In our last blog we considered the importance of patient consent. One of the key elements of valid consent is the patient’s capacity to give that consent and the Mental Health Act 2005, which came into force in October 2007, deals with all issues surrounding mental capacity.
First and foremost the Act imposes a duty on all healthcare professionals to have regard to the Mental Capacity Code of Conduct. It is therefore important to read and understand this document when considering whether a patient has capacity to provide consent.
A person lacks capacity if:
It is very important to note that capacity is to be assessed at the time the specific decision is required. Therefore, a patient may have capacity to consent to some treatment but not to others, or may have capacity at some times but not others.
Under the Act you must assume the patient has capacity unless you can establish that they do not. And simply because a patient’s decision to refuse treatment is unreasonable does not mean they lack capacity.
Assisting Those Who May Lack Capacity
If you are unsure whether a patient does lack capacity, all practical and appropriate steps should be taken to assist the patient in making the decision before you determine they actually do lack capacity. This will mean changing the way you provide information to the patient; giving the patient all alternatives to treatment; considering whether there is a time in the day they have more understanding to make the decision.
Best Interests of the Patient
Under English Law no one is able to give consent to the examination or treatment of an adult who lacks the capacity to give consent, even parents, relatives and healthcare professionals. The exceptions to this are where there is a Lasting Power of Attorney or a court appointed deputy.
However, the Act protects healthcare professionals from civil and criminal legal liability if treatment is provided in the patient’s best interests. The Act states that you must take the following steps before acting in the patient's best interests:
4. As far as possible, consult other people if it is appropriate to do so and take into account their views as to what would be in the best interests of the person lacking capacity, especially:
5. For decisions about serious medical treatment, where there is no one appropriate other than paid staff, healthcare professionals have to instruct an Independent Mental Capacity Adviser
6. If the decision concerns the provision or withdrawal of life-sustaining treatment, the person making the best interests decision must not be motivated by a desire to bring about the person’s death.
Assessing whether a patient has capacity will be a balancing act. You will also need to bear in mind your duties to treat patients with dignity. This may therefore lead to difficult situations; remember to take notes of any decisions made as this will later assist if any queries are raised.
With recent and foreseeable changes within the UK dental sector, it is crucial that dental care providers continue to evolve. The demand for excellent patient care and treatment remains high and indeed many will agree that it is intensifying with modern societal pressures and increased awareness among the public.
Alongside this requirement for clinical excellence and outstanding patient care, is the need to expand services and increase access to both NHS and private dental treatments across the nation. As such, leading dental providers have been developing their services and attempting to deliver the care and treatment needed in different areas of the country.
Someone that understands this need for growth and the processes involved is Richard Smith.
Richard has a huge wealth of experience and expertise in running and developing companies and groups within the dental and pharmaceutical sectors. He began his career at Unilever before spending 30 years working in a series of roles across customer service, multisite operations management, marketing, finance and operations, including a senior role at Somerfields Stores plc. Richard later became Managing Director of Lloyds Pharmacy in 2005 and then CEO of IDH in 2010. Richard is also the Chairman of Europe’s largest diagnostic and cancer care business, Affidea, and is therefore heavily involved in healthcare across Europe.
“Having previously developed a dental business over four years to become the largest in the world, as well as being actively involved in the expansion of a pharmaceutical chain company, I have a fair amount of experience regarding what happens when an organisation grows. With my responsibilities in previous roles including management of the financial, legal and technical aspects, I have also developed an extensive network in these areas.
“As with anything, you often learn the most when faced with situations where something has gone wrong. I have witnessed a variety of circumstances throughout my career in the dental, pharmacy and retail sectors, which have contributed to my understanding and knowledge of such projects. Even for companies that are very well run, some changes must still be made in order to ensure the new business structure is well supported.
“Despite growth plans, I believe it is very important for dental providers to remain true to their original ethos and values. Care for patients should always remain the top priority; it’s crucial to maintain this alongside increasing access and developing the business.”
This is a view share whole-heartedly with Rodericks, a leading dental group in the UK committed to providing excellent patient care and service and increasing access to NHS and private dentistry.
Richard recently joined Rodericks as a Non-Executive Director and he is looking forward to sharing his expertise in order to help drive the group forward.
“I initially met Shalin Mehra, Managing Director of Rodericks, when I co-founded the Association of Dental Groups and he became a member. A very down-to-earth and personable man, his passion for dentistry is evident and I quickly became impressed with his organisation. As a dentist running a dental group, he naturally brings dental excellence to the fore and I believe his group to be the best quality operation in the profession. When Shalin asked me to get involved I was delighted by the opportunity – I don’t think I would have gone anywhere else in dentistry.”
