World Cup – Last Comment

I didn’t hear this but my brother assures me that a German journalist said of the English team following their defeat by Germany.

“Their problem is that they think they play like Beckham looks, the reality is that they play like Rooney looks.”

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The Monday Morning Quote

“Your future is created by what you do today, not tomorrow.”

Robert Kiyosaki

Richard Emms wows LDC conference

I have never met Richard Emms but I would like to shake his hand after reading his speech to the LDC Conference, UK Dentistry needs more people like Richard. I have no idea if I am “out of order” by publishing this here but as long as Richard has no complaint then I can’t say I really care. If you are involved in Dentistry in any way at all do take a few minutes to read & digest.

LDC Conference chairman, Richard Emms received a standing ovation after his speech to the pre-Conference dinner. He called for consistency from Primary Care Trusts and honesty from the Department of Health. He called on the chief dental officer for England, Barry Cockcroft to trust the profession. ‘If our patients trust us to do the right thing why can’t the department, I think we’ve earned it’, he said.

“Distinguished guests, ladies and gentlemen. It is a great honour to stand before you this evening and to welcome you to this, the pre-conference dinner of the 59th Annual Conference of Local Dental Committees.

There is a mixture of emotions as I stand here, firstly pride… I’m proud to be on my home patch, very proud of the fact that you have elected me chair of this important body, and proud to be the third member of North Yorkshire Local Dental Committee to address you in this role, and I’d like to crave your indulgence to take this opportunity to thank two of my predecessors as conference chairs Stuart Robson and John Renshaw for the support and encouragement they have given me over the years since I joined the LDC as a fresh faced young pup almost twenty years ago.
As I look down and see John and Stuart’s name on this chain of office, it’s quite a humbling experience to read the other illustrious names of those that have gone before and to consider the contribution they have made to the profession, and the leadership that they have given.
The overwhelming emotion this evening however, is one of nervousness as one realises the fact that the audience at conference is traditionally, shall we say opinionated, and not one that will readily stand any bullshitting!
In recent years this seems to have been coupled with a predeliction for the ancient sport of chairbaiting, a situation that leads me to the feeling so quaintly described by Sir Alex Ferguson as teams approach the business end of the football season as, “squeaky bum time”.
And yet, and yet, I do feel a little more secure in having home advantage, as it were, and safe in the knowledge that I have played this venue previously, though it was a slightly different gig.
I appeared on the stage behind me here a few years ago in the Ripon Amateur Operatic Society’s 2002 production of Sound of Music so if things do go all a bit pear shaped this evening and I experience a Robert Green moment, I can always fall back on an impromptu Karaoke evening of such sing- along favourites as “How do you solve a problem like a Warburton contract” and that classic made popular by the PCTs “16 going on 17 pounds a UDA”
When you look around this magnificent auditorium you wouldn’t guess that when I was treading the boards up there as the Nazi butler of Captain Von Trapp, the building was close to being condemned, (unlike the performance I hasten to add). After 100 years the place was facing wrack and ruin, it was no longer fit for purpose. The Grand Circle behind you was unsafe, the roof leaked, and the dressing rooms, which are below us, were a hard hat area. A situation that was OK for the men playing the German soldiers, but it was hell for the nuns! I think we were the last company to perform here before it was closed for repair and refurbishment. After much thought and planning and several millions of pounds of investment, it was reopened last year and I’m sure you’ll agree it’s pretty impressive.
Around the same time I was elected to serve on the newly constituted GDPC where we soon began discussing another edifice that many thought was coming to the end of its usefulness, namely the old NHS contract.
Aha I hear the more astute and perhaps more sober members of the audience murmuring, he’s using the successful rebuilding of this auditorium as a metaphor for the reconstruction of NHS dentistry.
Would that I could. For while we began to put the foundations down for the new system, the plans suddenly changed and we were left with a structure vastly different from the one that had been envisaged. I’m sure you will remember those early days, Darrin Robinson, who was then with the Dept, was giving roadshows likening the new PDS system to a football match where we could stand on the sidelines to watch the early enthusiasts playing the game until we felt it was so good that we too were ready to participate.
You can picture the scene, the sun was always shining, the skies were blue, the grass was green, jumpers for goalposts, marvellous. Sadly just as we were all getting ready to join in, the park-keeper came along and not only moved our jumpers but told us all that from now on we would be playing a very different game.
Suddenly everything changed.

