a18 Setting Up in Practice- Jun 2008

Advicesheet

A18Setting up in practice

© BDA June 2008 2

Advicesheet

Setting up in practice A18

Part 1: Getting started

Making the decision 3Choosing a location 5Finding the right premises 6Planning permission 8Practice design 9Surgery planning and design 10Dental equipment 11

Part 2: Business planning

Developing a business plan 12Setting business objectives 13Marketing 14Customer care 17NHS or private practice? 18Finance 19Help for small businesses 22

Part 3: Managing the practice

Recruiting and managing staff 23Health and safety 29Clinical governance 32Other essential legislation 33Practice administration 34Quality and best practice 37

Opening up 38

Avoiding the pitfalls 38

Further information 39

contents pageMaking a success of a newbusiness takes more thanentrepreneurial flair and

desire to manage your owndestiny; it also takes

thought, planning,management skills,determination and

appropriate professionaladvice.

This introductory guideprovides ideas to help create

an entirely new practice,and is structured according

to the stages to go through.The information in each ofthe sections has been kept

brief, but references aregiven to more detailed

advice publications.Individual help is also

available and we are happyto talk through your ideas

on the telephone or inperson by contacting the

BDA’s Business Advisers on020 7535 5864.

© BDA June 2008 3

Making thedecision

First of all, it is important to think very carefully about whether creating a new businessis the right move for you.

Starting a squat essentially means securing premises that were not previously used fordentistry, equipping and staffing them, putting up a sign or a plate, informing the localpopulation you are there and then caring for anyone who decides they want to try youout. This option is complicated by the NHS contracting requirements in England andWales, where you have to have a contract before seeing NHS patients.

There are other options that may be more straightforward, such as buying an existingpractice or buying into a partnership. These involve less commercial risk, as you buythe goodwill associated with a list of patients and will probably be guaranteed aminimum 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 forstaff and premises and practice expenses may be high and not easily reduced. If you areentering into an existing arrangement between dentists, you will have limited controlover business decisions as partners and/or associates will need to be consulted, and thefeelings and rights of staff taken into consideration. But for many associates, avoidingthe stress of starting a business from scratch, along with the support of other dentistsand 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 aspatient demand, whether you want to provide NHS care and availability ofpremises)

� 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 developingnew 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 tobuy. Decide for yourself what advantages there are personally in setting up, and identifyrisks. Try and quantify the time involved and write a list of pros and cons. Estimate thecosts of each option, and develop and compare two contrasting cashflow forecasts: onefor 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 existingpractice in the area. Most of all, talk to your immediate family and make sure you havetheir support. It might be their future financial security you are putting at risk andinevitably you will be calling on them to offer emotional and quite possibly practicalhelp in the first few years.

It is important to realise that single-handed ownership can be a lonely position whereyou may be the only dentist on the premises in a new environment and where youcannot ask for clinical or management opinions from colleagues. New situations willface you, and you will have to cope with many additional responsibilities which do notgenerally 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 dentalpractice should run

� Complying with a host of legal requirements

� Taking full responsibility for the health and safety standards of the practice and thehealth, safety and welfare of staff, patients and visitors

Why choose to squat?

Can you cope?

© BDA June 08 4

� 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 withpatients and the local NHS and providing excellent care. If you would still like to goahead and find out more about starting your own practice, read on!

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 andhave enough financial security to take a calculated risk. Furthermore, they should havegained broad experience of situations encountered in general practice which gives theconfidence required to practise alone. Don’t be in a rush to go into practice ownershiptoo young as there are many problems which an inexperienced or unsupported dentistmight face and could find difficult to deal with. Dentists are required to comply withvery high standards of professional practice as members of a profession and providingan acceptable standard of treatment, possibly complying with NHS regulations as wellas the many ethical and legal requirements which are placed on practitioners, can beextremely tough when coupled with the pressures felt by owners of all new smallbusinesses. The pace of change, both within the dental profession and for smallbusinesses in general, can compound this sense of frustration. A young dentist withlittle professional experience or support might be tempted to compromise clinicalstandards or overlook the rules of professional conduct due to commercial pressures.

Dentists who have spent their careers in the armed forces, hospital or salaried primarydental care may also decide to enter general practice and be unwilling to start outworking for someone else. In this instance, they might be in a position where they arelearning about general practice at the same time as they learn about practiceownership, which is a massive step to take at once.

External factors will also affect when you go out on your own. Setting up any newbusiness is a major financial commitment, and the uncertainty over the future of NHSdentistry in England and Wales beyond 2009 entails a level of risk that may force manydentists to delay making a move. But this risk can be mitigated by gathering andassessing detailed information about the area. If you are planning to set up a practicewith a substantial NHS commitment, you should look carefully at the followinginformation about the practice location:

� The oral health needs of the local population

� The PCO’s attitude to dental services. For the purposes of this advice sheet, wewill 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 thefacilities and services you intend to establish, for the provision of NHS care or whethera 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 asmuch information as possible and talking through the options, you are unlikely toencounter problems you can not resolve.

When is the best time to makethe move?

© BDA June 2008 5

One of the most important factors in determining the success or failure of your newpractice is the location. When setting up a squat practice, you are able to choose notonly the location, but also the size and style of the premises. It is imperative to gatheras 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 tryingto establish:

� Do you want to concentrate on NHS or private treatment? An area with mainlyprivate 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 localorthodontic services like? Are they accepting referrals under the NHS or privately?

� Do you want to concentrate on private cosmetic dentistry? If so, will there beenough demand?

� What is the percentage of older people in the local population? Are you preparedto provide the dentures that may be needed? Is there a local practice or clinicaldental technician that accepts referrals?

You must ensure there is a need for your particular services in your chosen area. If youintend to set up a mainly private practice, for example, can patients afford the higherfees and are they willing to be treated outside the NHS? Look at local unemploymentrates and the percentage of patients on benefit in the area. If both are high, patientsmay not be able to afford private fees and go instead to other dentists in the area whooffer NHS treatment.

When weighing up a particular location, ask yourself:

� What are the economic conditions locally? Is there any financial assistance availableto 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 inthe 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 andthe 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 acontract must be obtained from the local PCO. Contracts will normally be givenfollowing a tendering process and new practices will be located only where there is aneed for NHS provision.

Population trends, economic conditions and town plans all have a bearing on yourchoice of area and particular type of practice. Personal as well as professional issuesshould be taken into consideration, so you may decide to live in close proximity to thepractice, become part of the community and not have far to travel should you be calledout. Consider also the thoughts and feelings of your family: will they feel at home in thearea and does the locality offer the right amenities, schools and leisure activities?

Type of practice

Choosing alocation

© BDA June 08 6

Primary care organisation

You can find out how many dental practices there are in a given area and where theyare by referring to the PCO, or by visiting www.nhs.uk. These references will notinclude practices which offer only private treatment, but those can be found by lookingthrough local Yellow Pages or by searching on Google or Yell.co.uk. Would you want toestablish a new practice in an area where the local population is already served by alarge number of practices, and where you would have to compete for new patients? Ifthere are few practices in a specific area, then this could suggest unmet need, but alsolow demand. Look at the global treatment patterns of dentists within the PCO and talkto the local dental practice adviser to find out whether they feel a new practice wouldsucceed in the locality.

The local council

The local council’s planning department can provide helpful information about the localpopulation, for example if there is a large number of young families or older people. Isthe population increasing or decreasing and are there any plans for new housingdevelopments? It is important to get a feel for the area and to know what the localeconomy 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 upthe practice. Obviously some local dentists will be more amenable to help than othersand approaches must be handled sensitively. The LDC secretary will also be able to tellyou if, in their opinion, a new practice is needed or not. Local estate agents, librariesand doctors will also have detailed knowledge of the area. Dental drug and materialssuppliers’ representatives might also provide useful information, since they visit localpractices. Another useful resource is upmystreet.com, where you can find informationabout an area by typing in a street postcode.

Check all the available statistics that allow you to compare prospects in one area withprospects in another.

NHS tendering opportunities

PCOs offer tendering opportunities for new NHS practices by placing advertisementsin the BDJ. Some of these tenders involve starting a new practice.

