Tuesday, 12 February 2019

Do you know a practice like this?


I have recently been contacted by several practices to help out and problem solve situations that have been presented to me as performance issues that need to be sorted. I am pleased to say that in every situation I have resolved the problems I have been brought in to address.

The following situations are a blend of the commonalties from many practices. Generally, I am contacted by the practice manager who is at the end of their tether, frustrated, and doesn’t know what else to do. Unfortunately, they often don’t have the support of the principal who wants nothing to do with the problems within the practice.

Generally speaking, the team is not functioning, everyone is having a stressful, tough time, tensions are high, conversations fraught and there is a cultural reluctance to support one another. High sickness, abscess and staff resignations, money is very tight and there is little, if any, investment in the practice or the team, appointments books are gappy and patients often arrive late or FTA. Despite this most practices that contact me have not yet had a serious patient complaint, significant incident, or unfavourable CQC assessment. I am contacted because there is the recognition that it will not be long until the house of cards collapses.


In most cases, the principal operates two or three multi-surgery practices 30 miles or more apart, one or two are usually fully NHS staffed by associates, and one is fully private which is where he is based.  Some associates from the other practices come to the private practice to do occasional sessions. The principal is stressed about money, the NHS practice(s) is haemorrhaging money, associates are behind on their UDA’s, they sell very little private work in the NHS practice, costs are spiralling and the spectre of clawback is looming. The nurses and receptionist clock watch and are out of the door as soon as it is home time and often arrive just on time or late and never early. The principal is often so concerned about time keeping they install CCTV or electronic clocking in systems. To keep an eye on the UDA’s the principal looks at appointment books remotely and are constantly on to the associates and practice managers about gaps that appear. The principal’s primary concerns are associates not achieving UDA’s, the practice manger not being on top of problems and bothering him, support staff not staying to get things done. They are fed up, stressed, and are considering throwing in the towel, this was not what they had imagined dentistry and practice ownership to be.


The practice manager may or may not have a nursing back ground, they struggle with understanding CQC and the other compliance issues. The principal is always moaning about his support staff and their inadequate performance, clock watching, being short staffed, lack of commitment etc. The manager feels undermined as the principal contacts her every time there is a space in the appointment book within the next fortnight - 3 weeks. She has not had any formal training in leadership, management, or how to run a practice. The managers without a nursing background are not given the opportunity to spend any time in the surgery to find out what happens. The practice manager has more than enough work to fill her hours and yet for at least half of the week she is taken away from her duties to help out the receptionist or fill in for an absent nurse. No wonder she feels overwhelmed.



The head nurse is at the end of her tether. She has been qualified for many years, has extra qualifications. She has recently been brought in to “get the nurses sorted out.” Despite the extra experience and responsibilities, she is still paid less than if she worked the checkouts at the local supermarket. All the nurses in the practice are apprentices or been nursing for less than 2 years, none have a qualification or enrolled in college. The head nurse expected to train them in-house even though she is allocated to surgery duties for all the hours she is in the practice. The head nurse is very concerned about cross infection control, policies are not being followed, HTM01-05 is not being adhered to and the surgery assistants will not remove nail varnish false nails, jewellery, tie back hair etc. Another source of frustration is clinical versus non-clinical clothes. When the head nurse asks her colleagues not to come to work or go home in their scrubs but instead to arrive in non-clinical clothes then change at work; she is told they don’t have time to get changed and prepare or close down their surgery in their contracted hours. Because they are not paid overtime, they are not prepared to come in early or stay late just to get changed. The head nurse feels undermined and unsupported by the principal and clinicians. At a recent social after work the nurses went to the pub in scrubs, when she said this was not compliant, no one would back her up. A predictable situation the nurses feel underpaid, undervalued and taken advantage of with how much extra they are expected to do unpaid in their own time and therefore play fast and loose with compliance. When the head nurse shows her colleagues the best way to pouch and date instruments, so they are correctly sealed, she is ignored. She is very aware that each surgery works completely differently and there is inconsistency, no protocols for set up/clear down or how procedures are carried out. Although she was brought in to train nurses there are no pre-existing training protocols and she has been denied time to develop and implement one and is expected to do it at home, in her own time with no extra remuneration, just for the love of it. She feels impotent, she is passionate about her job, sees the mistakes, and the opportunity for improvement and career development, yet she is not given the time, resources, or support to be able to deliver what she has been tasked with and she feels criticised and judged by the principal who is not seeing changes other than increased resentment.


The nurses are all young apprentices on apprentice salaries. Historically there has been a high turn-over of staff. The training is all arranged in-house with no one registered on a formal training programme. However, there is no time allocated for training or mentoring and the nurses are expected to ‘pick-it- up’ as they go along. The nurses are resentful of the new head nurse who is now telling them what they should or should not be doing and they don’t see why as no-one has told them off before.  Despite their lack of training they are convinced they know best and will contradict, the head nurse, practice manager and the clinicians. Lunchtimes are always shorter than 1 hour as that is when emergencies are seen and they don’t have time to get changed into and out of their scrubs when they go out for a sandwich or a cigarette. Why should they use even more of their own time getting changed when they don’t get paid over time for working through lunch? There is not a practice cleaner and the nursing duties include cleaning the practice before they leave. There is a lot of resentment between the team as they share a decontamination room and don’t have a dedicated surgery, a big area of resentment is that instruments are being left at the end of the day, not being pouched. The reason being is that they are not paid over time beyond their contracted hours,  they don’t have enough time to get everything done, including the cleaning, before they go, especially if the surgery is running late. The nurses would prefer to work in the private practice because there are fewer patients and they get time to do their work, however they are having to pay a lot more in travel expenses and child care and this leaves them out of pocket so they and so object to working in the private clinic. The nurses are resentful and feel under-valued and underpaid and don’t understand why the principal won’t pay them a respectful salary or overtime especially as he has at least 4 foreign holidays a year and his Mercedes are never older than 3 years.



