Many decades ago I entered general dental practice, bright eyed, energetic, ambitious and knowing everything there was to know about clinical dentistry. Like most newbies I started as an associate and was fortunate to work with two very kind and honest principals. But, like most young associates, I wanted to be a principal.
I did indeed become a principal with my own practice but with no business training I was soon engulfed by the labyrinthine of staff hassles, PAYE, sick pay, unhelpful banks, bad leasing agreements, here today gone tomorrow associates and dwindling NHS fees. My clinical skin was saved by leaving the NHS and practising privately, as it seemed to me that the administrative antics necessary to earn a healthy living in the NHS were the antithesis of the professionalism I had seen modelled as a student. Even so, a day came when a welcome letter dropped through the door from my accountant.
This was the fourth accountant I had used for whom I have nothing but praise. He was the first to proactively recommend courses of action that may be to my advantage. The other three were either too busy watching their own backs to avoid being blamed for advice that didn’t work out, or were content to earn a fat fee for doing little more than glorified bookkeeping.
Selling a practice
The letter advised me that having attained the noble age of 50, I could now sell my practice without having to pay CGT (capital gains tax) through a device called tapering relief. I never did understand what tapering relief was but if he could use this magic incantation to allow me to sell up tax free, who was I to argue? Like most principals it always seemed slightly galling that my associates banked a nice fat cheque from me every month whilst not caring a jot about the administrative and financial burden I carried. Suddenly the grass on the other side of the fence was looking very green.
To add to the allure of this new direction, I had an associate who was keen to buy the practice and allow me to carry on treating all my old patients as his associate. It seemed like a win-win situation and so the deed was done, fortunately without having to jump through all the ridiculous hoops that my fellow professionals have to do when selling a practice today. As far as I could see I had nothing before me but spending the rest of my practising life as a carefree associate. And that’s what it was like for a year.
I then sustained the first dent in my perfect arrangement when I found out that an associate’s contract was not worth the paper it’s written on if you want to remain in the practice. At a meeting with my principal I was invited to have a discussion about changing the way I was to be remunerated. Of course such changes are never going to be to the associate’s advantage nor are such meetings ever discussions or even negotiations. These meetings may be dressed up as such but the end result is always the same; you, the associate, are going to be paid less for doing the same work.
There will be many reading this that will say: ‘They can’t unilaterally alter a written, witnessed and legally binding agreement.’ Oh yes they can, because what are you going to do about it? Forget all the waffle about mediation or arbitration; your only final recourse would be to take the principal to court. Can you imagine carrying on working as an associate in a practice where you had sued the principal and won?
You would think that would be that wouldn’t you, but oh no. Twice more the financial arrangements were unilaterally altered, until one sunny August day, six years after the practice sale, I was handed a note. The note said that a potential partner wanted more surgery time, so they were giving him mine; here’s three months notice.
I was 57 at the time; where was I going to find another associateship in three months? Who was going to want a 57-year-old associate? Well, it turned out that I was more commercially attractive than I had thought. My CV was quite comprehensive and when I applied to a newly set-up private practice, I was welcomed with open arms. The practice was brand new and very well equipped. The demand was high and the fees were higher than the practice I had left. What was there not to like? I soon found out.
The blame culture
Within the first two months I realised there was an incredibly high staff turnover. All my practising life I had only known staff to leave occasionally, but I found out that in the two years the practice had been open they had got through 25 members of staff! I soon realised that the practice was suffused with an unpleasant blame culture that appeared to emanate from the principal, and it wasn’t long before I too witnessed the continuing musical chairs of staff arriving and leaving, sometimes the same day they had started! I tried to keep my head down and remain detached from it all but it was only a matter of time before the fingers of this culture crept into my surgery. Within 18 months I was on my third nurse.
Then it happened. The blame culture reached me. My first experience came after I had given some emergency treatment for pain relief to one of the principal’s patients. Because the treatment was different to that which she would have provided, I was told, in no uncertain terms, that I was never to do that again. This came as something of a shock as I had previously worked with colleagues where we would be politely grateful to each other for providing pain relief, even if the treatment was different to their preferred method.
Eventually the chilly atmosphere and the endless stream of sackings got to me. I found myself dreading what I would find each day and so I left. Fortunately I was working at another practice part-time so was able to continue there, but despite the starkly different happy staff and jolly atmosphere, I still felt as though I was regarded as a vocational trainee, whose diagnoses and opinions would always be wrong if they differed from those of the principal. The fact that I had been in practice for 40 years seemed to cut little ice; the effect was to make me very cautious about the treatment I offered to patients. I found this undermined the enjoyment of my dentistry because as a principal I had always been keen to push the boundaries and explore new techniques.
Grass always seems greener
Having now retired, a decision that once again was not of my choosing, I wonder if I would seek to be a principal if I had my time again. The answer is probably yes because I would not have wanted to spend my whole practising life feeling as subservient as associateship can make you feel. Whether you are a principal or an associate, the grass always seems greener on the other side. However, remember, there are big weeds on both sides.
Geoff Newman lives in Dorset and has recently retired after five years in the Navy and 36 years in general practice. During his practising career he has been both principal and associate. For the last six years of his practicing life he was a member of the GDC Private Complaints Panel. Geoff was also one of the founders of the charity Dentaid.