to handle them? Do staff know about the hazards involved with mercury, and what to do if some is spilt? Do you have a mercury spillage kit? Do you have adequate public liability/employers liability insurance? Is this displayed? Have workstations been assessed to ensure they meet the requirements of the display screen equipment regulations?

Clinical governance

Clinical governance is quality management and the development of practice management systems. It will help you and your team to understand what is supposed to be done and why, how it is to be done and who is to do it, and to show that it is being done in a consistent and reproducible way. A clinical governance system allows you to manage the quality of your patients experiences and to make sure that you meet and exceed their expectations through consistent compliance with your own standards. It will help you identify where there may be weaknesses and to put them right so service is constantly improving. GDS/PDS regulations require every practice to: Have a quality assurance system in their practice Appoint a person in the practice who is responsible for operating the system Display a written practice quality policy so patients can see it Provide the PCO with an annual report on the quality assurance system. The quality assurance system should ensure: All dental care is of a consistent quality Effective measures of infection control are used All legal requirements relating to radiological protection are satisfied The GDCs CPD requirements are satisfied. Clinical governance is equally important for private practices and the BDAs Clinical Governance Kit will take you through the requirements of clinical governance using a step-by-step approach. The Care Quality Commission will assume responsibility for clinical governance for all practices in the future and implement national quality standards.

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Dentists are affected by various acts of general legislation, and this section provides a brief round-up of the laws you are most likely to encounter as a practice owner, other than the employment and health and safety requirements detailed above. Dentists who process personal data about individuals on computer or manually in hard copy need to comply with data protection legislation under the Data Protection Act 1998. Information must be kept and used in accordance with eight statutory principles, being: Processed fairly and lawfully Obtained for a specified purpose Relevant and not excessive Accurate and up-to-date Only kept as long as necessary Used in accordance with the individuals rights Kept secure Not taken outside the European Union. If data is kept about individuals, you must notify the Information Commissioner. Patients have a right of access to their health records and a right to copies, though you can charge a small fee for copies. The Freedom of Information Act 2000 (FOIA) gives individuals a general right of access to all types of recorded information held by public authorities, sets out exemptions from that right and places a number of obligations on public authorities. NHS dentists are included in the scope of public authorities. Every public authority (and therefore NHS dentists) are now required to adopt and maintain a publication scheme setting out for the public how it intends to publish the different classes of information it holds and whether there is a charge for the information.

Other essential legislation

Health records, data protection and freedom of information

Consumer protection

For more information, see BDA Advice Sheet B2 Data protection and our Advice Note Freedom of Information Act guidance notes and BDA model publication scheme. All treatment provided by dentists comes under general consumer protection legislation. The laws mean that amongst other things: Goods must be of a satisfactory quality and reasonably fit for purpose and in the case of services they must be carried out with reasonable care Liability is imposed for damage caused by a defective product, including laboratory work If a fee is not agreed at the start of treatment, then there is an implied term in the contract that charges will be reasonable. If proper agreements are not reached with patients about private fees before the start of treatment (preferably written down) a patient may be able to say that nothing was agreed and take the matter to court for a determination of a reasonable charge It is a criminal offence to give misleading price indications Where credit is given to patients to allow them to pay by instalments you must obtain a consumer credit licence, unless the credit is tied to a particular purchase and the money is to be repaid in less than four instalments and within a year of the supply. The BDAs Advice Note on Consumer credit licences has more information. The Copyright, Designs and Patents Act 1988 requires a licence to be held wherever music is played in public. This covers both broadcast materials, such as radio and television, and recorded materials, such as CDs and DVDs. In public largely means anywhere outside a purely domestic setting, so waiting rooms and surgeries are counted as public since there will be a significant number of people (patients and staff) going through those places in one day, even if there are only a few people around at any one time. For broadcast materials a performing rights licence is required, whilst for recorded materials both a performing rights licence and a phonographic performances
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Copyright and music in the surgery

licence (for CDs, etc) or video performances licence (for videos, DVDs etc) are required. See the BDA Advice Note on Broadcasting licences for details.

