Your Health and Social Care contractual obligations
De-registering patients
A Principal is any dentist on the Strategic Planning and Performance Group’s (SPPG) dental list.
When deregistering a Health and Social Care (HSC) patient, a Principal must provide the patient with at least three months’ notice in writing that their access to HSC dentistry with the Principal will be coming to an end. At the same time, the Principal must advise the SPPG, in writing, that such notice has been given.
Open courses of treatment
You must complete any open course of treatment. If for some reason HSC treatments cannot be completed, then you will need to inform the SPPG what treatments are outstanding, including any arrangements made for completion of that care and treatment.
Be prepared to explain why they cannot reasonably be completed. You will also need to consider how to manage each patient’s situations, for example:
- Transfer the patient to another HSC Principal in the practice
- Offer a refund
- Continue with the treatment under the Health Service until treatment is completed, then deregister the patient, or
- Offer to complete on a private basis and only charge the patient the equivalent fee from the Statement of Dental Remuneration (SDR).
Any conversations with patients about moving to private treatment courses should be well documented.
Simply stopping the treatment and offering a refund may result in an unhappy patient and lead to a complaint. If you were to take this option, then you should ensure that you clearly document what advice you have given and risks the patient has been advised of, if they delay or do not seek treatment elsewhere.
When stopping a patient’s open treatment plan careful consideration will need to be given to both your HSC Terms of Service and the GDC Standards. You should seek advice from your indemnity provider in the matter of any complex cases that run over the three-month period or where you wish to stop treatment during an open course of treatment. However, the three months’ period is a minimum so longer notice may be offered as a solution to managing complex cases or cases that cannot be completed within the notice period. Arguably the more ethical approach would be to keep these HSC patients registered until their treatment is completed.
Deregistration process
In their letter of the 25 May 2023 the SPPG clarified the process to be followed when a dentist wishes to terminate a continuing care or capitation arrangement with a patient. Their letter also advises of potential Consequences of Termination of a Continuing Care or Capitation arrangement.
The patient deregistration form, WCA 966 available on the Business Services Organisation’s (BSO) website must be completed for every patient you wish to deregister. A patient cannot be deregistered until you have sent the form off to the BSO.
It is advisable to discuss any intention to deregister large numbers of patients with the BSO in advance. The BSO will need to process the deregistration form WRC 966. Advanced notification that they will receive a number of these forms will help the BSO plan for the influx. When you speak with the BSO, ensure that you have the most up to date form. This form must be completed for each patient and then sent to the BSO. The BSO in turn need to manually enter the details from each form into their system. It will take time for you to complete and send off the forms and time for the BSO to update their systems. The greater the number of forms, the longer the process will take.
There is currently no electronic version of this form, copies must be submitted by post. Work is underway to develop an electronic option for WCA 966 form submission, and we will update members once it is available.
A Principal may simply provide the patient with notice (no less than three months’) that, when the patient’s registration period ends, the patient will only be offered care on a private basis.
It is important that the date of deregistration in patient deregistration letters and the WCA 966 forms coincide.
If you fail to send in a WCA 966 form for a patient, then that patient is not deregistered. That means they are still entitled to Health Service dental care and must be seen in an emergency.
You will still receive a continuing care or capitation payment for that patient and that patient will still count towards the calculation of allowances in the SDR.
When you submit the WRC 966 form and it has been processed by the BSO, you will find that there will likely be a recovery in respect of the continuing care or capitation payments you may have for that patient. The BSO may also need to reconcile the patient registration figures for any allowance payments you may already have received.
The BSO is legally required to recover money paid to a Principal where the conditions of an entitlement, set out in the SDR, have not been met, including any overpayment of continuing care or capitation payments. While one patient may make little difference, if there are hundreds or even more patients who have not been properly deregistered via the form, then you may face a significant recovery.
Our understanding is that, when any recovery is linked to an payment through the SDR, the SPPG will be required to follow Regulation 23 of the General Dental Services Regulations (Northern Ireland) 1993, as amended, to recover the money. Further information on Regulation 23 is detailed below.
Failure to respond to letters from the SPPG may result in money being recovered under the dentist’s DS number or the matter being passed to the BSO’s debt recovery department, the Account Recoverable Shared Services (ARSS). The ARSS will then be responsible for recovering this debt.
Dentists can request that the SPPG agree a repayment plan. While the SPPG do not need to agree to this, there may be occasions where there is a good argument for a plan to be agreed. For example, when the recoverable amount is substantial, exceeds the dentist’s monthly Health and Social Care income, or may put the dentist in financial difficulty. It is advisable to set out in writing to the SPPG why they should agree to this sort of repayment plan.