What is it with change – we’ve just been through an election campaign where two of the parties’ slogans, not surprisingly perhaps, focussed on change. Its true that we are not happy with things the way things are and that something needs to be done, but why do we have to have so much change, so quickly and so all consuming. The only constant seems to be keep changing.
Confession time. I’m a bit of a traditionalist; I’m comfortable with the familiar and quite like the status quo. I like old fashioned musicals, test cricket and the fact they still sing Abide with Me at the cup final. There’s a line in that hymn which seems appropriate for dentists at this time and in the situation in which we find ourselves, ‘Change and decay in all around I see”
Was it always so, – did we ever face such changes in our working lives in such a short period of time. I suppose it’s inevitable that at these sorts of events one looks back before looking forward.
When I qualified in the early eighties the only acronyms required were MOD, ELA and RCT plus the occasional, not politically correct, tongue in cheek ones that suggested perhaps that a condition was “normal for norfolk”. Any jargon we used was purely clinical, Mandibular, maxillary, extraction, oro-antral fistula.
In the new NHS it’s so much more complicated. If you wish to open a practice you contact the PCT with an EOI. They will then give you a PQQ before an ITT where you can consider the KPIs and the QOF after which, if you are successful, you will need to register with the CQC. One needs to look at the dashboard and check the metrics, observe the traffic light system and allocate to Red Amber or Green.
If you want advice, it’s a toss up whether you call the BDA or the RAC. We seem to be talking a different language these days where just like Humpty Dumpty in Alice in Wonderland words can mean anything they choose them to mean.
How can all practices have an average value? By its very definition some must be better and some must be worse. I must have treated thousands of patients but I don’t think I’ve ever seen an average patient; I’ve certainly never seen one and only provided the average of 1.4 restorations. To criticise a practice for not having an average return is about as sensible as castigating a PCT for not having all their workers of average intelligence.
Ask any clinician about quality and you will get a range of answers but I guess some would include the margins on a crown, the longevity of a restoration, or the radiographic appearance of a completed root filling.
What you wouldn’t hear amongst the answers would be the number of new patients seen, the presence of a swanky NHS logo or the percentage re-attending within nine months.
And at what point did nine become a magic number. How can only one interval from NICE Recall Guidelines be taken, Recall Guidelines remember, and then that be misinterpreted and the meaning changed and re-attendance pattern used as a measure of quality. I’m sorry, that’s not quality, that’s rationing.
And its not just recall intervals. We seem to have entered a world that wants to measure everything. We forget that very often the things that can be counted don’t count and the things that do count can’t be counted.
Real quality is any number of timeless classics, reassuring the patient, continuity of care, time spent in communication, a willingness to go the extra mile. Which box do I tick for that data set? We are facing a steady erosion of what we have traditionally recognised as professional responsibility, “doing the right thing when nobody is watching” as Susie Sanderson quoted at last years conference. An erosion of the discernment that our professional education and experience has brought us. Most practices that are not achieving their UDAs are not doing so because they are slacking but because they ARE being professional and, despite the system, are trying to do what’s best for their patients.
I qualified at the end of the paternalistic era, the era of doctor knows best and patients were expected to have done to them what the dentist felt was best for them. We moved through to the phase, quite rightly, of agreeing options with the patient and listening to their wishes.
It’s a great privilege to metaphorically take a patient by the hand (CRB and ISA checks permitting of course) and lead them through an agreed treatment plan, and it’s why patients stay with us because they trust us to inform them and to do the right thing.
But that’s going, its been replaced with a ‘PCT knows best’ mentality with their hard enforcement of clinical data sets without the knowledge of the circumstances of the patient sat in the chair in front of us. Where there is a greater concern with structures and process than care. We heard just a few days ago that there’s to be a public enquiry into last year’s tragic events in Mid-Staffordshire when the quest for target achievement became paramount and patient care suffered.
I think it’s Goodhart’s law that states that when a measure becomes a target it ceases to become a measure. So, in the target driven NHS, its starting to get somewhat soul destroying, and I’ve lost count of the number of colleagues who have said to me that they are glad that they are at the end of their careers and not at the beginning.
That’s a sad indictment on a system that, when it was being discussed back in 2004, was supposed to be good for patients, good for the department and good for dentists. It took a special skill to get it wrong on all counts. But what can we do –
We have a new coalition administration and I understand they want to focus on outcomes. Ok that’s fine, but it will require a deal of thought and work not only by GDPC but also by practitioners like those in this room, those who are at the tooth face, to come forward with suggestions so that appropriate outcomes can be determined and how they can best be evaluated.
And yes at the moment we have Steele with his recommendations on a new way of working, and it will be interesting to hear Jimmy again tomorrow, one year on, as to his take on the state of change, and I am sure that there will be strong opinions expressed from delegates on the direction of travel.
But is it enough, have we gone down the road we’d rather not journey, too far away from our practice independence toward micro management ever to return. Perhaps.