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 toconsider 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 astructural survey. Furthermore, a property with a good outside appearance andwell-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 ifplanned for at a later date

� Potential risks to business continuity, such as flooding

� Utilities and services such as plumbing, broadband, electricity, gas, water, sewerageand telephone lines. A gas supply may not be available, whilst sewerage issometimes provided by means of septic tanks

� Visibility from the street. If passers-by can clearly see the practice, it is more likelyto attract patients

Finding theright premises

Source of information

© BDA June 2008 7

� Access to the building at night – will it be necessary to protect windows and doorsagainst potential vandalism or robbery?

� Availability of car parking and public transport. Car parking may be a significantplanning obstacle

� Ease of access for disabled people.

Practices may be situated in either residential or commercial premises. A practice in ashop 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 residentialarea or in an area which is known for dental practices, it is advisable to make sure thatpassers-by can see the premises is a dental surgery by putting up an external sign. If theentrance to the surgery is hidden, at the side of the building for example, you may loseout on potential new patients merely because passers-by cannot see you are there.Premises next to or near a doctor’s surgery, health centre and/or pharmacy may helpto integrate into the local community and increase footfall.

The Disability Discrimination Act 1995 (DDA) needs to be considered when setting upa squat practice with employers taking reasonable steps to accommodate disabledemployees and, as providers of services to the public, taking reasonable steps toprovide accessible premises for patients. The DDA means service providers mustensure their policies, procedures and premises are adjusted to provide auxiliaryservices and to take reasonable steps to reduce physical barriers a person with adisability might encounter. Where physical barriers make it impossible or unreasonablydifficult for disabled people to use a service, the dentist will be expected to takereasonable 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 beable to justify an inability to comply with the provisions of the DDA. Guidelines are setout in the codes of practice issued by the Disability Rights Commission. Someguidelines for reasonableness include the size and resources of the service provider, theeffect non-compliance would have on the disabled person, the effectiveness andpracticability of making the adjustment, the cost for making adjustments, and thefundamental nature of the service provider’s business. Where converting premises to adental surgery, there will be higher expectations and this should be discussed with yourarchitect, planner or designer.

The obvious attraction in purchasing a property is that you will acquire a capital asset inaddition to the practice itself. This means taking on a mortgage and the financialimplications 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 notalready used for this purpose. Your solicitor should check whether there are anyrestrictive covenants contained in the deeds for the property which might prevent itsuse 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 givesexclusive use of the property, or part of the property to the leaseholder (tenant) for adefined period. The word lease, however, can be used loosely, and it is important foryou to understand what rights you actually enjoy. If for example you are granted a non-exclusive 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 nosecurity beyond the agreed notice period. Greater rights of security will be enjoyedunder a normal business tenancy, providing protection under the Landlord and TenantActs. This includes a statutory right to renew the lease at its termination, unless thelandlord 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 Leasesand licences to help understand them. Ensure a solicitor is consulted about your ownrequirements, which will depend upon the nature of the property concerned.

Freehold

Leasehold

Access

© BDA June 08 8

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

Planning permission is usually required if the development of land is proposed. Thisincludes proposals to erect, enlarge or materially change the external appearance ofbuildings.

Permission is also needed for the change of use of a property or land. The desirableuses for every area are set out in the local authority’s development plan. Morespecifically the Use Classes Order, made under the Town and Country Planning Act1990, designates the acceptable uses of individual properties. This sets out sixteenclasses of land use, for instance shops (class A1), dwelling houses (class C3) or medicaland dental surgeries (class D1). A change of use between classes generally requires fullplanning permission; a change of use within a class does not. So, converting a retailshop (A1) to a dental practice (D1) constitutes a change between classes, necessitatingfull planning permission.

Planning permission should be granted if the proposal complies with the localdevelopment plan. Where the local plan has a policy, for instance that there should beno loss of residential accommodation, great difficulty may be encountered in gettingpermission to convert a house into a surgery. If the proposal does not comply with thelocal plan, you can still be granted permission if you can show a good reason why itshould be granted, for instance that there is a demonstrable need for dental services inthe area.

The local planning authority may take into account the effects of the proposeddevelopment, 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 otherpurposes such as agriculture or road improvements.

These considerations should be fully investigated with the local planning authoritybefore the application is completed.

If the need for planning permission is ignored, it is possible that the authority maydecide the development is unacceptable, and issue an enforcement notice requiring thedentist to cease their activities, or even to demolish a new building.

There are different types of planning applications: outline permission, application forapproval of reserved matters, application for full planning permission and application forrenewal of temporary permission or relief from conditional permission. For thesepurposes, the most likely application will be full planning permission, though this shouldbe checked with the local planning authority.

Planningpermission

© BDA June 2008 9

You should find out if planning permission is required at all. If it is, your applicationshould be submitted on the authority’s standard form, and accompanied by a plan andthe appropriate fee as laid down by Parliament. You must also include a certificatewhich states that the applicant is the sole owner or that the owners of the propertyhave been notified. You do not need to be the owner of a property to apply forplanning permission, so, if you are thinking of purchasing a property, you can make anapplication beforehand (but make sure the seller is willing to wait). Again, seek theadvice of the local authority when preparing the application.

The process for obtaining permission can be lengthy - the Secretary of State stipulates adeadline of eight weeks, but in reality it can take longer. Improve your chances of aprompt decision by getting information on the likely cycle of planning committeemeetings 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 canquickly become entwined in local politics, in which case it may be worth briefing a localcouncillor on the proposals. The local PCO may also be willing to lend support to aplanning application for an NHS practice.

It can be advisable to seek the help of a consultant chartered town planner. Townplanners often have an insight into the local authority’s 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 theirengagement.

If planning permission is refused, or unacceptable conditions are attached to thepermission, you can appeal to the Secretary of State for the Environment. The majorityof appeals are dealt with on the basis of written representations, but in cases ofparticular local importance the appeal will be a public inquiry. Decisions can take a longtime, with four months considered a reasonable time for considering an appeal basedon written representations. In the majority of cases, the Secretary of State will supportthe decision of the local planning authority. For these reasons, it is actually quicker ifpossible 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 anddesigned. Uncomfortable and cramped surroundings, harsh lighting, dental smells anddental noise can demotivate staff and make patients irritable and edgy. A negativeenvironment will have a negative effect on morale; a positive environment may increasegoodwill. 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 canprevent 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

� Décor

� Private areas, both for staff and for discussing matters with patients

� Odours

� Will there be a children’s play area?

Practice design

© BDA June 08 10

Consider professional help with the layout and design of your practice. There arearchitects and design consultants who work in dentistry and a list is available from theBDA. Before talking to the consultant think about:

� How many surgeries do you ultimately see the practice having? This will affect thesiting 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 withthis?

� How can you personalise your practice?

Some dentists try to make their practices feel like extensions of their own homes sopatients feel welcome, relaxed and secure. When briefing the designer, provide asmuch 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 patient’s 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 installation is quite simple if planned properly. Consider thefollowing 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. Anormally relaxed patient may become anxious when faced with uncertainty and theneed to know where to go and what to do. Good direction from reception staff andclearly marked passageways and doors are a must.

For the patient, access should be obvious and simple. For the dentist and nurse, it isbeneficial if the layout places them where they face and greet patients as they enter theroom, whilst having a seating area for anyone who may be accompanying a patient is agood 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 ofthe floor, along with the availability of electrical, plumbing and waste services, will allplay a part in your decision-making.

Early in the planning stage, professional advice can be well worth the investment andcan make big improvements. There is a temptation to reproduce the type of surgeryyou 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 relationshipwith the headrest of the chair, so determine the optimum chair position first. Bothdentist and nurse should be able to reach everything required for normal procedures,without the need to over-stretch or rise from a seated position.

Surgery planningand designOverview of the generalpractice environment

The surgery

© BDA June 2008 11

Delivery system

The question of which handpiece delivery system to choose can only be answered bythe individual dentist. There are several options: traditional garage or cart or an over-the-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 child’s headrest. Willthe practice be computerised? Can the system link into filmless radiographic equipmentor intraoral cameras? Is there forthcoming health and safety legislation that would bemore sensible to comply with now? Would your existing equipment be adequate if youdecided to expand at a later date?

