Here’s what you need to know about private and mixed practice:
-
Moving to mixed or private practice
-
Diversifying your practice
-
Financial management
-
Business structures
-
Buying a private practice
-
Complaints management
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Pensions and planning for the future.
1. Moving to mixed or private practice
With many dentists and the wider dental team feeling disillusioned with NHS dentistry, an increasing number of dental professionals are considering making the move from NHS to mixed or private dentistry.
Converting your practice is a personal decision, with advantages, disadvantages and preferences on both sides.
Private practice can offer:
- Reduced bureaucracy
- Increased income
- Opportunities to specialise or diversify
- The chance to spend more time with each patient.
However, it also means:
- Less certainty around income
- No access to NHS-specific allowances and grants, for example, in Scotland you lose access to rent reimbursement, capitation and continuing care payments, GDPA (General Dental Practice Allowance) and other funding
- No NHS benefits, such as parental leave and sickness payments
- No access to the NHS pensions scheme
- Your practice may struggle to be sustainable in a disadvantaged area, or if the local market for private care has already been cornered.
Some practices opt to continue a proportion of NHS work, aiming to find a balance between both systems which maximises the advantages of both.
It's a big decision, and one that needs careful consideration so you can decide whether the move is right for you and your practice.
Associates going private
If you are an associate that wishes to move to mixed or private practice, we recommend you speak to your practice owners about converting and agree changes to their associate agreements.
Associates should be aware that their conversion to private practice may place strain on the balance of NHS and private activity within the practice, which may be challenging for the practice owner to manage. Both parties should try to make these discussions as collaborative as possible, or seek our advice on negotiation.
Before making any contract changes, members should seek advice from our practice support team.
A practice's first steps towards conversion
- Informing the NHS and relevant authorities
- Informing your patients
- Planning for media enquiries
- Reaching out for support
1. Informing the NHS and relevant authorities
Converting from NHS to a solely private practice will take three months from the time the NHS notice is served, but planning for the change will need to be started sooner.
In England, if you have the NHS GDS contract or PDS agreement it will contain the right for you to unilaterally terminate the contract by serving notice at any time. Clauses 310 and 379-381 of the standard GDS contract and clauses 295 and 357-360 of the standard PDS agreement, cover this. You will be required to serve three months' notice, which runs for three months from the last day in the calendar month in which you serve it. Good communication is key to a smooth transition, so we advise you to discuss your intentions with your local commissioners.
In Wales, you will need to provide the local health boards with at least three months' notice to terminate your GDS contract or PDS agreement in the same way as in England. We advise you to discuss your intentions with your local Health Board – good communication is key to a smooth transition.
In
Scotland, if you wish to stop providing all NHS general dental service care, then you will need to provide the Health Board with at least three months' written notice that you intend to leave the dental list. It is advisable to discuss your intentions with the health board as soon as possible and agree what can be communicated to patients about the options patients have for receiving health service treatment elsewhere. You will also need to consider and plan for funding implications, as some recent funding from the NHS has been on the basis that dentists retain their NHS commitment levels.
In
Northern Ireland, if you wish to stop providing all Health Service (HS) general dental service care, then you will need to provide the Department of Health (DoH) with at least three months' written notice that you intend to leave the dental list. It is advisable to discuss your intentions with the DoH and the BSO as soon as possible and agree what can be communicated to patients about the options patients have for receiving HS treatment elsewhere. You will also need to consider and plan for funding implications, as some recent funding from the DoH has been on the basis that dentists retain their health service commitment levels.
Our template letters are designed to help you deliver this news to patients in an appropriate way. When communicating with patients, it is essential that you are not negative about the quality of NHS clinical care.
Mention can be made of the difficulties you perceive with government policy, but do not major on this. It is not appropriate, and your patients will be more concerned about the care they can receive and the cost to them. Avoid mentioning the following as patients will not be sympathetic:
- Any desire to achieve higher earnings
- Need to comply with increasing GDS regulations
- High costs and expenses
- High levels of stress and long hours.
Instead, you may wish to mention some of the benefits of private care including: staying with your current dentist, access to a broader choice of treatments, improved facilities, more flexibility in appointment times, less rushed appointments and prompt treatment.
