WheelcropDr David Houston outlines how he has successfully grown his group of practices using a hub-and-spoke system

Our group of four practices is based upon the model of a large central hub (established 26 years ago) and three major ‘spokes’, which have been developed in sequence over the last eight years.

The ability to refer patients within the group is a core principle of our operating methods and is central to our philosophy of maintaining a full-service practice with continuity of quality cohesive care provision on behalf of all of the patients for whom we provide treatment.

Obviously excessive distance could be a deterrent to patients’ attendance at any referral practice whether within a group structure or out with it. Consequently, we have confined the establishment of our outlying spoke practices to a distance of less than 20 miles from our central base hub. This range does not seem to deter patients from travelling to receive specialist secondary care. (Although we concede that we are fortunate to benefit from excellent motorway links between the practices which undoubtedly assist in facilitating the ease of patients’ journeys.)

A one-stop shop

Inherent within the methodology behind our working protocols is the desire to provide a full-service, multi-disciplinary referral practice.
Thus, we have recruited professional colleagues who have developed their careers in the fields of: oral surgery, implant dentistry, periodontics, IV sedation, facial aesthetics, restorative dentistry, removable prosthetics and endodontics. These individuals provide private sector secondary care on behalf of the 35 clinicians within our group.

Although, it is conceded that our relatively unique size – we have 90,000 regularly attending patients – provides us with a substantial in-house referral base, we believe that our model could be applicable to any practice seeking to develop in a similar manner, although they may require to source an increased number of outside referrals.

Due to the nature of today’s society and the need to service the expectations of a private patient demographic, almost all of these practitioners work on a Saturday to supplement their weekday sessions. Consequently, reducing potential barriers to treatment uptake.

Despite our relatively large size with over 30 clinicians providing mixed private and NHS dental care to almost 90,000 patients, commercial viability is assisted by accepting referrals from other practices across our region.

In order to help generate these referrals, patient and clinician referral packs have been produced for widespread distribution within our own practices and to numerous other practices within a conceivable travelling distance – which in reality has become approximately a 30 miles radius. Printed referral forms remain a popular contact medium of choice for most user clinicians but our practice website allows for electronic data communications. Naturally, some of the specialists will cross-refer in-house for multi-disciplinary cases.

Facilitating change

The relative lack of Government funding for NHS secondary care in our region (despite the nearby presence of Bristol Dental Hospital) is a very helpful facilitator for patients seeking and accepting private sector care on referral. Long NHS waiting lists and occasional refusal to accept referrals for certain types of case at local secondary care provider sites, undoubtedly increases patients’ acceptance of private sector alternatives. Although, in our provincial location gaining consent can still remain a price sensitive issue. This was particularly relevant during our initial establishment of the service which took place during the recession.

Inevitably, a considerable number of the patients who receive treatment on referral are primarily recipients of NHS dentistry. Consequently, to meet their perceptions of private sector secondary care we provide our referral services from dedicated, stand-alone buildings (even for our own patients) with their own self-contained facilities.

In this way we seek to reassure any referring practitioner from outside our group that no ‘poaching’ of their patients will occur and that they will be returned to their care without having been exposed to our general practice facilities or encouraged to remain as a routine patient of our group.

Model for expansion

Size really does matter! (At least in our business model.) Although we operate as a cohesive and intimately linked group, each branch practice must be commercially viable and thus by definition self supporting.

Our aim has always been to purchase practices with unrealised potential. These possibilities should relate to both its size and the range of services provided. As such, our starting point has primarily been to seek well-established, two-surgery practices of local repute with space for expansion. The ideal combination of cost efficiency and manageability for these regional spoke practices appears to be a four-surgery design providing mixed NHS and private-sector care.

We provide some NHS care to help encourage initial patient attendance, such that no perceived barrier exists to accessing care should a new patient have reservations concerning an immediate commitment to private-only care at a new practice of which they have no previous experience.

The model aimed for is that three of the surgeries are dedicated for associate dental surgeons with the fourth being used by a dental hygienist. Obviously we seek practices in locations where the population size and demographic can sustain such an immediate and substantial expansion primarily in the private sector.

Fortunately, the Government’s house building policy across the South West has resulted in many local towns that have been forced to expand their populations in order to meet statutory residential property targets. Together with the budgetary restraints which have endured since the instigation of the nGDS NHS Contract in 2006 which ensure that the NHS LAT have no funds to increase NHS access, these two factors have provided us with fertile grounds for expansion in the private sector.

Design matters

Discerning patients receiving private sector care expect a certain level of facility and design to be applicable ‘as standard’ to their experience of visiting a private general or referral practice. We have recognised and responded to this by creating a bespoke style of interior which, whilst clearly linked by colour scheme and consistent furniture choices between each separate location, is redolent of a quality, if neutral design, suited to the architecture of the building in which it is housed. Our hope is that this reassures patients that their expectations of care and administration will be met both front of house and behind the scenes.

Marketing efforts

By definition, any referral practice requires practitioners to supply patients for advanced or secondary care. Our in-house referrals can be facilitated by an internal mail system. However, we seek and require additional outside referral sources for the overall growth and development of the service.
In the internet age, naturally our practice website is configured to allow and provide a function for e-mailed referrals from professional colleagues. Similarly, browsing patients have the ability to self-refer for consultations should they seek a direct access option. The website is detailed and informative, being heavily illustrated and deliberately champions the use of jargon-free language.

Nevertheless, we continue to find that printed hard-copy referral and information packs remain a staple and invaluable marketing, educational and sales tool. These consist of a group-branded card folder which can be filled with topic or treatment specific information booklets. (The actual printed referral forms are dual-sided with a patient medical history form on the reverse for ease of use.)

All of our marketing publications can be dispensed by both clinical and reception staff such that even a casual walk-in enquirer can leave with a wealth of information and publicity material.

Equally, they are clearly and attractively displayed in all of the public areas of each of our practices in order to encourage interest from and uptake by patients.

Something for nothing?

Despite the contentious nature of the policy for some readers, we maintain the principle of offering free initial consultations for any interested patient.
Naturally, we concede that this can be open to abuse, resulting in some missed appointments and critics will state that this is because a prospective patient does not value that which is provided free. However, our own analysis supports the perceived benefit of placing nothing in the way of a patient’s enquiry and thus encouraging speculative approaches which can be converted into consented treatment plans.

Commercial realities mean that our treatment pricing structure includes a retrospectively applied margin to cover the costs associated with offering these initial free consultations.

Extra curricular activity

To engage with potential referrers, evening post-graduate education events are held at the hub practice’s in-house lecture theatre. These are free to attend for local practitioners and they are hosted by the individual specialists, who provide updates on developments within their respective fields of expertise.

We consider that such events foster good relations with referring practices and facilitate comfortable working relationships with other clinicians who we hope are reassured by the knowledge, skill and character of the specialist.

Similar open-evenings have been provided for prospective patients. To ensure attendance they have been held on a by-appointment only basis with all bookings confirmed in advance. In order to retain attendees’ interest it is essential that any presentations are tailored to be short but detailed plus light-hearted but informative. Suitable interval breaks are provided in which the clinicians mix with patients over food and drink so helping to break down the conventional barriers to communication and interaction. Sufficient support staff should be available at the conclusion of the event that bookings can be made on behalf of the hopefully consequently motivated patients who are encouraged to make subsequent individual consultations.