Having chosen a manufacturer, discuss your plans with one of their equipmentspecialists and compile a realistic plan of action before committing yourself. Include indiscussions the level of service, support and maintenance, availability of spare parts andhow fast emergency call-out responses would be. A comprehensive maintenancecontract 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 madefully aware of the work they are required to carry out and of the necessity to keep toagreed completion dates.

Immediately after the site meeting and when all costs are known, address the questionof 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 theequipment which is important and elect for a leasing arrangement. Look at the terms ofthe lease carefully and, if in doubt, take advice. Whichever route you choose it is wiseto cover the cost of the maintenance contract within the overall capital equipmentpackage.

When the finance is agreed and the delivery/installation dates are known, you can goahead with any major underfloor plumbing or electrical work. The floor can go downonce this has been completed, which should offer anti-static and anti-slip propertiesand 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 andlayout. Train surgery staff on the operation and maintenance procedures necessary tokeep your investment in pristine working order, and the manufacturer’s representativeshould help in this respect.

It is essential to purchase the right equipment for your needs. Here are some points toconsider 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 andsuppliers

� If buying a whole new surgery, negotiate as discounts should be available

� Make sure that servicing and repair facilities are reasonable. Ask about call-outtimes and charges

� Take time to consider the options before making your final decision

� Ask local colleagues for recommendations. Dentists who have recently set up willbe a good source of information.

Discuss with the equipmentmanufacturer

Arrange a site meeting

Discuss with finance supplier

Installation

Dentalequipment

© BDA June 08 12

Buying the most expensive, attractive equipment in a bid to impress patients will notnecessarily pay off. Patients are more likely to be impressed by the general practiceenvironment, cleanliness of the surgery and the attitudes of staff and dentists. So, whenselecting equipment, be more concerned that it will do the job properly rather thanwhat it looks like. If money is scarce, don’t be afraid to buy cheaper, simpler equipmentwithout all the latest gimmicks because, if it comes from a reliable and well-knownmanufacturer, it will probably function just as well.

There is no reason why you should not buy equipment secondhand. Ask other dentistsif they have equipment to sell and look for adverts in the dental press. Make sure it is insafe, good working order and that maintenance contracts and spare parts are stillavailable.

General office furniture and cabinetry can also be bought secondhand. Items such asfiling cabinets, desks and chairs can be used in your office and reception area and areeasily obtained from office supplies firms.

Many companies now have modern showrooms demonstrating the latest equipment inan ideal operational environment. Services they provide include:

� Installation and servicing, although your own plumber and electrician will probablybe able to help with the final connections

� Professional advice on interior design, down to the choice and selection of colourschemes

� 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 differentcompanies and do not be seduced by large discounts from unknown suppliers. It isalways better to deal with established companies who are selling reliable and well-known equipment at a reasonable discount.

The BDTA (www.bdta.org.uk) can send you a list of all the dental equipmentcompanies currently members of their Association and can advise you where best tobuy your equipment if you have particular requirements.

When looking for dental equipment a visit to either the BDA’s Annual Conferenceexhibition or the BDTA’s International Dental Showcase should prove invaluable.

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 long-term.

Defining your market is a crucial part of the plan. This can cover geographicalsources of patients and the general characteristics of your ‘market’ or location.This information should have been gathered as part of your initial decision aboutlocation and premises.

A potential lender will expect to see a clear marketing plan, outlining how your servicewill 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.

Saving money

Dental equipment companies

Objectives

Market

British Dental Trade Association

Developing abusiness plan

Marketing

© BDA June 2008 13

Comment here on the adequacy of the existing or proposed premises, equipment andfuture 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 leaseremaining, 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 estimatedcosts? 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- orpart-time).

The lender will want assurance that you have the ability and relevant experience tomake 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 thatcareful 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 thefinance required. Expect to present a cashflow forecast - a monthly estimate of incomeand expenditure - for the first year. Think about this carefully and make your besteffort, but the lender will appreciate it is an estimate and will not be surprised if thereality does not conform exactly to what you predicted.

Further help in developing the business plan can be obtained from potential lendersthemselves. Banks and other lending institutions generally offer a small business adviceservice. It may be worth arranging a meeting with one or more of these for an informaldiscussion when plans are at an early stage, as they can take you through their ownmodel 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 abusiness plan, whilst C6 Financial management for general dental practice can help withcashflow forecasts and financial planning.

Deciding on a philosophy can be helpful as it will underpin the care you provide. It willfocus your employees’ minds and shape your customers’ expectations. Here are somepossible 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 teamin drafting it. Consider why customers might want to visit your practice. What are yourgoals? What promises are you going to make? Are they realistic within the constraintsthat you will be under?

Premises and equipment

Supplies

staff

Personal details

Finance

Settingbusiness

objectivesPractice philosophy

© BDA June 08 14

Your objectives for the practice will form an important part of your business plan. Youneed to devise short, medium and long-term objectives, which should be SMART:

Specific – address a specific target or area of the practice’s 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 fromstartup, 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 administrationmatters

� 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 BDA’s 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 seemimpossible to plan this far ahead, but these will be high-level strategic objectives, suchas:

� 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-basedframework, an alternative way to structure them is under the headings Finance, People,and Quality. Again your lender’s small business adviser should be able to give furtherhelp.

There are two key stages in marketing a new practice. The first is to discover whatpotential patients actually want from a dental practice; what are their needs, demandsand expectations? The second is to tailor your service; ideally, in such a way that thesecriteria are exceeded.

You need to consider primarily the type of patients you want to attract; do you want totreat the whole community from children to pensioners, or would you prefer to try todevelop a niche market whereby you concentrate on one segment of the market, forinstance young professionals? Once this question has been answered, the needs andexpectations of your intended patients have to be identified.

Although you may find it easy to formulate your own list of what potential patientswant from the practice, your understanding will be far more accurate if you actually askthem. Conduct research into the potential market by sending out surveys, talking tolocal shopkeepers, health professionals, and public/patient involvement groups abouttheir ideas of a good dental practice. Get copies of patient information leaflets of otherpractices, and have a look around. What do the practices have in common? There maybe merit in identifying these common services and making sure you offer thesealongside additional ones to create a unique selling point to differentiate your practice.

Business objectives

Marketing

What do patients want?

© BDA June 2008 15

Look for niches within the marketplace. Do any of the practices offer something whichyou are able to provide, for example hypnosis, a crèche or computer imaging?Concentrate on a few unique selling points, but do not tackle too much at once at thebeginning. Adding new services in the future and continuously improving can createpublicity 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 bestpossible 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 byany 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 additionaltwo ‘Ps’: people and process. For more detailed information, see the BDA AdviceSheet A6 Marketing in dentistry.

Price

If you are going to operate under the NHS, then your patient charges are set centrallyand you have no scope for altering them. But, if you are practising privately, then youare free to set your fees as you see fit. Naturally you need to cover your expenses andmake a profit for yourself.

The basic way of setting fees will be to divide the total predicted expenses for the yearby the total chairside hours to be worked, to get an hourly rate to charge patients. Amore 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 thepractice provide and how will these services be customised to meet the needs ofpatients?

For example, market research might indicate that local residents would like a dentalpractice 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 addressthe overall service experience. So, the quality of customer care, attitudes of staff andpleasantness of surroundings are all components of your ‘product’ requiring dueconsideration.

Developing a marketing plan

© BDA June 08 16

Place

Within the context of the marketing mix, place equates to where you intend to deliveryour products and services. Is the surgery up to scratch with the latest equipment anddoes 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 offeredand their general overall picture of the practice, and therefore is an integral part ofmarketing.

Promotion

Once you have decided on the services you will offer, you need to come up with a planfor how you will promote them. Again, you should choose a promotion method thatfits with the type of patients you wish to attract; so if your services are targetedtowards 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 don’t overspend atthe beginning. During the first year you will need to promote the practice regularly tobuild up a patient base. This promotional activity may be enough to bring severalhundred new patients into the practice. These patients will be the ones who will be thesource of your patient base and who will promote you to their friends, neighbours andacquaintances.

Building up a good professional relationship with your patients will encourage them todiscuss with you first any problems they may have with the practice, rather than goingaway and telling everyone else about it. The later section on customer care gives moreguidance on this area.

Remember, promotion goes beyond traditional advertising methods like leaflets andadverts taken out in a local newspaper or Yellow Pages. Anything that raises awarenessof 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 fête.