We recommend that wherever possible, you use our template letters and tailor the advantages mentioned to the needs and aspirations of individual patients. This way they are more likely to see the benefits as relevant to them.
England:
Wales:
Scotland:
You will need to deregister your NHS patients, either with three months' written notice if you do not have the patient's agreement, or immediately with the patient's agreement; as long as the appropriate form from the Health Board is filled in and signed by both the patient and the dentist consenting to this. Practices with many patients may find it easier to give them all three months' notice rather than seek agreement from every single patient.
Northern Ireland:
If you wish to deregister a HS patient, unless you have the patient's agreement, you must give the patient three months' written notice and notify the Business Services Organisation (BSO) on the appropriate Form. However, if you have the patient's agreement, you can deregister immediately.
Some patients are likely to be unhappy with the change and they may contact the practice to complain. We recommend you take such complaints as an opportunity to explain the reasons for the change, offer reassurance that their current treatment will be completed, and take them through their private care options. It may be helpful to research if there are local dentists who are taking on more health service patients. If your patient is unwilling to move to a private arrangement, then suggesting a health service dentist who they could register with may go a long way in resolving a complaint.
This approach will hopefully help avoid the scenario where a patient escalates their complaint to social media, leaves negative online reviews, complains to the local health authority, the local press, or even local politicians.
You may find it helpful to give advance warning of the practice move to people such as the dental practice adviser, the local authority dental team and/or even make local politicians aware. If these people are already aware of the change, then they will hopefully be better prepared in dealing with an unhappy patient/voter. This should also reduce the risk that you then receive communication from them asking for more information or you then become embroiled in having to retrospectively explain and/or justify the changes you are implementing.
3. Dealing with media enquiries
Dealing with media enquiries can be challenging. That's why it's essential to be prepared. Our media team can help members plan for the kinds of media enquiries that are likely to come up during a transition to private practice.
If you are aware of media interest in your decision to move from NHS to private dentistry, or you would like some assistance in planning for the possibility, then please get in touch as early in the transition process as possible on MediaPRandParliamentary@bda.org.
4. Reaching out for support
No matter where in the UK you practice, we recommend you talk the matter through with our advisors before making your final decision on conversion.
For more advice on terminating your NHS contract, getting the wording right in any communications with patients and/or setting up private capitation schemes, speak to our expert advisors, who provide
Extra and
Expert members throughout the UK with unlimited, one-to-one advice. Call 020 7935 0875 or email
advice.enquiries@bda.org.
You can also find out more about this change, through our private practice webinars:
Getting your team on board
Once you have decided to move your practice from NHS to mixed or private, we recommend you clearly communicate the benefits of conversion to associates and the dental team.
Associates
You will need to discuss conversion with your associates. Take time to set out your vision, to get them on board. Talk and listen to your associates.
Part of the process is moving all associates to private only contracts. Before making any contract changes, members should seek advice from our practice support team.
Associates should be able to charge what they wish for private work. If they wish to charge less than the practice fee scale for private work, they will still need to pay the licence fee based on the practice's fee scale.
Associates are not employees, and cannot be forced to undergo training. However, they can be encouraged to do so and may wish to in the context of going private.
Dental staff
Discussing your plans with your staff may help allay fears for their own job security.
Clear and timely communication is essential and can help reduce staff turnover. As an employer, you are obliged not to do anything which would negatively impact or "destroy the mutual trust and confidence" that exists in the relationship, so make sure to take staff with you on the journey as much as you can.
Where possible include them in the decision-making process and actively seek their views. It may be that they are existing NHS or private patients of the practice and can give you an insight into the concerns of the wider patient base and how best to manage these concerns to avoid losing your current patient base.
Offering staff training to habituate them to new systems may be helpful.
2. Diversifying your practice
Whatever treatments you plan to offer patients outside of those covered by an NHS contract, training or post-graduate education is key. Make sure you are indemnified for those new practises too.
When planning your schedules and staffing arrangements you will need to make sure you are able to maintain your NHS contractual obligations whilst giving the practice capacity to grow the private element of the work.