Concerning his new role with the dental group, Richard clearly has an abundance of experience and skills on which to draw.
“It is still early days for my involvement with the dental group, but my major focus with be on what we can bring to the growth plan of the business. As changes are implemented to facilitate growth, I hope to help make sure the transition is as easy and as effective as possible. Based on my previous experience, I hope to help the group avoid any potential pitfalls as it continues to expand with a key focus on excellent patient care.”
For Richard, a huge benefit of returning to dentistry is the opportunity to visit practices and meet the staff on the ground.
“I have really enjoyed visiting the practice and management teams – it’s probably the main element I really missed when I took a break from dentistry. It’s great to meet the team in-person and discuss any concerns or successes, and I am looking forward to doing this again.”
Looking to the future of dentistry, Richard comments:
“There is a definite move towards consolidation of the dental market, but approximately 85% remains independent. While I believe there will always be a place for the independent practices, I think there will be a growing place for corporates to introduce brands and collective ways of working in dentistry.
“What’s more, the future of dentistry might soon encompass other primary care. In various industries I have experienced diversifying from the core services provided, because there is the opportunity to provide more for patients within the existing setting.
“In my opinion, Rodericks’ clinical background will make it well-placed to capitalise on these prospects in the future. However the ownership looks in 20, 30 years time, the organisation could be the embryonic beginning of a very successful, major force in corporate NHS and private dentistry. Whatever happens, the group will be an incredibly good platform from which to successfully develop a model synonymous with the future dental sector.”
For instance, there can be many reasons why a particular strategy or business approach doesn't garner the results you desire, but without the experienced know-how of business specialists, dentists may find they lack the commercial insight needed for their practice to be a success.
Naturally, such insights are gathered over a long period of experience – lots of trial and error – and are based on seeing first hand what works and what doesn't. Having worked with dental practices for many years, at 7connections we have established the following 7 pain points that at some time every practice will have to overcome in order to succeed.
1. Lack of Balance
In a recent survey that asked what factors are most important to the UK population, 53.7% said work-life balance was the top concern.[i] And yet according to data from the office of national statistics, almost one in two adults report low satisfaction with their work life balance.[ii]
As a practice owner, you can spend 28-35 hours a week performing clinical activity, and then still have to run your business; this can be at least another 10 hours! Achieving a balance therefore requires reducing the time spent working, which means either getting a better team or utilising better systems.
2. Lack of Profitability
When you work hard, you naturally want to see your business making money. However, most practices will suffer at some point from a lack of profitability. In short, if your practice costs more to operate than the amount of revenue generated, then it will soon face real problems. But if you employ the correct model and well-established systems this can easily be avoided.
3. Lack of Growth
Business growth is essential, you should aim for growth to be at least in line with inflation, and more if you want to eventually sell for a profit. Therefore if you experience a drop in turnover or a lack of progress across your business, it’s time to consider a change.
4. Lack of New Patients
A dental practice will always need new patients. To achieve a steady flow, all you need is 20 leads per full time dental surgery per month. Ideally these patients will spend between £1,500 and £1,700 in their first year with you. This will help deliver the sustainable growth required. But bear in mind that every aspect of your practice affects how new patients invest in your services. From your marketing to your systems, to the way your reception looks, it is essential the patient journey reflect the demographic you want to attract.
5. Lack of Team Trust
For any successful business, you need a motivated team who all perform and behave according to your exacting brand standards. However, developing and maintaining a dedicated workforce can be one of the biggest challenges you’ll face. Remember any system you create is only as good as the people you have implementing it.
6. Lack of Systems
We talk a lot about systems, and for any business to be a success it needs well thought out systems that underline everything you do. Every part of your business should have a system that exists in a manual that your team can refer to and implement. To begin with this requires a lot of hard work, but will ensure that later down the line, your business is ready for the future growth and expansion you desire.
7. Lack of Productivity
A key component of success for any dental practice comes down to the individual profitability of every fee-earner in the business. It’s vital to analyse the productivity and profitability of each clinician, and to ensure they are always kept busy – and in order to do that you need leads and conversions.
If these pain points are sounding familiar there are solutions that will help to address them all. In order to fix these points and build your business you will need to optimise every part of your practice – both through the right use of human resources, and through implementing efficient systems and protocols.