People

A dental practice relies heavily on the quality of the people working for it and therapport built between patients and staff for successful delivery of services. It istherefore worth developing your people, both in their clinical skills (if necessary) aswell as the softer people skills, so they are able effectively to handle patients in the bestmanner.

The practice staff are the human face of the practice – imagine them as walking, talkingbillboards for your practice, and ensure that they give the right impression in order tobe able to market the practice. If they give efficient, polite service, then this is going tohave 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, ill-informed receptionist answering calls when the call eventually is picked up, this willhave a negative impact on the patient’s perception of the practice. Thus, it is importantnot only to attract and retain quality individuals to the practice, but also to developthem and ensure they are valued and content within their jobs.

© BDA June 2008 17

Process

Process looks at the way in which services are delivered to patients – right from thetime they first have contact with the practice, until the time they step out the door atthe end of their treatment – in other words, the patient’s journey within the practiceand how efficiently it is managed.

Consider aspects of the patient journey and how it can be managed – are remindersfor appointments sent out? Are patients kept waiting around for a long time? Can theyget appointments when they want them? Is there a smooth transition from reception todental chair to hygienist?

The smoother this patient journey, the better the impression for the patient and thehappier the patient. A happy patient should mean a repeat patient; an unhappy patientmeans not only that they may not return, but also adverse publicity for the practicethrough negative word of mouth. One well known marketing statistic is that consumerswho have a bad experience tell on average nine people, whilst one study has shownthat 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 withthe service they are receiving - that the patient has been placed at the centre of thepractice. When considering the above points, always try to look to see how thepractice would be viewed through patient’s point of view.

Customer care is a key element in running a successful practice, especially with regardto retaining patients. One approach that is becoming increasingly widespread iscustomer relationship management (CRM), centring on two concepts:

� A business’s customer base is as varied as the number of customers it has. In otherwords, your service should be customised to the level of individual patients, movingaway from ‘market segmentation’, whereby you assess and serve the needs ofgroups of patients who share similar attributes, and towards the idea of a ‘marketof one’, whereby each individual patient’s expectations are identified and exceeded

� Customers are not all equally valuable, and a business should devote most effortand resources to its high-value customers. That is certainly not to say that lowervalue patients are neglected; indeed, this would present ethical concerns (forexample if you were to start to neglect fee-exempt patients). Instead, it isconcerned with providing a very personal, attentive service which exceeds theexpectations of every patient.

This may seem complicated, so how might you go about adopting a customerrelationship management approach? There are several key activities involved:

� Profile your patient base: This means tracking their activity through all the channelsyou have available. How often do they proactively book routine appointments/recommend another patient to the surgery/fail to attend an appointment, forexample? What types of treatment do they have and how often? Are they a nervouspatient? Have they shown any interest in cosmetic treatments? These sorts ofquestions can be used to build a ‘scorecard’ reflecting the value of any particularpatient.

Evidently, you will be relying on a level of information to make this assessment andthis highlights the supporting role of technology in CRM.A patient database isextremely valuable in providing a basic level of data, from which you can form aninsight into a patient’s historic activity and thereby their potential future behaviours.Patient surveys or questionnaires can be useful in determining patients’ views of theservice you provide to them and where it can be improved.

Customer care

© BDA June 08 18

� Identify and flag high-value customers: Having reviewed the activity of your patientbase, 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, orpeople who introduce a lot of new patients to the practice. These are the patientswhom you must absolutely ensure you do not fail. As such, it is important toidentify 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 affordto lose.

� Adapt your service: Always show respect for all patients at all times, but devote themost time and effort to your highest-value customers. For example, contact themafter major treatment to check they are all right, telephone before a surgicalprocedure to check they are feeling relaxed, or send Christmas cards. In addition,CRM would suggest that, instead of fining patients who fail to show forappointments, you might encourage less regular attendees by proactively sendingemail or SMS text message reminders to book an appointment or remind them ofan existing appointment. The point is to try and gradually increase the value of allpatients, so low-value, poor attendees ultimately become regular attendees whoare happy to recommend the practice.

The majority of dentists now operate in mixed practice, offering both NHS and privatetreatment. A new practice may wish initially to offer NHS care to build up a patientbase 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 listof 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 andyou will not earn enough to repay debts incurred by starting the practice. On the otherhand, you may wish to accept all patients, concentrate on treating children or set up inan area where patients are on low incomes and cannot afford private treatment.

In order to offer NHS treatment within a new practice in England and Wales, the PCOhas 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, theirbudget and the dental needs of the population for which they are responsible. Moreinformation on tendering for contracts can be found in the BDA’s Advice Note anddetail 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 fairlyeasily. The new practice will have to be inspected by the local PCO to check it meetshealth and safety standards.

There is a variety of reasons for wanting to set up a totally private practice, includingfreedom of choice, the feeling of being unable to provide the best service within NHSconstraints and starting out privately is easier than converting later on, and wantingmore time for your patients and your family.

When building up a purely private practice you should be aware that patients willexpect more personal attention, to see more up-to-date techniques and equipment anda better result than they would expect from the NHS. It is also worth rememberingthat a patient receiving private treatment can still make formal complaints through thecourts or the Dental Complaints Service instead of through the PCO. You may wish torefer to our Advice Sheet B11 Handling private patient complaints.

One of the most common complaints made by patients is that the cost of privatetreatment was not made absolutely clear in advance, and it is important to display or

NHS or privatepractice?Benefits and drawbacks of eachtype of practice

NHS treatment

A private practice

© BDA June 2008 19

make readily available your schedule of private fees. To reduce the likelihood of apatient 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 feelevels is also important and BDA Advice Sheet C8 Fee setting in private practice explainsthis topic.

When setting up a brand new private practice, consider:

� Marketing: patients paying private charges will expect high standards of qualityacross 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 investmentand 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 spreadthe cost of their dental care.

One of the first issues to tackle when considering setting up in practice is securing thenecessary 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 isalso important to the future health of the business. No new business can survivewithout financial plans and control systems.

This section deals with the basic aspects of resourcing your new business. Furtherinformation is also available in BDA’s Advice Sheet C6 Financial management for generaldental practice.

You will probably need to borrow money in order to set up a new practice. As withborrowing money to buy a home, it is best to shop around to get the best possibledeal. Your own bank is a sensible starting point, but consult other lending institutionstoo.

Find out if a bank has any branches which have a large number of dentists as clients, asthey are likely to have a greater understanding of your needs and a better idea of howsound your plans are.

Ensure that you prepare well before approaching a potential lender. A lender will wantas much information as possible to satisfy itself that you are a reasonable risk. This iswhere a business plan will be useful to you – it will demonstrate that you have carefullythought 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 currentfinancial health and the track record of your personal finances

� Whether you have taken the trouble to prepare a good business plan

Setting up a private practice

Finance

Securing finance

© BDA June 08 20

� The amount being asking for, and if it is realistic: don’t assume that asking for aslittle as possible improves your chances! Banks would rather see a realistic amountof money being asked for, rather than someone going back to them cap-in-hand formore 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-preparedcase.

As mentioned above, your first cashflow forecast will only be a rough estimate. Onceset up, your cashflow forecast will be a vital management tool and indicator of what ishappening in your practice. It should estimate how much cash you will have available atparticular points in time (usually on a monthly basis), telling you whether you are likelyto have a surplus or a deficit, and allowing you to plan what to do in each case. Adeficit may mean certain bills may not get paid. Preparing for this possibility andknowing when it is likely to occur is very important, otherwise your businessreputation will suffer. More businesses go into receivership because they fail to controlcashflow 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 businessover a given period. For most businesses, weekly measurement is preferable sincecorrections can be quickly made. If there is insufficient money in the bank account tomeet withdrawals for a given period, then the funds will have to be found from a bankloan, 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 bothincome 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 cashflowmeasurement is accurate, then expenditure can be planned to cope with periods whenthere is little or no projected surplus. The actual month-by-month cashflow can bemeasured 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 worthacknowledging the importance of the forecast as a management tool in your businessplan, for example by describing what system you will have for dealing with debtors. Asa 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 onlate payment. Make sure you take full advantage of these regulations by establishing andfollowing a clear credit control procedure.