Practice administration

Dental practices are managed in different ways and there are no right or wrong administration systems. Most practice owners want patients to receive good service and for staff to be happy and well-motivated. Those that put this vision into practice are almost always profitable, highly popular and well-managed. Whatever the quality of service provided by your practice, it will be managed using particular administrative systems designed by you. The following section takes you through the basic characteristics of a well-organised practice.

Practice manual

Many practices have practice manuals, setting out rules and procedures for the way the practice operates. The best ones are written by the staff who carry out the duties and are then agreed with the practice owners who adapt them as necessary. So the production of a manual can be an excellent teambuilding exercise during which everyone has a chance to stand back and look at the way they carry out allotted tasks and improve efficiency. A typical manual might include procedures for: Answering the telephone Making appointments Retrieving and filing records Dealing with new patients Handling petty cash Preparing day sheets and other lists Stock control and ordering policy Dealing with laboratories Collecting money and recording payments from patients Handling complaints Infection control routine Confidentiality policy Equipment instruction manuals Dealing with emergencies in the surgery NHS procedures. As well as sections on: Insurance certificates Telephone/address list Standard letters Job descriptions Abbreviations used in the practice Rules for dress and conduct. Managing a practice is no easy task and it takes effort to make sure everything runs smoothly. This section describes some of the main aspects of administration which you should think about in order to ensure effective systems are set up. The descriptions given do not assume that the practice is fully computerised, but if it is, administration will be far simpler.

Records - completion and storage

As your defence organisation has probably impressed on you, completing patients records fully, clearly and accurately is absolutely vital if you are to defend a claim by a patient. Under the terms of the Data Protection Act 1998, patients have the right to inspect their records, so it becomes even more important that there is nothing included in them (even in abbreviated form) which you would not be happy for them
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to read. Records should contain the following information: Medical history (regularly updated) Drugs given with dosages Prescriptions issued Diagnosis and treatment given Radiographs with any relevant notes Models/photographs Correspondence/referral letters Copies of written estimates and treatment plans Receipts and payments made Laboratory orders/worksheets Record of consent obtained and advice and warnings given Factual accounts of any complaints made or any other incidents. Records can become very bulky and for convenience are usually separated into current files and dead files, for patients who havent attended the practice during the last three years. Records (including radiographs and study models) must be retained for a minimum of eleven years from the date of the patients last visit (and up to age 25 for children or eleven years whichever is the longer) but preferably indefinitely, so storage away from the practice in a secure location may be needed. Files should not be accessible to patients or visitors and should be in lockable cabinets, have a lockable shutter or be placed in a locked room. This is because unlocked or accessible files could lead to a breach of your duty of confidentiality. One of the characteristics of a successful, profitable practice is an efficient appointment system. This will ensure you: Rarely keep patients waiting Can handle the unexpected Do not get booked up ahead for key procedures Maintain a steady income flow Remain in control. If you are to avoid burning out, fix the number of hours spent in surgery each day and have adequate breaks. Equally important is to ensure surgery time is used efficiently. Fix appointment times to suit the needs of the patients you hope to attract. Some practices work from 8am to 6pm or from 8am to 8pm on some days, sometimes working a shift system to offer patients the opportunity to attend outside of working time. Generally speaking, most practices will open at various times between 8am and 8pm Mondays to Fridays and Saturday mornings, with Sunday opening not unknown. Whatever happens, you need to be firm about your working time and make sure it does not encroach on your personal time. Dentistry is a stressful occupation and rest and relaxation are important. The basis of a realistic appointment system is a study of the average time it takes to perform each treatment. Over, say, two weeks your nurse might keep a record of the time taken for each appointment, including turnaround time. Calculate the average time it takes you to perform, for example, a scale and polish, a crown preparation and a new patient exam. It then becomes a simple matter for you to allocate appointment times to the receptionist (usually by writing the time needed on the patients record card). You should make sure never to allocate less than the norm and do not allow the receptionist to do so, however desperate the circumstances.
The treatment sensitive system A fixed working day Appointment scheduling