Terms of Service
Dentists must provide the full range of treatments offered in the SDR even if the cost of providing that care is less than then the Health and Social Care fee set out in the SDR.
Failure to offer all the treatments listed in the SDR would be a breach of the dentist’s Terms of Service. The dentist could face disciplinary action from the SPPG and even a financial recovery. It may even result in the dentist being referred on to the GDC.
You need to carefully consider your reasons for deregistering a patient or group of patients.
- You cannot make another patient registering as a private patient a condition of registering a Health and Social Care patient
- A patient cannot be deregistered simply because they have raised a complaint
- You need to consider any potential allegations of discrimination when looking at patients you may wish to deregister
- Your process for moving patients to a private arrangement must be fair and transparent.
Leaving the dental list
A Principal is required to provide the SPPG with three months’ notice in writing if they wish to leave the dental list. Providing the SPPG with three months’ notice is only necessary when a Principal is ceasing to provide all HSC. If you are simply reducing the number of HSC patients on your list, then you need to remain on the SPPG’s dental list.
Communication is key
Communication with different groups and organisations is important to both help you decide to proceed and mitigate any potential problems along the way.
We have listed below the different groups of people you may wish to consider consulting and discussing your plans with.
Deciding if this is the move for you
Before moving away from Health and Social Care, it is advisable to make sure that this is the best move for your business.
Family and peers
You may find it helpful to discuss what you are considering with your family and peers. You may need the support and understanding from your family. There may be other dentists who have gone through the process and can offer you practical advice.
Your staff
Consider the benefit of discussing this with your staff. Certainly, you should discuss it with the other dentists. You need to know if this is a route they want to take.
Other dentists/the associates at the practice may have different views or thoughts that you need to consider. Depending on what they wish to do, it may lead to a discussion on what can happen to your Health and Social Care patients who wish to remain in the Health and Social Care service. Will the other dentists agree to take on these patients, or will you have to think about deregistration?
Is it just you or is it some or all the dentists who are moving to private practice? The answer to this question will shape how you communicate this to patients and what you tell them.
Your patients
It may be helpful to do a patient survey to gauge your patient’s appetite for a change. How would you explain it to them, without being detrimental to the Health and Social Care they are receiving? If you are going to survey patients, then what if you do not like their answers, will you still go ahead with change? Or will you adjust and amend your business plan. If not, then is there anything to be gained by asking them?
Dental plan providers
You may consider going into partnership with a dental plan provider. Or you may decide on a pay-as-you-go offering to patients. You may create your own capitation plan offering. For example, two check-ups and two scale and polishes every 12 months. It may be advantageous to speak with dental plan providers to see how they could support you. Ask them how much support they would provide you, and what advice can they offer. Look into the costs and take the time to consider the model they are offering and how it will fit into your practice.
We work with and endorse Lloyd and Whyte who provide financial planning and specialist insurance services. They offer white label patient payment plans. In other words, they provide the product, and dentists can brand it how they want.
Practice facilities and equipment
If you intend on focusing on private care, consider if you need to upgrade the equipment in the practice. It may be that a complete overhaul of the premises, surgery, reception and waiting area is required.
Think about how you will show patients what the extra money they may have to pay is getting them. Will you need to source alternative, more expensive materials? How much will this cost? Have you factored in these costs? Upgrading the practice could be expensive. It is something you need to budget for and a factor to consider when you are working out pricing. Our Setting and collecting fees advice sheet and Private fee setting advice sheet can help with this.
Having reached the decision to reduce your Health and Social Care commitment
If a Principal (any dentist on the SPPG’s dental list) is ceasing all HSC care or intending on reducing their HSC list, it is advisable to discuss this decision with the SPPG. You must try to complete any open treatments and inform the SPPG of any treatment that will be outstanding. It is advisable to agree what communication will be going out to patients from the practice. The SPPG may ask for details of the communication that will be going to patients. This is not unreasonable.
Sometimes, the message from dentist to patient and patient to the SPPG may become less accurate. The message the SPPG receives may, if they are not already aware of what you are intending, result in a knee jerk reaction based on inaccurate information from a group of patients. Especially when there are payments that are linked to maintaining HSC patient numbers, you do not wish to experience any withholding of money or recovery of money from the SPPG because they thought you had done something in breach of your HSC Terms of Service.
You should also discuss with the SPPG what the other dentists at the practice are intending to do. It may be that these dentists are content to take on your patients who do not want to go private. If the SPPG knows this type of information, then it can help them in dealing with any patients that may contact them.