Further information on cashflow and financial management generally is available in BDAAdvice Sheet C6 Financial management in general dental practice.

The profits generated by your new practice will be subject to taxation, as will theindividuals you employ - use the professional services of an accountant to help you inthis and other aspects of the practice’s finance. There is no need for you to become anexpert on tax, but it will be helpful for you to understand the basic principles and knowthe right questions to ask. Look at the BDA’s advice notes on the different taxes.

Cashflow forecasting

Taxation

© BDA June 2008 21

Information is also available from the HMRC’s Business Support service, available freeof 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 witha business adviser. All these services are free of charge and telephone numbers for theBusiness Support Team regional support offices are:

Central England 01332 724410London 020 7667 4827/28/29/30West Midlands & Northern England 0151 242 8380Northern Ireland 02890 532755Scotland 01355 275551Southern England 01233 653673 Wales 02920 326854

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 bythe level of risk you are comfortable with.

Professional indemnity

You must have adequate professional indemnity insurance to provide cover againstprofessional negligence or claims for damages. Furthermore, you must also haveadequate funds to ensure that you can cover the costs of compensation arising fromclaims of professional negligence.

Sickness and accident insurance

If you are not insured against sickness, you will only receive basic social securitybenefits in the event of a prolonged absence from work. You should protect yourselfagainst this possibility through sickness insurance.

How much you pay in monthly premiums depends on the level of cover you want (withreference to your normal income) and whether or not there is a period of delay beforebenefit is payable. Policies can also be taken out to meet your overheads during periodsof sickness.

Personal accident insurance/income replacement

These policies will provide a lump sum and permanent income in the event of anaccident which prevents you resuming your career as a dentist. Beware here ofproportionate benefit provisions in such policies which would restrict the benefitpayable if you are also receiving benefits under other policies. The main purpose of thiskind of provision, which is now quite common, is to prevent people over-insuringthemselves 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 avoidwasting money on too many.

Life assurance

If you are married, have a partner, a family or a mortgage, you should consider a lifeassurance 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 soadequate surgery insurance and loss of earnings cover is essential.

Insurances

© BDA June 08 22

Employer’s Liability (Compulsory Insurance) Act 1969

Employers must take out adequate insurance to cover for liabilities for injury or diseasecaused to their employees as a result of their employment. A liability insurancecertificate must be displayed at the practice premises.

BDA Plus

The BDA has special insurance deals for members on car, home contents, surgery andprivate health insurance. For further information, contact BDA Plus on 0845 130 1366.

Help, support and advice is available to small business people, including dentists, from anumber of organisations both locally and centrally in the UK.

The Business Link network (www.businesslink.gov.uk) provides impartial businessadvice and information in England to existing small firms and those just starting up, via anetwork 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 andcounselling and, in many cases, additional services such as access to loan funds andinformation services.

Business Eye (www.businesseye.org.uk) offices are a source of local help and advice fornew businesses in Wales. Business Eye has 28 regional offices which offer free adviceand can direct to other sources of financial and business help and support.

Scotland’s 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 helpwith business start-up and expansion. Telephone 0845 6096611 or visitwww.scottish-enterprise.com.

The Highlands and Islands Enterprise (www.hie.co.uk) provides business supportservices, training and learning programmes through ten Local Enterprise Companies(LECs) to the highlands and islands of northern Scotland.

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 accessto business and commercial information.

Many local authorities offer services to small firms in their area such as business adviceand information, help with marketing, premises, training and raising money. Search foryour local council’s website via a search engine to find their website to contact yourcity, 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. Lookin 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 offormats:� 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 ofmodel policies and forms needed in running a dental practice.

Help for smallbusinessesEngland

Wales

Scotland

Northern Ireland

Local authorities

Chambers of Commerce

BDA

© BDA June 2008 23

Employing other people carries tremendous responsibility. Staff have to be motivatedto work well, counselled if they have problems and disciplined if they fail to performproperly, as well as being paid!

Some dentists perform these functions naturally and have happy, motivated teamswhilst others have more difficulty, perhaps not feeling it is a priority, resulting in lowstaff morale and high staff turnover. Management training can help here – it won’t solveall the problems but it can equip you with skills to provide the right environment forstaff to function effectively. Think about participating in BDA MasterClass – go towww.bda.org for details.

Take time to recruit the team. The calibre of person that you recruit to assist you willhave a significant effect on the success of your business. Do not be too hasty and takeon the first presentable person who comes along. If you are looking at a receptionistfor example, their behaviour, efficiency and attitude to the practice and its patients willshape its reputation, regardless of your clinical skills. BDA Advice Sheet D12 Staffrecruitment 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 employee’s 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� Don’t 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 surethere is adequate (but not excessive) cover is important. One person to act as nurseand receptionist is not sufficient. Dentists should be chaperoned at all times by dentalnurses, which is impossible if one has to cover reception. Dental nurses must either beregistered with the General Dental Council or in a GDC-approved course of training. Itis therefore essential to ensure that dental nurses that you recruit meet theseconditions. You might start with one dental nurse and one receptionist who can swaproles when necessary. Employing a number of part-timers can also work well, as longas there is continuity.

You may start your practice on a part-time basis and want to give employees flexiblecontracts whereby they are contracted to work only when required and paid on anhourly basis. You may initially be quiet as you build up your patient base, and prefer notto have to pay staff when there is no work. But there should always be someone onthe premises during opening hours to answer the telephone and deal with personalenquiries.

Recruiting andmanaging staff

Recruitment

© BDA June 08 24

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 andthe terms and conditions of that work

� A good contract should outline how to deal with most of the circumstances thatyou 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 anemployee’s duties, hours of work or work location

� Disputes will be minimised, as employees will know what is expected of them fromthe beginning.

BDA Advice Sheet D1 Contracts of employment explains the requirements in detail andthere is a model contract in the BDA Practice Compendium.

Deciding on rates of pay can be difficult when you start out. Incremental scales rewardloyalty but you will need to set the increments carefully to ensure that salary increasesdo not greatly exceed the level of inflation. Incremental scales also take no account ofindividual 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 localChambers of Commerce who will have an idea about the local job market, althoughbear in mind the dental job market has special characteristics.

BDA Advice Sheet D2 Rewarding staff provides further information on paymentsystems.

Every employee who pays NI contributions (in 2008/9, those earning £90 or more perweek) is entitled to receive statutory sick pay from the fourth day of illness. Smallemployers can reclaim a percentage of the SSP paid. Control employee absence byimplementing a policy whereby employees must explain absences and any suspectedabuse is dealt with at an early stage. Some practices will also give their employees acertain amount of occupational sick pay whereby the employee receives full or half payduring periods of illness up to a yearly maximum. The BDA’s recommendations for paidsick leave and holiday entitlements are given below:

Sick pay

Length of service Full pay Half payLess than 6 months SSP only SSP only6 months – less than 2 years 2 weeks 2 weeks2 years – less than 4 years 3 weeks 3 weeks4 or more years 3 weeks 5 weeks

Holiday pay

Employees are legally entitled to 4.8 weeks’ annual paid holiday (including bankholiday). 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 staffworking 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,

Conditions of service

Pay and benefits

Sick pay and holiday pay

© BDA June 2008 25

you give 5.6 weeks holiday to all staff, then someone working five days a week willreceive 5 x 5.6 = 28 days’ holiday (four weeks’ plus bank holiday). Someone workingtwo 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 theyhave 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 andyou could agree that they can take additional unpaid holiday.

When staff take leave, staffing requirements and cover must be considered, although itis possible for the practice to close and for everyone to take leave at the same time. Asthe employer, you can request this, as long as you give sufficient notice, though takeinto account employees’ wishes as far as possible. You must check whether closing iswithin the terms of your NHS contract with your PCO.

Many practices buy Christmas and birthday presents for staff or give Christmasbonuses. Some practices offer private health insurance and provide dental treatment atno cost to the employee, whilst others organise outings away from the practice, givingstaff a chance to bond away from work.

Stakeholder schemes were introduced by the Government in an attempt to increasepension coverage for the UK working population, intended to be low cost personalpension schemes.