Direct access to hygienists and therapists
Practices may decide whether to provide direct access treatments only after an initial examination by a dentist, or if direct access treatments are available to existing and new patients. New patients who do not wish to see a practice dentist should, at their appointment with the hygienist or therapist, be given information on the limitations of the treatment that the hygienist or therapist can provide and be advised of the need for a full oral health assessment by a dentist.
Direct access policy
BDJ collections on clinical dentistry
Webinar:
Non-surgical facial aesthetics: clinical cases
Cosmetic injectables
Injectable cosmetics such as Botox® (botulinum toxin) and dermal fillers are becoming more popular and increasing numbers of dentists are offering
non-surgical cosmetic treatments
to their patients.
The administration of Botox® is not the practice of dentistry, so it does not appear in the GDC's Scope of Practice document. It is a prescription-only medicine (POM) and must be prescribed by a registered doctor or dentist who has completed a full assessment of the patient.
BDA Indemnity includes cosmetic injectable procedures above the lower border of the mandible.
Indemnity protection
Choosing your
professional indemnity arrangement is one of the most important decisions that you will make in your professional life; apart from the obvious financial consequences, it can make the difference between being able to continue practising or not.
This is a personal choice, with personal consequences; it is not a purchase that should be determined by price alone.
No two indemnity products will be the same, so any price comparisons will not be on a like-for-like basis.
3. Financial management
To achieve your business objectives you need to research, forecast and monitor your financial performance. Good
financial management
deals with the day-to-day cash-flow of a business and financial planning to meet future business needs.
The success of your practice will depend on the right pricing structure, accurate management of operating costs and monitoring financial performance against forecasts. Cash flow forecast plan
(Expert members only)
If you are converting from an NHS to a private practice be sure to prepare for any financial impacts of the switch.
A fully private provision will not have access to various NHS allowances – in Scotland for example, you lose access to: rent reimbursement, capitation and continuing care payments, GDPA (General Dental Practice Allowance) and other funding.
In Scotland, wholly private practices also have to pay for their own practice inspections. There has also been early discussion amongst some NHS Boards who are considering ceasing clinical waste collection for private practices in Scotland.
All these extra cost implications should be considered in cost analysis, and they are likely to increase over time. Dentists will need to increase their prices annually to cover these costs, so it is better to do this regularly in small increments.
Business plans
A
business plan
sets out what you want to achieve for your business, where you are now and how you can reach your goals.
With it you can:
- Identify strengths and weaknesses to help you develop a strategy and plan
- Outline your options, areas for development/growth and monitoring/control
- Develop a benchmark to monitor progress against tasks and targets
- Monitor practice finances and identify funding requirements
- Set the direction of the practice.
Without a realistic and measurable business plan, you may:
- Lack insight into services that you could develop and the potential income
- Be unaware of potential threats from competitors
- Overestimate demand and expand too quickly
- Experience cash-flow problems
- Lack a marketing strategy to recruit and retain patients.
Business continuity planning
A simple
business continuity plan
may include details of key staff and suppliers, data backups from the practice computer system, copies of insurance contracts, certificates, NHS and governmental instructions, and other important documents.
A more detailed plan might include potential alternative work sites, technical requirements for re-equipping the practice and fully costed plans and suppliers to re-establish services.
Expert member template:
Business continuity and disaster recovery policy
Fee setting and collecting
Setting your fees at a level that covers all your costs and provides you with a target income can go a long way to mitigate uncertainty.
The
fee setting
process requires a disciplined approach to identifying all your costs and realistically setting an income that covers your general and day-to-day expenses.
Most practices have a strict policy for collecting fees. There are various approaches to
written estimates, payment methods and timing.
Ensuring the prompt
collection of fees
is crucial to maintaining cash flow and keeping your business operational. Be clear with patients about the fees they need to pay and when.
- Make it easy for them to pay
- If you offer credit, check if you need authorisation
- Follow up late payments promptly but consider how you pursue them and how far.