The best place to start this is in reviewing your Patient Journey and evaluating how you attract and retain new patients. The much discussed seven-step principle known as ‘lifecycle marketing’, can help you to optimise this process, as it effectively encapsulates the process of attracting new patients and retaining them by building and developing long-term relationships.
Alternatively, please visit the new website www.7connections.com.
[i] What do workers look for in a job? http://careers.theguardian.com/careers-blog/what-employees-want-job-company-around-world [accessed 13.3.15]
[ii] 48.4% of UK adults reported relatively low satisfaction with their work-life balance. Office for national statistics, http://www.ons.gov.uk/ons/rel/mro/news-release/measuring-well-being-initiative-highlights-work-life-balance/whatwedonr0312.html [accessed 13.3.15]
This study looked in detail at the patient journey and found that: “for most participants [this] involved feelings of trepidation and anxiety in the lead-up to the appointment.” It went on to state that, “Much can be done to set patients at ease through good communication and friendly and relaxed staff.”
While plenty has been achieved since 2009 in regards to improving the patient experience, many practices could still benefit from addressing the fundamental communication issues that lie at the heart of the patient journey. After all, whichever business model your practice follows, whether Private, Mixed, NHS or multi-practice, the key aim will be to increase sales and profitability, and at the centre of that is the patient journey. This is what keeps your patients coming back or encourages them to attend your practice in the first place.
So by understanding your patient journey, looking at each stage in turn – and clearly communicating it to your patients – you will naturally create a more successful practice. Some do this extremely well, while others are far less consistent. For instance, a practice that has taken into account their patient journey might have a clear description on their website, detailing everything from first contact right through to aftercare and follow-ups.
This approach empowers patients with the foreknowledge of what to expect. Which in turn creates more and better quality leads, happier patients who appreciate you and are easier to serve and a more efficient business where you can cope with increased patient numbers without the need for more team members.
This might all seem too good to be true; it isn’t – but it does take a lot of hard work to achieve and is not an overnight project. Central to it all is understanding your own patient journey, providing clear communication and enhancing and enriching the patient experience.
What is the patient journey?
The patient journey comprises everything from the first visit to your website to any treatment itself and beyond. It covers every interaction or point of contact between patient and practice and is impacted by everything you do, this includes:
· Phone calls (in and out bound)
· Communications by post
· Text messages
· The service provided in reception
· Interactions with the dentists and associates
· Interactions with the dental nurses and treatment co-ordinators
· Posters, advertising, leaflets
· The content of your website
· Follow-ups post treatment and aftercare.
In order to get to grips with your patient journey and understand how this affects your patients and their decisions, it is crucial to analyse each interaction, deciding what you want those exchanges to say about your practice and what the desired outcome of each is.
To get this right you will need to focus on your brand and consider exactly what it stands for. You might decide your brand is clinical and professional, or friendly and welcoming, but whatever message you want to deliver must be consistent throughout each and every interaction; from the tone of voice to the way your practice is described.
Each point of contact will likely have a slightly different key message, so it is also vital that this is clearly communicated. For instance an email sent to a prospective patient should have a very different message and content to that of a phone call to arrange a follow-up.
Whatever the message, medium or content of your interactions, it is crucial that each one works to build trust in your practice and services.
Most dental patients don’t understand what they’re buying – they know their teeth hurt, or they look bad, but they don’t understand how to make the right choice. This means you have to assure them they can trust your practice and every member of your team.
To do that you need to be consistent: have the same branding everywhere, with every communication to the same standard, and all the team in the same uniform. You must be accurate, having the correct pricing on every document, good spelling and grammar, and their paperwork ready when they come in. You also need to be up-to-date – not having pictures of old team members on the website; and provide all the necessary details when asked, explaining exactly what’s going to happen, and what the differences between treatment options are.
Once you’ve spent time considering and designing your patient journey, looking at the ways you build trust and communicate with your patients, you will need to find the best way to implement these changes. This is where turning to a proven solution can help. 7connections, along with software giant Infusionsoft can assist your practice in implementing the ideal patient journey using the much-discussed Artisan Lifecycle Marketing approach. A marketing and lead generation system, it addresses the patient journey from start to finish, so that you can begin to grow your business through increased efficiency, higher productivity and more satisfied patients.
A strong patient journey is one of the most fundamental aspects of creating a successful practice. By spending time focusing on how your patients experience your practice from start to finish, you will ensure the service you provide is always of the highest calibre.
Alternatively, please visit the new website www.7connections.com.