In many cases an employer must offer access to a stakeholder pension scheme, knownas the Employer Access Requirement, although employers do not have to contributeon behalf of their employees. The employer has to select a stakeholder pensionscheme employees can join, should they wish, but employee membership of thescheme is not compulsory.

There are exemptions to employers joining the scheme, which include:

� The employer already offers an occupational pension scheme that all staff areeligible to join, within one year of commencing work for the employer

� The employer employs less than five people. In determining this, all employeesmust be counted, which may include company directors but not self-employedpersons. If the employer has five or more employees, but fewer than five meet theconditions to have access, then these employees must be given access to thescheme

� If the employer already offers to make contributions to a personal pension schemein respect of that employee providing the scheme:

� Receives a contribution from the employer of at least three per cent of the employee’s 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 practice’sstandard working week. Part-timers:

� Enjoy exactly the same statutory employment rights as full-timers, which includecompensation for unfair dismissal, maternity leave and redundancy payments

� Are entitled to statutory sick pay and statutory maternity pay if they pay Class 1NIC (National Insurance Contributions)

� Must not suffer discrimination compared with full-time colleagues, which meansthey must receive the same pro-rata holiday and sick pay entitlements. Forexample, if a member of staff working 40 hours per week receives 24 days’ holidayper 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

Other benefits

Stakeholder pension

Part-timers

© BDA June 08 26

� Should receive the same benefits as other employees, such as promotionopportunities, training opportunities, perks, pension provisions and overtimepayments

� Can be given standard BDA employment contracts. Simply state the hours and daysworked and that in the contract one week means X hours.

You should keep the following personnel records for each employee:

� A copy of the employment contract/written statement of main terms andconditions 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 wassick 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 afteran employee leaves. The BDA Practice Compendium contains standard forms and staffpolicies, including:

� Maternity

� Sickness

� Absence

� Equal opportunities

� Prevention of violence and aggression towards staff

� Confidentiality

� Redundancy

� Dismissal.

As an assistant or associate you will have developed your own way of managing yourdental nurse. As you will know from your own experience, effective managers havehard-working, committed and motivated employees with low absenteeism and staffturnover and high quality of service. It therefore makes sense to put some thought intoyour own leadership style and perhaps undertake some management developmentcoaching as part of your preparation for setting up your practice, such as BDAMasterClass.

In a new practice, experienced, competent staff are essential. You will be seeingpatients ‘on approval’ and they may be highly critical at their first few visits. Forexample, a new patient might say to a friend ‘I went to that new dentist in the healthcentre - 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 whileshe finished a phone call, and then she kept sighing because I couldn’t make any of theappointments she suggested. In the end I just turned around and walked straight backout the door. I won’t be going back there again’.

You are responsible for your staff. Their attitudes, actions and behaviour reflect howyou treat them, how they have been trained and how they are managed.

Personnel records

Management style

© BDA June 2008 27

Employment law provides employees with the following rights:

� To a written statement of main terms and conditions within two months of startingwork

� 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 year’s service

� To receive a written statement of reasons for dismissal after one year’s service(except in the case of pregnancy when a statement must be supplied within twoweeks of dismissal)

� Depending on the circumstances, to recover certain losses in the case of anemployer’s insolvency

� Not to have deductions made from pay unless authorised or it is provided for in thecontract (for example, deductions from final pay if inadequate notice of leavinggiven)

� 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, statutorypaternity 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/familyresponsibilities

� To redundancy payments after two years’ service

� To have time off with pay to seek alternative work or to arrange training in aredundancy 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 thisaffects employment

� Not to be dismissed for attempting to assert a legitimate statutory employmentright

� Not to be dismissed if they bring a legitimate health and safety concern to theattention of the employer/other authorities

� To a minimum period of notice, depending on length of service:

Length of service Notice

1 month – 2 years 1 week

2 years 2 weeks

3 years 3 weeks

4 years 4 weeks and so on, up to a maximum of:

12 years 12 weeks.

As an employer you are responsible for the acts and omissions of your staff. What doesthis mean in practice? What responsibility does it place on you to provide propertraining? 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 appointmentis pregnant

� Tells a school (without the parent’s permission) that a pupil is not booked in for anappointment on that day

� Tries to persuade a patient to accept a private bridge by stating that it is notavailable on the NHS

� Makes private appointments for a new patient without informing the patient of thecost of a private consultation at the time the appointment is booked

Employment law

Staff training

© BDA June 08 28

� Sends an overdue account to a debt collector without pursuing the debt in writingwith the patient first

� Forges a patient’s signature on the NHS form because they have forgotten to askthe 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.

Some of these actions are the result of staff being unaware of the importance of properpatient care, of the many regulations that dentists must observe and not appreciatingthe 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 amistake. All could be prevented by enabling your team: giving them adequate trainingand information, as well as providing a culture in which staff can admit mistakeswithout fear of being unfairly treated.

If staff are aware of their and the dentist’s professional responsibilities, they will bemore supportive and less likely inadvertently to cause more serious problems.

Help prevent staff making avoidable mistakes by sharing information with them. Forinstance, give staff BDA advice sheets to read and refer to and have a copy of theGDC’s guidance in the practice. Encourage staff to read BDA News, BDJ and otherdental 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 DentalTherapists, the British Dental Receptionists’ Association or the British Dental PracticeManagers Association) will help to keep staff up-to-date through journals, writtenadvice, national and local clinical meetings. These organisations can also provideinformation about recognised vocational training courses.

Some dentists prefer not to devote resources to training staff, feeling the investment inexplaining or providing information is not worthwhile. But aware staff are interestedand committed staff can contribute so much more to making the management of apractice smoother.

It is important staff understand the need to report mistakes to the dentist or practicemanager. Breaches of confidentiality or serious breaches of health and safety rules mayresult in dismissal, but any mistake will only be compounded if it is hidden, so staffshould be encouraged to admit mistakes: from simple things like the till not balancing atthe end of the day or a receipt not being issued, to the mercury spillage discussedabove.

If you need help or advice about any aspect of your new role as an employer ormanager contact BDA Practice Support on 020 7563 4574 for advice. They can adviseon contracts of employment, policies and procedures. A list of relevant advice sheets ison page 39.

Training

Access to information

Creating a supportiveenviornment

Further information

© BDA June 2008 29

Health and safety covers every aspect of dentistry, from making sure you provideadequate facilities and arrangements for the welfare of your staff to performing anassessment of all the hazardous substances in the practice. The 1974 Health and Safetyat Work Act (HASAWA) makes it the responsibility of the employer to ensure thehealth 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 hasthe power to dismantle your facilities and even shut down the practice. You shouldtherefore make sure that you understand all the legal obligations expected of you as anemployer. For a comprehensive guide to health and safety law, see BDA Advice SheetA3 Health and safety law for dental practice.

Under the HASAW Act, employers have a general responsibility to provide adequatefacilities and arrangements for welfare at work. The Workplace (Health, Safety andWelfare) Regulations 1992 set the general requirements of employers into four broadareas: the working environment, safety, facilities and housekeeping. These regulationsaffect 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 withoutexperiencing eye-strain.

Temperature: The workplace should be reasonably comfortable without the need forspecial clothing. The temperature should normally be at least 16°C.

Ventilation: Windows will generally provide sufficient ventilation. Where necessary,mechanical ventilation systems should be provided for parts or all of the workplace, asappropriate. Recycling air conditioning systems are not recommended.

Room dimensions: Workrooms should have enough free space to allow people to movearound with ease. As a guide, the total volume of the room, when empty, divided bythe number of people working in it should be at least 11m³. This may still beinsufficient if much of the room is taken up by furniture.

Workstations: Should be arranged so each task can be carried out safely andcomfortably. Seating should provide support to the lower back and be appropriate forthe task.

Floor surfaces: Should be free from holes or unevenness that could cause a person totrip, slip or fall, or to drop anything being carried.

Windows and skylights: It should be possible to open, close and clean these in a safemanner from the inside. Glazed doors and partitions should be made of a safetymaterial or be protected against breakage, for example by obvious marking. Doors andgates 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 touse them without delay. There is a minimum number of toilets and washing facilitieswhich 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 changeinto uniforms. Work clothing and personal clothing should be stored in a well-ventilatedplace where it can dry out if necessary. Effective measures should be taken to providesecurity 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 bemaintained in efficient working order and good repair. Equipment should be regularlyserviced and maintained, and records should be kept to demonstrate this has beendone.