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Your appointment system must include time for: Rest breaks Returning telephone calls Over-runs Emergencies An emergency session of say twenty to thirty minutes mid-morning and mid-afternoon might be allotted with the receptionist booking these periods no more than three days in advance. If the appointments are not filled, the time can either be used as buffers or to return telephone calls (you shouldnt be interrupted whilst a patient is in the chair). Emergency sessions should occur at the same times each day, and these sessions should be clearly marked in the appointment book using a highlighter. As well as emergency sessions, some practices also allocate and highlight (in different colours) private sessions and those for new patients, anxious patients and those having sedation. Outside of these specific sessions, the receptionists should allocate your surgery time according to your requirements. The best approach is to write on the record card the amount of time needed (using your average time calculations). The receptionist will then offer the patient the most appropriate appointment time according to your preferences. For example you might work best in the mornings and so prefer to do your crown preps then and your try-ins and examinations in the afternoon. Alternatively you might also want to centre your system on complex procedures with examinations and short treatment appointments slotted in around them. The appointment book should be the sole responsibility of the receptionist who should be the only person who enters or changes appointments. Obviously the writing should be neat and most receptionists use a pencil and rubber rather than a biro and tippex! Books can have dated or undated pages (undated is more flexible) and can be loose leaf or bound. Books are available from companies such as Admor or the British Dental Health Foundation.
Day book/sheets

The information contained in the appointment book should be transferred into a day list for each surgery. This can be produced by photocopying the appointment book, typing or writing out a list. Daybooks give an accurate record of patients seen and the value of those treatments and it is most helpful if the fees are written in and totalled on a daily basis. This will provide a check that NHS forms have been completed and sent in correctly (if applicable). Some practices take time at the beginning of each day to look at the day sheets for five minutes or so as a team. Any particular problems can be raised while there is still time to take remedial action and it helps build an efficient team if all staff know what is going on.

Recalls

There are several ways of organising recalls, and these could be critical to the practices success: Having no system at all. Some practices feel they have quite enough patients who do not need to be reminded and who do not need to be seen routinely Encourage patients to make check-up appointments at the end of their course of treatment. This works well if they are reminded of them at a later date Patients are sent letters/SMS/emails reminding them an examination is due and are invited to make an appointment. NHS dental patients should be recalled according to Guidelines on dental recall from the National Institute of Health and Clinical Excellence www.nice.org.uk/guidance/CG19. Generally, patients should be given an oral health assessment by the dentist and the assessment should include a recommendation on when the patient should be recalled.

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At the outset, and certainly before expensive or extensive treatment commences, patients need to know how much it will cost. A customer cannot be expected to agree to buy a service if they have no idea how much it will cost. This particularly applies to extensive treatment which can represent a considerable expense. In these cases, full written estimate should be given. Most practices have a strict policy for the collection of fees. There are various different approaches to collecting money, which are detailed in the BDA Advice Sheet C2 Fee collection.

Estimates

Collecting money

Quality should run throughout all aspects of your practice and a code of best practice is a useful tool to enable you to know more fully what is happening and help develop common approaches to dealing with situations which might arise. It will ensure: You justify your patients confidence and trust in you Patients know what they can expect from you Patients are encouraged to feedback and participate in developing the service offered at the practice Staff know what is expected of them You can develop and extend your services to meet the needs of your patients. It is important to ensure that everyone working at the practice is committed to providing a high standard of service. Include in your code of practice only promises which you are certain you can achieve, albeit with some effort on the part of your team. Ask staff to write down what they feel the practice can provide and develop these suggestions into some simple written standards. Make sure everyone agrees to the standards and works with them over the next few months (as a pilot). You may find, from the suggestions given by those working with you, that you can develop a code of practice with general aspects (to which everyone aims to work towards) and more specific aspects which can be measured and quantified. The practice policy for collecting fees and for dealing with complaints should be made available to patients or advertised in the reception room. Also displayed should be a commitment to improve continuously the practices standard of service together with encouragement to give feedback. The BDAs Good Practice Scheme provides a solid starting point for any practice looking to adopt best practice techniques. The Scheme is built around ten commitments of how the practice is managed and how patients are looked after and offers a ready-made, structured code of practice to work to in managing quality into your practice. The ten commitments are: 1. To provide dental care of consistently good quality, for all patients 2. Only to provide care that meets your needs and wishes 3. To make your treatment as comfortable and convenient as possible 4. To look after the health and safety of patients while receiving dental care 5. To follow the British Dental Associations guidelines on infection control 6. To check for mouth cancer and tell patients what we find 7. To take part in continuing professional development to keep your skills and knowledge up-to-date