 The Patient Perspective, 2009. Available at: http://www.gdc-uk.org/Aboutus/policy/Documents/RevalidationThePatientPerspective.pdf [accessed 29.4.15]
The companies have already benefited many patients across the US and UK, and continue to grow through their new partnership with Toothpick, the UK’s leading online booking platform for dental appointments. The new partnership aims to further increase accessibility to private dentistry, ultimately reducing the gap between NHS and private care, and it all begins with the introduction of the ‘Toothpick VIP’ card.
How does it benefit the patient?
The ‘Toothpick VIP’ card is cost effective and simple to use, and through its use, patients can benefit from an immediate 20% discount on private dental treatment at participating practices in the UK.
The card is available for a low annual fee and it is possible to include family members into the plan. This money-saving scheme offers unlimited use, and can be used for both pre-existing conditions and emergency dental treatment.
How does it benefit practices?
Because this scheme is not an insurance policy – it is a money saving option – it is beneficial to dentists and patients alike. Essentially, any practice in the UK that is registered with Munroe Sutton can offer this service, which is likely to attract new patients, in turn increasing practice profit. What’s more, practices are likely to receive positive reviews and build a good rapport with new and existing patients.
Working with Munroe Sutton offers copious opportunities for networking and free promotion, as it liaises with customers of leading companies within insurance, finance and healthcare. Ultimately, involvement with this scheme could allow you to develop and unlock your business potential and it is completely free to join the network.
With studies showing that only 61% of people in England attend their dentist regularly[i], it is crucial that schemes such as ‘Toothpick VIP’ continue to be implemented. As prices continue to rise, so will the number of people that miss out on necessary treatment.
For more information please call 0808 234 3558 or visit www.munroesutton.co.uk
[i] British Dental Health. National Smile month. Facts and figures. May 18 - June18, 2015. Accessed online June 23rd 2015 http://www.nationalsmilemonth.org/facts-figures/
Its becoming very apparent that there is a distinct lack of transparency where some practitioners are concerned with regard to what is and isn’t available on the NHS. This has been going on from the beginning of the new contract, and has caused much heated discussion over the years.
When you consider that not even the CDO was prepared to give an actual list of NHS treatments, instead relying on the ‘All that is Clinical Necessary’ definition that is deliberately intended to obfuscate, then it isn’t really surprising there are almost as many different interpretations as there seem to be contract holders.
We can argue amongst ourselves as to when something should be, or can be provided on the NHS, but the end consumer, the Patient, is stuck in the middle of this unsatisfactory situation, and that should be our prime concern.
The GDC are now starting the come down on those practitioners who they feel have been misleading, or even dishonest in their definition of what is available, and since the balance of probability legal test is used, the weight of evidence does not have to be as high as a criminal issue to find a practitioner guilty, and then suffer the consequences.
However, until recently, the difference of opinions as to what is legitimate and what is ‘gaming’ has largely been discussed only within the dental profession itself. This is NOT intended to be a blog about what gaming is; it’s sufficient to say though that we have to acknowledge it exists within the profession.
This week, Which? have now waded into the argument, with a campaign to ‘Clean Up Dental Costs’
It would appear that they have found this distinct lack of transparency in the pricing of dental care, and in particular the differences between private and NHS care. Not only that, they appear to have also found that about a quarter of those surveyed were unsure of the differences between NHS and Private.
More worryingly, 40% of respondents were unaware that all treatment that was clinical necessary was available on the NHS. This lack of awareness plays right into the hands of those practitioners who have been guilty of perhaps ‘massaging’ the NHS contract to their benefit and not that of the patient. One question it asks is who is responsible for the overall education of the general public as to what is available to them; it is accepted that expert opinion and advice is needed when the general public seek the aid of a professional, so they can perhaps not be held completely responsible for not knowing the ins and outs of dental treatment. On the other hand though, is ‘All that is Clinically Necessary’ too difficult a concept for the Government via NHS England to convey to the populus in some way? The lack of this clarity has lead to varying degrees of confusion, alternative interpretations of the contract (not tested in law to my knowledge) and downright dishonestly and misleading behaviour at the expense of the patients.
Whenever gaming rears it head in discussions on this and any other forum it polarizes opinion hugely, and usually ends up in a slanging match of NHS vs Private. As I’ve said this is not the aim of this blog, but merely to get people to think about the consequences of what we in the profession have begun to create for ourselves and our patients.
It’s one of the huge elephants in the room in our profession at the moment.