Premises

Working environment

Safety

Facilites

Housekeeping

Health andsafety

© BDA June 08 30

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 methodand should not present a health or safety risk.

Dentists as employers are required to maintain the practice premises in a safecondition and without risk to health. This includes providing suitable floor coveringsand adequate and suitable lighting, temperature and ventilation. An approved posterentitled Health and safety law – what you should know (ISBN 0-11-7014 24-9) is availableand must be displayed in every workplace.

Staff must:

� Make and keep a record of all reported injuries sustained at work. An accidentbook that complies with data protection requirements can be obtained from theHSE (www.hse.gov.uk)

� Be familiar with the whereabouts of a first aid box which should always beadequately stocked

� Be familiar with the fire regulations including knowing where the nearest fire alarmis and knowing how to use a fire extinguisher effectively. Written fire procedurenotices must be displayed and brought to the attention of all employees. Your localfire protection officer will be able to advise on this

� Notify the HSE (Incident Contact Centre) of accidents causing death, major injuryor dangerous occurrences. Tel: 0845 300 9923.

Practices with five or more employees must draw up a written safety policy. Asuggested format can be found in the BDA Practice Compendium. The employing dentistwill also need to have a risk assessment carried out and documented to include thesignificant hazards in their practice. Comprehensive information on this can be found inBDA Advice Sheet A5 Risk assessment in dentistry.

� Electrical equipment should be in safe working order at all times. All appliancesmust be correctly wired and fused and must be checked and tested by anappropriately qualified person, usually an electrician. Records should be kept todemonstrate that this has been done

� Staff using laser equipment must be appropriately trained. A Laser ProtectionAdviser (LPA) should be appointed. If you use a class 4 laser or intense pulse lightsources in your practice in England, you must also register with the HealthcareCommission

� You should notify the local HSE of the use of radiation in the practice and allpractitioners should be thoroughly familiar with the regulations for the safe use ofradiographic equipment. A Radiation Protection Adviser (RPA) also needs to beappointed. BDA Advice Sheet A11 Radiation in dentistry provides advice oncomplying with the Ionising Radiations Regulations 1999 and the Ionising Radiation(Medical Exposure) Regulations 2000.

All clinical staff should be trained in the use of autoclaves and compressors. Theinspection of pressure vessels should be carried out at intervals recommended in thewritten scheme of examination for each vessel, with records of all inspections beingkept.

The practice must comply with the Water Supply (Water Fittings) 1999 regulations.Dental equipment such as the handpiece cooling system, ultrasonic scalers, three-in-one syringes, wet line suction units and automatic radiographic processors should beisolated from the main water supply by the relevant air gap. This eliminates thepossibility of back siphonage of contaminated water from the surgery to the mainssupply. Further information on this is available from BDA Advice Sheet A3 Health andsafety law for dental practice.

In the surgery

Safety of pressure system(autoclaves, compressors)

Water supplies

General surgery safety

© BDA June 2008 31

Dentists have a duty to take appropriate precautions to protect patients and staff fromthe risk of infection. Failure to provide and use adequate sterilisation facilities may leadto proceedings for serious professional misconduct before the GDC.

BDA Advice Sheet A12 Infection control in dentistry contains guidance and detailedinformation for dentists about implementing an infection control policy to minimise therisk 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) requireemployers to assess all work which is liable to expose any employee to hazardoussubstances. The BDA Advice Sheet A5 Risk assessment in dentistry contains informationon 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 premisesof 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 wheneither 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 theirlist. If, following the visit, it is considered the premises do not meet requirements, itmay defer the dentist’s admittance until the premises are brought up to a satisfactorystandard. 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 equipmentand drugs, maintenance, compliance with regulations, radiographic equipment,steriliser, compressor, surgery hygiene, disinfection procedures, instrumentcleaning, disinfection and sterilisation, appropriate patient protection, electricalwiring 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 formalityand 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 Noteon 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 fireextinguishers or fire escape?

Hazardous substances

Practice visits

Health and safety checklist

Infection control

© BDA June 08 32

� Do staff know regulations covering the use of radiographic equipment? Who is theRadiation Protection Supervisor? Has a Radiation Protection Adviser beenappointed? Has your radiographic equipment been assessed for safety by theNational Radiological Protection Board or another competent authority during thelast 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 schemeof examination for these and certificate or report to demonstrate this has beendone?

� Have portable electrical appliances been recently checked and tested by anelectrician?

� Do you have a laboratory? Have you identified all the hazards?

� Do all clinical staff use the necessary protective clothing? Are official guidelines oninfection control followed?

� Who looks after the first aid box? Is there an accident report book that complieswith current data protection legislation? Do you have adequate employer’s liabilityinsurance 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 handlethem?

� Do staff know about the hazards involved with mercury, and what to do if some isspilt? Do you have a mercury spillage kit?

� Do you have adequate public liability/employer’s liability insurance? Is this displayed?

� Have workstations been assessed to ensure they meet the requirements of thedisplay screen equipment regulations?

Clinical governance is quality management and the development of practicemanagement systems. It will help you and your team to understand what is supposedto be done and why, how it is to be done and who is to do it, and to show that it isbeing done in a consistent and reproducible way. A clinical governance system allowsyou to manage the quality of your patients’ experiences and to make sure that youmeet and exceed their expectations through consistent compliance with your ownstandards. It will help you identify where there may be weaknesses and to put themright 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 GDC’s CPD requirements are satisfied.

Clinical governance is equally important for private practices and the BDA’s ClinicalGovernance Kit will take you through the requirements of clinical governance using astep-by-step approach. The Care Quality Commission will assume responsibility forclinical governance for all practices in the future and implement national qualitystandards.

Clinicalgovernance

© BDA June 2008 33

Dentists are affected by various acts of general legislation, and this section provides abrief round-up of the laws you are most likely to encounter as a practice owner, otherthan the employment and health and safety requirements detailed above.

Dentists who process personal data about individuals on computer or manually in hardcopy need to comply with data protection legislation under the Data Protection Act1998. 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 individual’s 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 youcan charge a small fee for copies.

The Freedom of Information Act 2000 (FOIA) gives individuals a general right of accessto all types of recorded information held by public authorities, sets out exemptionsfrom that right and places a number of obligations on public authorities. NHS dentistsare included in the scope of ‘public authorities’. Every public authority (and thereforeNHS dentists) are now required to adopt and maintain a publication scheme setting outfor the public how it intends to publish the different classes of information it holds andwhether there is a charge for the information.

For more information, see BDA Advice Sheet B2 Data protection and our Advice NoteFreedom of Information Act guidance notes and BDA model publication scheme.

All treatment provided by dentists comes under general consumer protectionlegislation. The laws mean that amongst other things:

� Goods must be of a satisfactory quality and reasonably fit for purpose and in thecase of services they must be carried out with reasonable care

� Liability is imposed for damage caused by a defective product, including laboratorywork

� If a fee is not agreed at the start of treatment, then there is an implied term in thecontract that charges will be ‘reasonable’. If proper agreements are not reachedwith patients about private fees before the start of treatment (preferably writtendown) a patient may be able to say that nothing was agreed and take the matter tocourt 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 mustobtain a consumer credit licence, unless the credit is tied to a particular purchaseand the money is to be repaid in less than four instalments and within a year of thesupply. The BDA’s Advice Note on Consumer credit licences has more information.

The Copyright, Designs and Patents Act 1988 requires a licence to be held wherevermusic is played in public. This covers both broadcast materials, such as radio andtelevision, and recorded materials, such as CDs and DVDs. ‘In public’ largely meansanywhere outside a purely domestic setting, so waiting rooms and surgeries arecounted 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 atany one time. For broadcast materials a performing rights licence is required, whilst forrecorded materials both a performing rights licence and a phonographic performances

Health records, data protectionand freedom of information

Consumer protection

Copyright and music in thesurgery

Other essentiallegislation

© BDA June 08 34

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

Dental practices are managed in different ways and there are no right or wrongadministration systems. Most practice owners want patients to receive good serviceand for staff to be happy and well-motivated. Those that put this vision into practiceare almost always profitable, highly popular and well-managed.