Most practices will have a procedure for dealing with bad debts. This should involve sending letters and accounts to patients and, when all reasonable steps have been taken to obtain a settlement, referring the matter to a reputable debt collector or the small claims court.
Debt recovery letters
(Expert members only)
Capitation schemes
Private dental plans
allow you to offer treatment options to your patients for an agreed price and can ensure a regular income if built up successfully.
The available commercial plans vary in the range of treatments covered, eligible patient groups, and the terms and conditions, including costs.
Members can get preferential rates on Lloyd & Whyte's patient payment plans. Find out more by
watching the webinar from the Flexiplan team.
Useful resources:
Practice management books and ebooks are available from our library.
BDJ collection: marketing and dentistry
4. Business structures
Partnerships
Partners are two or more dentists who jointly own and run a practice. Decisions about the business are made together; each partner owns a share of the goodwill and assets.
Profits can be jointly owned and shared, or the partners can share the business costs but retain the fees from their own work, this is known as an expense-sharing partnership. Many practitioners prefer this rather than sharing fees equally.
A
partnership is a commercial agreement
between persons carrying on a business together with a view to profit. Partnerships are governed by law, under the Partnership Acts. Partners are liable for each other's actions and enter into a very close working relationship based on trust and openness.
Dentists should only enter into a partnership after taking professional advice from a solicitor and an accountant. The practice itself and the partners should ideally be well-known to the new partner. A good arrangement is where an associate of long standing becomes a partner.
Limited companies and LLPs
Limited companies and limited liability partnership
(LLPs) offer an alternative structure for running your business. Both can limit your business liability by separating your business and personal finances and assets. Limited companies require a formal structure that is regulated, whereas an LLP allows more flexibility but does not offer the same tax advantages.
Whether you run your practice as a limited company or LLP, you will need to follow various legal requirements, including choosing an appropriate business name, identifying those with significant control in your business, and registering your company or LLP with Companies House.
Incorporation as a limited company or LLP will not suit every practice so you must seek independent legal and financial advice before embarking on such a change.
Practice Owners in
Scotland and
Northern Ireland considering incorporation, should first seek advice from
a NASDAL accountant, and review this summary of
Incorporation concerns in NI and Scotland
.
5. Buying a private practice
Owning a dental practice is, for many dentists, the culmination of their professional ambition. If you decide to
buy a practice
, achieving your goal will require a considerable amount of work.
You will need professional help to ensure that you know what to do and when; many aspects require careful planning, and timing can be crucial. Being aware of what lies ahead can help with planning and managing expectations, especially with timescales – it is likely to take longer than you think.
Having an idea of the type of practice that you want and how would you like it to develop will allow you to focus your search. Be realistic and think ahead – if you buy an NHS practice with many fee-exempt patients, a future dream of going private may be difficult. Undertake careful market research before deciding to buy or buy into a practice and consider the location, the premises, the equipment, the dental team, the patients and its financial performance.
Useful resources:
Naming your business
Choosing the right
business name
is important. It allows people to separate you from other
practices and patients to promote you in discussions about their treatment.
A name can have good and bad connotations – see our advice on choosing the right one for your business.
Protecting your business name and trademark is important. You should know where you stand if another practice decides to use your business name, or one that is very similar, especially if it confuses your patients.
Premises and sites
For many dentists, buying the premises for their practice is not an option, so finding the
right property and negotiating a lease
is crucial. You must be aware of aspects to look for (and to avoid) alongside understanding the implications of each clause and your legal obligations (and protections).
If you rent premises, your status as the occupant will carry various responsibilities.
Understanding the extent of these and the responsibilities of the landlord will allow you to plan for developments and work within the limits of the agreement. Leasing part of your practice to another professional (an associate, for example), has implications for you and the occupant that should be reflected in any working arrangement.
6. Complaints management
Patients have the right to claim a refund, repair or replacement if the quality of their treatment is not satisfactory or the treatment is not fit for purpose or as described. So,
resolving patient complaints
without delay is vital for good patient relations.
Your practice must have systems for handling complaints, and your team must be confident in dealing with complaining patients. Our advice outlines how your practice can manage complaints and feedback in a consistent and effective way.