There is no doubt that gaming is rife amongst some practitioners. Not all of them, but I would wager that there will be a fair number of mixed practices that are operating at the very edge of what is actually the correct definition of ‘Clinically Necessary’ throughout the country. The fact this aspect of the contract has not been tested in law is probably somewhat fortuitous for all concerned.
Of these practices, I think there will probably be some of them actually deliberately seeking to maximize their financial advantages over those of the patient. This is in direct breach of the GDC standards relating to putting a professional’s needs over that of the patient. It wont be an excuse to use ignorance of the rules of the contract to defend this either, or the continued financial survival of a practice. The continued ignorance of the patients in knowing what is and isn’t available themselves, and the plausibility of the explanations given (‘its isn’t available on the NHS’ is a difficult phrase to argue against for a majority of patients) mean it is simple for some practitioners to pull the wool over the eyes of the public.
If we want to take a stance against the way the GDC is acting at the moment, but there is sufficient evidence that some practitioners are being more ‘flexible’ with the interpretation of clinically necessary, then we can hardly take the moral high ground against them, as individuals are misleading the public the GDC are tasked to protect. How can we protest at that? When we have a Chairman of the GDC who has a background in the Office of Fair Trading it is not beyond the bounds of thought that his wish to broaden his remit has the tacit approval of the powers that be, and will include any future tests of NHS vs Private provision. Incidentally, Which? are not calling on the profession to clean up their act; they’re calling on our regulator and NHS England to do it for us.
In addition, if the Big Lie is to be exposed in all its glory, we as a profession can’t then be seen to be obscuring the failure of the contract by blurring the treatments that patients are receiving on the NHS and Privately. By misleading patients as to what is and isn’t available, to the benefit of the practitioner, is never going to expose the lack of funding inherent in the system.
Lack of transparency of fees has always seemed to be a problem with our profession. The artificially low NHS prices when compared with private means a significant number of the population have no understanding of the real costs of dentistry, and I think we really as a profession don’t go far enough to explain this to the public. Couple that with the confusion now as to what is and what isn’t available on the NHS then it is no wonder Which? have waded into the fray on the side of the consumer.
I personally don’t think it will be long before some form of disclosure along the lines of that seen by Independent Financial Advisors will be compulsory. With the GDC being final arbiters of our professional conduct, any lack of transparency in financial issues are already taken as being as serious as those of clinical errors. We will therefore reap what we sow where it come to financial misdemeanours.
We are in an ever increasingly consumer driven society, and we have to get our house in order if we are to retain the professional status we think we deserve. If we don’t, then we only have ourselves to blame for what is then enforced on the profession in the future. We can resist consumerism and try to hang on to the last bastions of professionalism, but if some of our profession are less open with their dealings with those consumers, then we will all pay the price.
The consequences of gaming are coming home to roost whether we like it or not.
As the autumnal fall returns once again and the ominous portent of a Comet Ison in the morning sky passes I am minded to wonder at our innate ability to disagree. There is a really intriguing book out there called Them and Us: How Neanderthal predation created modern humans by Danny Vendramini  Basically, our behaviour is nothing new!
The BDA saga has not gone away, we are told – well, actually we are NOT told … but the vox pop of internet chat suggest that those in office at the BDA are running in internal disagreement, and of course all the outsiders like myself are far better placed to run the show. There is no agreement it seems, and we are polarised into them and us.
Then of course there is how to deal with ‘the problem patient’. Not only do we all differ, separating into the “This is how to do it” camp on the one hand, and the “No you fool, do it this way” camp on the other. Never mind that the poor bloody patient is always wrong. Them is always right and Us is never wrong.
Orthodontics appears to be generating a fair share of divisionary comment: Far from everyone synergising to the wider benefit of the patient community and for the greater good, we just have to bicker and squabble over long term or short term, GDP or specialist , ultra modern self ligating or out of date elastics. Throw in a spooful of commercial self interest and the fuse is lit for a right royal bust up.
What would the public think? Oh – them and us again!
There is a fine line between appropriate professional disagreement and internecine warfare. We must as a profession beware of breaching it ... if we actually care. Maybe we just like a good fight!
Gawd ‘elp the poor old GDPs if the BDA and BOS combine forces …
Seriously: who will draw this disparate medley of headstrong prima donnae professionals together?
If we fight amongst ourselves, the Governments work is done.
Ah … now there is the Ultimate “Them and Us”.
I blame Comet Ison. Enjoy Thanksgiving, don't all fight over the Turkey now. That would far too Neanderthal ...
Them and Us by Danny Vendramini
With acknowledgement to the author for the image