Whatever the quality of service provided by your practice, it will be managed usingparticular administrative systems designed by you. The following section takes youthrough the basic characteristics of a well-organised practice.

Many practices have practice manuals, setting out rules and procedures for the way thepractice operates. The best ones are written by the staff who carry out the duties andare then agreed with the practice owners who adapt them as necessary. So theproduction of a manual can be an excellent teambuilding exercise during whicheveryone has a chance to stand back and look at the way they carry out allotted tasksand 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 runssmoothly. This section describes some of the main aspects of administration which youshould think about in order to ensure effective systems are set up. The descriptionsgiven do not assume that the practice is fully computerised, but if it is, administrationwill be far simpler.

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 apatient. Under the terms of the Data Protection Act 1998, patients have the right toinspect their records, so it becomes even more important that there is nothingincluded in them (even in abbreviated form) which you would not be happy for them

Practiceadministration

Practice manual

Records - completion andstorage

© BDA June 2008 35

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 currentfiles and “dead” files, for patients who haven’t attended the practice during the lastthree years. Records (including radiographs and study models) must be retained for aminimum of eleven years from the date of the patient’s last visit (and up to age 25 forchildren or eleven years whichever is the longer) – but preferably indefinitely, sostorage 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 oraccessible files could lead to a breach of your duty of confidentiality.

One of the characteristics of a successful, profitable practice is an efficient appointmentsystem. 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 andhave 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. Somepractices work from 8am to 6pm or from 8am to 8pm on some days, sometimesworking a shift system to offer patients the opportunity to attend outside of workingtime.

Generally speaking, most practices will open at various times between 8am and 8pmMondays to Fridays and Saturday mornings, with Sunday opening not unknown.Whatever happens, you need to be firm about your working time and make sure itdoes not encroach on your personal time. Dentistry is a stressful occupation and restand relaxation are important.

The basis of a realistic appointment system is a study of the average time it takes toperform each treatment. Over, say, two weeks your nurse might keep a record of thetime taken for each appointment, including turnaround time. Calculate the averagetime it takes you to perform, for example, a scale and polish, a crown preparation anda new patient exam. It then becomes a simple matter for you to allocate appointmenttimes to the receptionist (usually by writing the time needed on the patient’s recordcard). You should make sure never to allocate less than the norm and do not allow thereceptionist to do so, however desperate the circumstances.

Appointment scheduling

A fixed working day

The treatment sensitive system

© BDA June 08 36

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-afternoonmight be allotted with the receptionist booking these periods no more than three daysin advance. If the appointments are not filled, the time can either be used as buffers orto return telephone calls (you shouldn’t be interrupted whilst a patient is in the chair).Emergency sessions should occur at the same times each day, and these sessions shouldbe clearly marked in the appointment book using a highlighter. As well as emergencysessions, some practices also allocate and highlight (in different colours) private sessionsand those for new patients, anxious patients and those having sedation.

Outside of these specific sessions, the receptionists should allocate your surgery timeaccording to your requirements. The best approach is to write on the record card theamount of time needed (using your average time calculations). The receptionist willthen offer the patient the most appropriate appointment time according to yourpreferences. For example you might work best in the mornings and so prefer to doyour crown preps then and your try-ins and examinations in the afternoon.Alternatively you might also want to centre your system on complex procedures withexaminations and short treatment appointments slotted in around them.

The appointment book should be the sole responsibility of the receptionist who shouldbe the only person who enters or changes appointments. Obviously the writing shouldbe 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 leafor bound. Books are available from companies such as Admor or the British DentalHealth Foundation.

The information contained in the appointment book should be transferred into a daylist 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 thevalue of those treatments and it is most helpful if the fees are written in and totalled ona daily basis. This will provide a check that NHS forms have been completed and sentin correctly (if applicable).

Some practices take time at the beginning of each day to look at the day sheets for fiveminutes or so as a team. Any particular problems can be raised while there is still timeto take remedial action and it helps build an efficient team if all staff know what is goingon.

There are several ways of organising recalls, and these could be critical to the practice’ssuccess:

� Having no system at all. Some practices feel they have quite enough patients whodo 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 oftreatment. 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 areinvited to make an appointment.

NHS dental patients should be recalled according to Guidelines on dental recall from theNational 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 theassessment should include a recommendation on when the patient should be recalled.

Day book/sheets

Recalls

© BDA June 2008 37

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 agreeto buy a service if they have no idea how much it will cost. This particularly applies toextensive treatment which can represent a considerable expense. In these cases, fullwritten estimate should be given.

Most practices have a strict policy for the collection of fees. There are various differentapproaches to collecting money, which are detailed in the BDA Advice Sheet C2 Feecollection.

Quality should run throughout all aspects of your practice and a code of best practice isa useful tool to enable you to know more fully what is happening and help developcommon 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 serviceoffered 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 toproviding a high standard of service. Include in your code of practice only promiseswhich you are certain you can achieve, albeit with some effort on the part of yourteam. Ask staff to write down what they feel the practice can provide and developthese suggestions into some simple written standards. Make sure everyone agrees tothe 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 candevelop a code of practice with general aspects (to which everyone aims to worktowards) and more specific aspects which can be measured and quantified.

The practice policy for collecting fees and for dealing with complaints should be madeavailable to patients or advertised in the reception room. Also displayed should be acommitment to improve continuously the practice’s standard of service together withencouragement to give feedback.

The BDA’s Good Practice Scheme provides a solid starting point for any practicelooking to adopt best practice techniques. The Scheme is built around tencommitments of how the practice is managed and how patients are looked after andoffers a ready-made, structured code of practice to work to in managing quality intoyour 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 Association’s 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

Collecting money

Quality andbest practice

Estimates

© BDA June 08 38

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 safelyunder General Dental Council guidelines.

If you would like further information about the Good Practice Scheme or have alreadydecided that your practice would like to take part and wish to purchase an audit pack,call 020 7563 4598 or email: [email protected].

Once you have obtained premises, designed and equipped your practice, recruitedyour staff and produced your marketing plans, you are ready to open up. Some newpractices have a special ceremony to which a local celebrity or MP is invited, along withthe press, resulting in positive newspaper publicity. Decide beforehand whether to puta notice and a telephone number outside the premises informing passers-by that a newpractice will be opening on a certain date and the practice will be pleased to makeforward appointments. But be certain that you will open on that date! Even if you don’thave a public party, have a private one. Go away for a long weekend, treat your familyto 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 bookedin, make sure everything is set up, all the staff have arrived, there is petty cash in thetill, milk for coffee/tea and pens that work! Make sure everyone knows what they aredoing and then wait for your first patient.

Good luck!

By using the ideas in this guide you can avoid most of the pitfalls which can beset a newpractice owner. The most important points to remember are:

� Don’t 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 businessesmoney

� 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 don’t develop fixed ideas on how to solve problems

� Be prepared to work harder than ever before

� Don’t take setbacks personally – find out why they happened and learn frommistakes

� Keep on good terms with local colleagues – you never know when you will needhelp

� Take advice – as much as you can, as often as you can. Telephone BDA PracticeSupport whenever you are in doubt!

� Always follow GDC guidelines on professional conduct.

Opening up

Avoiding thepitfalls

© BDA June 2008 39

www.bda.org

BDA Advice Sheets

A1 Planning permission

A3 Health and safety law for dental practice

A4 Simple steps to private practice

A5 Risk assessment

A6 Marketing in dentistry

A11 Radiation in dentistry

A12 Infection control in dentistry

B2 Data protection

B10 Handling complaints

B11 Handling complaints in private practice

C2 Fee collection

C3 Business plans

C4 Private dental plans

C6 Financial management in general dental practice

C8 Fee setting in private practice

C9 In-practice capitation schemes

D1 Contracts of employment

D2 Rewarding staff

D10 Redundancy

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 containsover 100 models in MS Word to tailor to your practices needs - £157

Pictures for patients: A collection of images to help dentists describe to patientsdifferent 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 on020 7563 4555 or email [email protected]. All prices quoted are BDA member rates.

Furtherinformation

British Dental Association64 Wimpole Street London W1G 8YS Tel: 020 7563 4563 Fax: 020 7487 5232

E-mail: [email protected] www.bda.org © BDA June 2008