If your actions are going to result in less HSC registered patients, discussing this with the SPPG may be helpful if deregistration may result in financial recovery by the SPPG.
Any phone conversations with the SPPG should be confirmed in writing. If both the SPPG and dentist are ‘on the same page’, it should be easier to deal with any patient complaints.
You may decide to give patients more than three months’ notice and seek to engage with them and discuss any concerns, or you may feel that there are too many patients to attempt this. If you decide on a long lead in time, then decide if you will speak to your patients when they are at their next appointment. Alternatively, you may decide to simply send out deregistration letters with a contact phone number and email address for them to contact the practice with questions. It may be sensible to create a separate email address for this exercise. Decide who will deal with these contacts. Consider what information will you post on social media.
When you do communicate with patients you should not be negative towards the quality of the Health and Social Care they are receiving. Focus instead on the benefits of switching to private care.
GDC Standards
Under GDC standard 1.7 of the Standards for the Dental Team, dental professionals are required to put the interests of the patients before the interests of
- Colleagues
- A business
- An organisation.
Patients are unlikely to be sympathetic if you state your reasons are:
- To achieve higher earnings
- To comply with increasing dental regulation
- Having to manage higher costs and expenses or
- Due to high levels of stress and long hours.
Alternatively, you may wish to mention some of the benefits of private care including:
- Staying with your current dentist
- Having access to a broader choice of treatments
- Improved facilities
- More flexibility in appointment times
- Less rushed appointments and
- Prompt treatment.
It is important to note that the GDC states that dental professionals must:
- Make it clear which treatments can be provided under a Health Service contract or can only be provided on a private basis
- You cannot mislead a patient about the services available to them
- You cannot pressurise a patient into having private treatment.
MLAs
If a large number of patients that are to be de-registered, then it may be worthwhile contacting the local MLA and discussing the change. This is because unhappy patients may well reach out to their MLA to complain. An MLA who understands the reasons behind the change, may well be more supportive. At the very least it could help mitigate the need for MLAs to write to you on behalf of their constituents.
Advice for associates wishing to increase their private commitment
If you are an associate wishing to increase your private earnings, then this is something that will need to be discussed and agreed with the practice owner. It may not be the route the practice owner wishes to take. It may considerably impact any HSC support that the practice may benefit from.
If the practice owner does agree to this move, then a review and possible update to the written Associate Agreement is advisable. For example, the current BDA Model Associate Agreement has a Schedule (3) that sets out the associate’s continued responsibility for more specialised private treatments, that have not been completed by the time the associate has left the practice.
If the practice owner does not agree to you reducing your HSC commitment, then it may be time to consider a move. If you do decide to leave, then you will need to give written notice as per the Associate Agreement. There may be other obligations and aspects of the Associate Agreement that should be considered, for example, the restrictive covenants, and money retained for remedial work. Please see our Associates leaving a practice advice for more information.
Completing treatments
A Principal who is leaving the dental list/deregistering a patient must complete any open treatments. If HSC treatments cannot be completed, then the treating dentist will need to consider how to deal with that patient, for example, offer a refund or continue with the treatment under HSC until treatment is completed, offer to complete on a private basis and only charge the patient an equivalent HSC fee.
Advice may need to be sought from a dentist’s indemnity provider in the case of any complex cases that run over the three-month period. However, the three months’ period is a minimum so, longer notice may be offered.
Moving a patient to private care
A capitation or continuing care arrangement may be terminated without the need to provide the patient with three months’ notice, if the patient agrees to transfer the whole of the care and treatment, which might have otherwise been provided under the capitation or continuing care arrangement, such that the treatment will then be provided privately.
This process involves speaking with each patient to seek their agreement, and so this option may only be practicable for a small number of patients, to do this for a large number of patients could be quite problematic, administratively heavy and time consuming.
You should keep paper records which demonstrate that the patient was doing this voluntarily and aware that they were entitled to three months’ notice. If the patient agrees to be deregistered without the full three months’ notice, then Continuing Care or Capitation Payment will also cease at the time they are deregistered (see above about the submission and processing of the WRC 966 form.) It may be worth also considering the financial advantage/disadvantage of deregistering patients early vs continuing to be paid Continuing Care and Capitation Payments for three months.
Out of hours provision
You will need to consider how you will provide out of hours and emergency care for private patients.
A dentist who is no longer on the dental list may not be able to participate in the HSC Out Of Hours (OOH) service and or the Emergency Dental Clinics (EDC) service. This may cause issues in the dentist’s patients being eligible to access any OOH service.