The associates are all young, qualified between 1-5 years and all but one is an overseas qualified dentist. They cover both the NHS and private clinics. The associates are fed up with being berated about UDA targets. They feel they are doing their best and they find it difficult because they are frequently working with different nurses, who are unskilled and unfamiliar with both the surgery and the dentist’s style of working. The clinics often run late with double booked emergency appointments, patients complain and nurses put pressure on the clinicians to dish out antibiotics rather than opening a tooth for drainage, because they dont get paid for working through lunch or at the end of the day. Added to this the equipment often fails and they are expected to sort out problems because the principal won’t get an engineer in. All of the associates were offered the jobs on a low % of gross with the promise of mentoring and private work to compensate and this has never been forthcoming even when requested. There has been a frequent turn-over of associates and newer associates have been pressurised into signing contacts with large financial penalties if they leave within 2 years, these associates now feel they have been misled and trapped. Areas of concern that the associates have include, not understanding the NHS UDA system, what they can legitimately claim for, what private options they can offer and why they have to use the same materials for NHS and private patients.



Reception is generally covered by only one receptionist although there can be five surgeries running. When things are very busy, she is helped out by the practice manager. She feels like she is never on top of anything as the phone rings off the hook, all the estimates are directed to her printer and she has to go through the treatment plans and get all the paperwork signed. The receptionist has never worked in surgery and does not understand what treatments involve and feels that she should not be talking through treatment options on the front desk and that dentists should have printers in their surgeries and discussing treatment plans. One of her biggest challenges is managing pain and emergency appointments, the principal will not allow emergency times to be pre-allocated because that risks gaps in the book if there aren’t any emergency slots and consequently the patients are double booked or seen in lunch times. The receptionist feels that she is working in a war zone, constantly fending off patient’s criticism, she knows that it won’t be long until a serious complaint letter arrives.

How would you manage a situation like this, put the nurses through an aggressive performance management programme, which is what the principal wants to do?

For us this is not a performance issue is is a paradigm issue. Resolving the problems in a practice like this are simple when you use a simple multifactorial approach. When a practice is struggling, a team is in mutiny, finances are tight, there is seldom a single factor as a cause and therefore not a one hit wonder solution. We create long lasting cost effective solutions


How we work.
We offer a comprehensive multifactorial holistic approach to the health and well-being of the practice and the team as required.


A key starting point is the principal has to admit that the present situation is not working and acknowledge a new approach is required, investing time, attention and money. A process of active evaluation, reflection, decision making and taking action.

Areas that we support our clients in will include,

1.     The culture and values of the practice. What is it that the practice has been established to achieve, how will everyone know when this has been achieved? Highly successful practices are built on a solid foundation of key values and a culture code which are consistently demonstrated in behaviours creating an environment which exists with integrity.
2.     Time management. How is everyone making best use of the time available, without being put under duress. How can the appointment book be run so that patients can be offered appointments when they need them and appointment lengths are sufficiently long to do the correct treatment well?
3.     Financial control. Make sure everyone in the team has an understanding of the income and expenses budget, profitability goals, and their role in helping the practice achieve them. Get conscious about the costs and pricing structure so everyone knows how much the practice needs to generate to stay afloat.
4.     Team work. Create an organisational structure that guarantees that all the functions of a sustainable practice are fulfilled to a high standard. Create a culture where the team are respectful, respected, appreciate, appreciated, help and helpful. This will involve regular conversations that are curious and constructive. A pay structure that is fair and transparent. Appropriate training, mentoring and coaching programmes for all members of the team so they are able to master the skills they need.
5.     Customer service. Putting the patient’s wants, needs and preferences and the centre of what you do. Actively creating a world class patient journey and experience that delivers great dentistry, beautiful smiles. Who wants easy jet when you can fly Singapore or Quatar?
6.     Systems. Development of systems, processes and a practice-operations manual.
7.     Leadership. Understanding what leadership is, who are our leaders and influencers in practice, what are their roles, responsibilities, and the inspirational repercussions.
8.     Work-life balance. Creating a way that all team members can balance their work and home commitments so they can be the best version of themselves in every environment without sacrificing their sense of self or personal values. Creating practices free from stress, anxiety and worry, full of confidence, calm and commitment.

Once the solid foundations have been established then we will assist you in focusing on marketing and sales to generate and retain more patients and deliver larger more complex and profitable treatment plans.

Experience shows that to chase the money and the profit before the secure foundations have been established, the money runs away.

We work with our clients to build the solid foundations through
  • Workshops such as Transform your practice in 10 Days
  • 1-2-1 Coaching and mentoring
  • In-house practice training.


If you would like to know more, please e mail Jane@IODB.co.uk or call 07989 757 884



If you know a practice similar to the one above please contact us, we are here to help, support and transform.