Expert member templates:
The Dental Complaints Service
The Dental Complaints Service is a team of trained advisors who aim to help private dental patients and dental professionals settle complaints about private dental care fairly and efficiently. It provides a free and impartial service funded by the
General Dental Council.
National standards authorities
England
Each year 10% of practices in England are selected for a comprehensive inspection by the Care Quality Commission (CQC). You will usually receive two weeks' notice to minimise disruption to patient care.
The
inspectors use an assessment framework
that relates directly to the five key questions: is the service safe, effective, caring, responsive and well-led?
Each question has several subsections, each with a series of prompts to help you demonstrate how your practice meets the requirement. The inspection framework is described fully in the CQC's publication Key lines of enquiry for healthcare services.
What a good CQC inspection looks like
Northern Ireland
The Regulation and Quality Improvement Authority inspects dental practices in Northern Ireland. Their
provider guidance outlines what you need to know about inspections.
Scotland
The
Combined Practice Inspection
(CPI) Checklist includes items that are categorised as 'essential', 'best practice' or 'for information'. All items identified as essential must be met.
The CPI checklist covers:
- Practice details and personnel (part 1)
- Practice requirements (part 2)
- Observation of decontamination process (part 3)
- Individual surgeries (part 4)
- Practice/Clinic inspection visit report.
Wholly private practices will have to pay for their own practice inspections.
Wales
Healthcare Inspectorate Wales is responsible for carrying out inspections of dental practices in Wales. They assess whether practices:
Your practice will generally receive up to twelve weeks' notice of an inspection.
7. Pensions and planning for the future
It's never too early to begin planning for your retirement.
A
NASDAL accountant or a member of our pensions advice team can help you to understand how best to prepare for retirement. You'll need to:
- Learn how to maximise value and minimise tax when you retire
- Evaluate what your practice is worth
- Understand the legal aspects of disposing of your practice
- Prevent post-sale problems arising from clinical care.
Converting an NHS pension
If you have an NHS pension and are looking to convert it to private, we strongly recommend that you seek independent financial advice before making a decision.
NHS Pension benefits are considered to be relatively generous, matching those benefits in the private pension arena may prove to be expensive. If you leave your NHS Pension in the Scheme when you move to private practice your pension would be preserved, it will still attract the cost of living rise (currently based on CPI) each year. Your beneficiaries would also benefit from dependent entitlements if you died with a preserved NHS pension. If you transferred your NHS benefits to a private scheme you would have to ensure that you make alternative provision for your beneficiaries in the event of your death.
However, if you continue to make a small contribution to the NHS Scheme every month, by way of performing a small amount of NHS activity, it will keep your pension membership active. This means that you would continue to receive an increase in your benefits of CPI plus 1.5%. It would also mean that in the event of your death your beneficiaries would receive a more generous benefit entitlement.
To put the scheme into context, if we were to consider a young dentist, aged 25, with pensionable earnings each year of £60,000. For the purposes of this example, their earnings stay at exactly this level until they retire. The 2015 pension scheme would pay an annual income of £66,000 from their state pension age of 68. Over their career, they would pay contributions totalling of £322,000 (before tax relief is given). If those contributions were directed into a private pension, which was assumed to have net annual investment growth of 3% above inflation, the member would have pension savings worth £650,000. Of the many options available for using these savings, buying an annuity that would provide a guaranteed, index-linked pension (similar to that provided by NHS) would yield £28,000 per annum.
Or they could take early retirement, and the scheme would pay £33,000 at age 60. In this shorter career they would pay contributions of £262,000. If those contributions were directed into a private pension, which had net annual investment growth of 3% above inflation, the member would have pension savings worth £460,000. This would buy a guaranteed, index-linked pension (similar to that provided by NHS) of £14,000 per annum *
*all of these numbers are purely indicative and based upon a host of assumptions. Primarily they don't account for any inflationary growth or other pay growth. It assumes the NHSPS in its current form is retained. The annuity conversion rates (which convert a savings pot into an annual income for life) are based on current rates for a healthy individual and partner.
More information can be found on the NHS Pensions website
Member hub | NHSBSA
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