Quality and best practice

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8. To train all staff in practice work systems and review training plans annually 9. To welcome feedback and deal promptly with any complaints 10.To ensure that every member of the practice is aware of the need to work safely under General Dental Council guidelines. If you would like further information about the Good Practice Scheme or have already decided that your practice would like to take part and wish to purchase an audit pack, call 020 7563 4598 or email: goodpracticescheme@bda.org.

Opening up

Once you have obtained premises, designed and equipped your practice, recruited your staff and produced your marketing plans, you are ready to open up. Some new practices have a special ceremony to which a local celebrity or MP is invited, along with the press, resulting in positive newspaper publicity. Decide beforehand whether to put a notice and a telephone number outside the premises informing passers-by that a new practice will be opening on a certain date and the practice will be pleased to make forward appointments. But be certain that you will open on that date! Even if you dont have a public party, have a private one. Go away for a long weekend, treat your family to a fun day out, do what you enjoy most to take your mind off your business worries. Then on your first day, arrive at the practice an hour before the first patient is booked in, make sure everything is set up, all the staff have arrived, there is petty cash in the till, milk for coffee/tea and pens that work! Make sure everyone knows what they are doing and then wait for your first patient.

Good luck! Avoiding the pitfalls

By using the ideas in this guide you can avoid most of the pitfalls which can beset a new practice owner. The most important points to remember are: Dont overstretch yourself Take proper financial advice and engage a well-respected accountant Understand the importance of cashflow Ensure that you know the difference between your money and the businesses money Engage capable staff and treat them well Pay attention to detail Take out sufficient insurance cover for your premises and your own ill health Take every opportunity to advertise ethically Try to think creatively and dont develop fixed ideas on how to solve problems Be prepared to work harder than ever before Dont take setbacks personally find out why they happened and learn from mistakes Keep on good terms with local colleagues you never know when you will need help Take advice as much as you can, as often as you can. Telephone BDA Practice Support whenever you are in doubt! Always follow GDC guidelines on professional conduct.

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www.bda.org BDA Advice Sheets A1 A3 A4 A5 A6 A11 A12 B2 B10 B11 C2 C3 C4 C6 C8 C9 D1 D2 D10 Planning permission Health and safety law for dental practice Simple steps to private practice Risk assessment Marketing in dentistry Radiation in dentistry Infection control in dentistry Data protection Handling complaints Handling complaints in private practice Fee collection Business plans Private dental plans Financial management in general dental practice Fee setting in private practice In-practice capitation schemes Contracts of employment Rewarding staff Redundancy

Further information

BDA Practice Compendium: A manual in both print and CD-ROM format of law, regulations, good practice and other aspects of running a business. CD ROM contains over 100 models in MS Word to tailor to your practices needs - 157 Pictures for patients: A collection of images to help dentists describe to patients different treatments, which comes either in a binder (45) or CD ROM (25) formats To discuss your requirements and order the above, please call the BDA Shop on 020 7563 4555 or email bdashop@bda.org. All prices quoted are BDA member rates.

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British Dental Association 64 Wimpole Street London W1G 8YS Tel: 020 7563 4563 Fax: 020 7487 5232 E-mail: enquiries@bda.org www.bda.org BDA June 2008