When the lockdown was announced, Mihir Shah had only been a practice owner for 18 months. Here he explains his struggles as he looks towards a post-covid era.
I purchased Kreate Dental a little under 18 months ago. When I first took over, I totally underestimated the journey, the workload and responsibilities as a practice principal. I took over a very run-down old-fashioned practice. It still relied on the production of wet films to assist with radiological diagnosis and assessment. However, I knew that the practice had a very loyal patient base. With time, care and steady modernisation, the practice could eventually thrive.
Initially for the first three-four months, I was the only dentist working at the practice. The previous owner retired quite suddenly due to health reasons. It took time to rebuild the practice and the list.
The practice had been under the previous ownership for over 30 years before I took over. So it took a while for patients to firstly build trust with me and then secondly to start implementing change and modernisation. However, steadily, by offering a greater range of services, modernisation in terms of equipment and developing a stronger union with my patients, the practice began to grow and thrive.
We now have three part-time dentists and a hygienist working at the practice. Prior to the COVID-19 lockdown we were imminently due to start a full practice refurbishment. This would add two extra treatment rooms.
COVID-19 and lockdown struggles
COVID-19 and lockdown has created an enormous challenge as a young practice principal. Unlike my more well-established principal dentists, I have only had 18 months trading. With constant reinvesting into the practice, we do not have the same level of financial reserves as more established practices. I firmly believe that after the CDO’s letter on the 25 March, no dental professional within the UK expected the government restrictions to last as long as they have. We would have at least been able to provide emergency care for our own patients whilst operating safely within the regulations set out by NHSE.
Although Kreate Dental is a mixed practice, the NHS portion of the practice barely covers the overheads of the practice. We are a predominantly private dental practice. Financially, this has been devastating for many practice owners and particularly private dentistry. There has been no exemption of business rates relief, which I know the BAPD and BDA are heavily lobbying the government for. Generally dental practices, unless they qualify for small business rates relief, do not qualify for any form of government grant. I have written to my own MP and the chancellor regarding this with little luck.
Cashflow crisis
COVID-19 has created a cashflow crises for many principals. I very quickly, with the assistance of my team, reduced the fixed cost base of my dental practice to the lowest possible amount. Unfortunately, we simply cannot reduce some expenses. Such as utility bills and phone services that have been essential in order to maintain our advice, antibiotics and analgesia service. After a lot of back and forth with my bank, I was lucky enough to receive a loan payment holiday for six months, which has substantially helped.
My thoughts then quickly turned to ensuring the long-term survival of my dental practice. This meant I required detailed financial analysis and projections with the assistance of my accountant. I have to say the team and Elan Tax and Co who are reputable NASDAL accountants, have been exceptional over the past few months. Through the assistance of my accountant, I was able to secure a Coronavirus Business Interruption Loan that enabled the medium-term security of my organisation. I must also give credit to the government and HMRC regarding their furlough scheme. Without this no dental practice within the UK would be able to maintain all its staff wages.
Urgent dental care centres
The COVID-19 outbreak has posed substantial struggles for my patients, my dental team and financially to the practice. We do not know for sure as of yet when we are going to restart working within a dental environment. According to speculation this could happen at the end of June or July. This has meant that the practice has been operating a telephone triage service only since the 25 March.
Until the middle of April, there was no opportunity to provide face-face care for patients within my area. However, the introduction of urgent dental care centres has proved most welcome. It provides the opportunity to refer the most serious dental emergencies via the dental electronic referral system (DERS) to receive face to face treatment.
The system has worked quite well in Kent. Here our dental team triages a patient. If the patient requires intervention, the dental team refers via the DERS pathway to an urgent dental care centre. The dentist within the urgent dental centre will then secondary triage the patient within 24 hours. They will contact the respective patient with either a phone call or through video conferencing to understand the secondary care input they will require. The dentist will then see the patient within the urgent dental centre to receive treatment following the standard operating procedures set out by NHS England (NHSE).
Opportunities
Lockdown has provided challenges, but has encouraged innovation throughout this time. It forces clinicians, such as myself and dental teams around the UK, on the importance of technology and how to use it modern clinical pathways. If practices were not previously computerised, COVID-19 will simply force them to, otherwise these practices will not survive. As clinicians we are now able to remotely prescribe and liaise with pharmacists around our local areas.
We have also been able to introduce virtual consultations with our patients. Smile tools such as Smileview by Invisalign has helped tremendously. Patients are able to see an instantaneous before and after snap-shot of how their teeth will look like following Invisalign Go treatment. This tool has really assisted with our virtual/smile consultations and develop leads. Additionally, virtual consultations have helped connect with some of our more anxious patients and patients who have emergency dental problems. We provide more tailored advice and alleviate a lot of their concerns. Our practice has also been emailing our patients regular newsletters and providing updates through social media.
Post-covid era
Currently, there is a lot of speculation and uncertainty as to where dental practices stand within the government’s regulations. As a mixed dental practice owner, I am keen to await the chief dental officer’s stance as we enter the recovery phase of resuming dental service provision. This is before we start to consider resuming dentistry in any shape or form.
There has been substantial debate regarding the CQC’s position and whether or not private dentistry can provide emergency service provision. If there is a strong indication that this is possible, then we will follow strict standard operating procedures.
NHS England issued its latest standard operating procedures on Friday 22 May with respect to urgent dental care centres. It is quite clear that any aerosol generating procedures will require level three PPE in the form of FFP3 masks. All healthcare staff involved within the surgery for these types of procedures will require an FFP3 mask to be fit tested to ensure adequate fit and seal. Clinicians and staff within the surgery setting will also be required to wear full sleeve disposable gowns, full face eye protection and disposable gloves.
The guidance from NHS England states that clinicians can wear level 2 PPE for non-aerosol generating procedures. This involves the wearing of type II fluid resistant masks, disposable aprons, disposable gloves and full-face eye protection.
Conclusion
My thoughts as a principal are that we need to carefully consider any resumption in dental service provision along with its sustainability. There is no point starting until there is complete confidence in our PPE supply chain and that all staff feel confident working under a new normal. Naturally, there are huge financial burdens the longer the lockdown period for dentistry continues. But I want to stress the importance of a positive mindset. COVID-19 could be an opportunity to develop your practice.
Consider improved and more efficient systems of working. Consider ways in which the patient journey could be better. Ways that will set you apart from your competitors and constantly communicate with your teams and patients. As a dental community we have been blessed with the content many members of the profession have produced over the past few months. It has helped keep clinicians motivated, engaged and excited to see their patients once again.
I wish everyone well. I am sure we will come out of this stronger and more united as a profession.
