Associate crimes and the principal of cooperation


During the last 10 days I have been working with some groups of associates and hygienists and it’s got me thinking about the unique and sometimes frustrating relationships between practice principals and their hired clinicians.


In my experience, very few practices behave as one business and it is the nature of the (self-employed, autonomous) relationship between the practice owner and the clinicians that is usually the problem.


Simply put, the associates and the hygienists are often inadequately led by the principal and left to get on with it, with little idea what the principal and the practice stands for. This serves up a variety of standards and behaviours to the patients, depending on which clinician they see. This then leads to a covered market situation where (understandably) associates and hygienists refer to “their patients” and “their goodwill” as they operate their own standards and even charge their own fees.

The advantages of behaving as one practice are many, including:

  1. A team of clinicians working in harmony and supporting each other are more likely to succeed in today’s market than a bunch of disparate clinicians ploughing their own lonely furrows
  2. Patients move easily and seamlessly between clinicians so as to access different skill sets
  3. You can market just one (not many) propositions and clinicians can sell to each other’s patients.

In order for this to work, the clinical team needs a willing and competent leader and (of course) the team must be willing to be led. Also, both parties must find (unpaid) time to meet together and agree on a unified approach to clinical standards, treatment protocols, opening hours, running on time etc.


So far, I’m sure, all this sounds like a good idea. However there are forces at work which will surely capsize this idealised way of working together and most of these forces concern money.


In the uneasy marriage between dentistry and money, it seems the default response to any challenge to behaviour is for the clinicians, especially the associates (the principals tend to be more commercial – they have to be) is to run to the ethical moral high ground.


It’s very tedious and usually duplicitous (I read a debate on a dental forum where some associate explained that he didn’t feel the need to polish patients’ teeth on the NHS as this was clearly a “cosmetic” procedure. I mean, really…).


Anyway, now we’ve got money out into the open and now you associates have agreed to stop running to the ethical/moral high ground, would it be useful to lay out some of the behaviours (usually around money) which stop clinical teams behaving as if they all worked together and for the patient?


Here are seven behaviours that drive principals nuts:

1. Low gross. A surgery costs between £300-£500/day to open the door (unless it’s a single surgery practice or if it’s in the West End of London) before the clinician gets paid to sit on a stool or any materials or lab work is put in the cabinetry.

This means the first £400 going across the reception desk every day goes straight back out again in overheads. So, if an associate grosses £1,000/day on a 45% deal and their lab bills are 10% of gross, this is how it breaks down:

For the associate. £1000 less £100 lab = £900 X 45% = £405 in their pocket. 

For the principal. £1000 less £100 lab = £900 X 55% = £495. 7% of gross for materials = £70. £485-70 = £415 – Fixed costs of £400 = £15 in their pocket. 

2. Discount the fees. This simply makes the problem illustrated in No 1 (above) worse.

3. Single unit dentistry. Many associates indulge themselves by delivering single unit dentistry. A single filling, big composite or crown is easier to sell to a patient than replacing a quadrant of deteriorating restorations. This is often compounded by the associate trying to service a large list of patients, doing small amounts of dentistry on lots of patients.

4. Not referring to hygienists. Many associates seem content to treat patients to a half-hearted exam scale and polish rather than spend time doing a remarkable examination and referring their patient to the practice hygiene team. Clearly, they would rather earn a few extra pounds for a quick flick around with an ultrasonic scaler than actually help stop the patient’s periodontal disease. This is NHS-style thinking and very common. Many associates also expect a referral fee for asking the hygienist to see a patient despite the GDC rules on back handers… Amazing!

5. Refusing to sign a contract. For reasons best known to themselves many associates, when given a contract, take it home and hide it. Surely professionals need to behave professionally and have a proper contract between them. There is also the additional benefit that a properly worded contract protects both parties when the Inland Revenue comes asking about self-employed status.

6. Behaviours such as arriving late, running late, going home early, hurting patients, being unwilling to attend practice meetings, failing to come on team events, using their mobile between patients etc.

7. Leaving and trying to pinch the patients. The clue may be visible in the associate’s language, “my goodwill”, “my patients” etc. Another reason associates refuse to sign contracts.

And here are three behaviours that annoy the hell out of associates and hygienists: 

  1. Not walking the talk. Principals who ask their clinicians to behave in a certain way and then don’t do it themselves…
  2. Mean. Unwilling to provide materials, lab or kit of an appropriate quality.
  3. Hog all the new patients. In most practices, new patients are more valuable than a returning one, for obvious reasons. It’s that money thing again…

I accept that we’re in difficult territory here, mixing money and health care. However, a bit of honesty will go a long way. Everybody (including me) wants to optimise their earnings, however, if we are to deserve the accolade of professional, we simply have to put our clients’ interests before our own…


Maybe you will be brave enough to print this piece out and stick it on the staff room wall in order to encourage some debate. Or better still, buy your associates and hygienists a copy of our new book Moonwalking For Dentists which deals with this and much, much more.


I’d be really interested to hear your thoughts about this and will be talking about it today on my LinkedIn page – why not connect with me?

This entry was posted in News, Uncategorized. Bookmark the permalink.

Leave a Reply

Your email address will not be published. Required fields are marked *