But its no good just moaning about it and throwing our hands up in despair. Some LDCs have not joined us this year as they feel that some of our meetings and conferences are pointless, we never change anything, and that it is just one big whinge fest. I’d like to hope that surely we could be more than that. Yes, things are now more locally and regionally focussed, and we are building a strong network of regional LDC groupings, but it is still centrally where the big decisions are made and it is only through national gatherings such as this that we can hope to influence policy.
In the film Network, Peter Finch plays a grizzled cynical anchorman in a US news station who eventually has had enough. He goes on air and announces to his audience that “I’m mad as hell and I’m not going to take it anymore” a mantra that is taken up by the viewing public.
Perhaps that’s what we need to do. We need to stop our whinge fest and say we’re mad as hell and we’re not going to take it anymore. We need to retake a hold on our professional lives and livelihoods and articulate our thoughts, and our concerns, to put forward our ideas for change because that surely is the function of this conference.
Where can we start. Flippantly, I could suggest at the very beginning. It may not be raindrops on roses or whiskers on kittens but perhaps I can share with you some of my favourite things!
How about some consistency from PCTs?
How can it be that using the same guidance, one PCT does one thing and another takes a contrary view? One willingly collecting LDC levies whilst another refuses. I’m all for local solutions, but for one PCT to say that practice transfers are not allowed whilst another encourages it is unfair, confusing for everyone and breeds uncertainty.
How about some honesty from the department? We might not like what you have to say but at least we would know where we stood.
· if you don’t like the idea of independent contractors – say so.
· if you want a service to be purely access driven – say so
· if you want limited treatments and a core service – say so
but please – don’t pretend to us or our patients that in the current climate you can provide all of the treatment, to all of the people, all of the time. That fools nobody.
And what about trust?When this place was a wreck and PDS was on the horizon, we were promised, don’t laugh, a high trust environment.The Chief Dental Officer believes we should have ‘earned autonomy’ in other words we should show that we can be trusted. Well I’m sorry Barry but we have been educated over many years to think, to diagnose and to treat on an individual basis. Yes we are mindful of the wider aspects of health care but our responsibility lies with the patient in front of us. Their needs and yes their demands are paramount.
If our patients trust us to do the right thing why can’t the department, I think we’ve earned it. So here we all are, gathered on the eve on conference. We come from the four corners of the country, from the North of Scotland, from Southern Cornwall, from East Anglia and from West Wales. We come to represent our constituents, their practices and their patients and it’s an opportunity to make known their feelings as to what is happening and to present our ideas for change, in a constructive fashion I hope, with knowledge and with passion. I hope we will have robust debate and by the close of conference have articulated not only the personal views of the delegates but of those we represent.
I started this evening with a theatrical allusion and I’d like to close with one. Towards the end of Howard Barker’s play Victory, which is set in the aftermath of the English Civil war and the restoration of the Monarchy, one of the characters has this line, he says; “You have nowhere to go to in the end but where you come from”
I hope that during the debates tomorrow you too will remember where you come from and what our purpose is. Enjoy the rest of the evening, I shall be able to now, and have a great conference. Thank You”

Kolbe Case Study – A long way away in a practice by the sea

This is a study of a practice set up that is by no means unique in my experience. Neil and Sharon are married dentists, and are partners and owners of this 5 year-old practice. They rely heavily on their practice manager Julie and have just appointed a new associate Debbie. What they wanted to know was how well this new set up would work, what would be the strengths and the potential weaknesses.

Their Kolbe scores:

Fact

Finder

Follow Through Quick

Start

Implementor
Neil (partner) 4 2 9 4
Sharon (partner) 7 3 7 3
Julie (PM) 7 7 2 4
Debbie (associate) 7 6 2 6

I had been working with Julie for six months or so before Debbie was appointed and already knew the main problems that existed in the management team of the two partners and practice manager.

Neil, who initiates in Quick Start, is an instinctive innovator who:

  • Challenges
  • Originates
  • Promotes
  • Brainstorms
  • Risks &
  • Intuits

Sharon scores equally in Fact Finder & Quick Start but in the Kolbe “Theory of Dominance”, Fact Finder will dominate the other mode.

Both Julie and Debbie initiate in Fact Finder also. This means that all three will:

  • Probe
  • Prioritise
  • Prove
  • Specify
  • Calculate
  • Define

That’s a certain amount of theory behind things but what happened in practice? Let’s not forget that Neil & Sharon are married and both can initiate in Quick Start, so one problem was predictable and happened as predicted. Julie would have management meetings with both of the partners where decisions would be made, Julie with her high Fact Find & Follow Through wants to plan, co-ordinate, seek order, establish procedures and work sequentially.

The partners would go home, talk things through, change decisions and act on their intuition. Result – one thoroughly irritated Practice Manager not because she disagreed with anything that her bosses had done, as she would say “It’s their business and ultimately their success, so they can do what they think is best”, but rather because, as she prevents in Quick Start, her instinct is to not be impulsive, ambiguous or to create chaos, neither will she want to operate in crisis mode whereas Neil & Sharon thrive on that.

One other problem was that Sharon, with her high fact find, a trait common in dentists, would frequently duplicate Julie’s efforts and draw conclusions leaving Julie feeling by-passed.

Sadly, although the partners had introduced Kolbe analysis into the practice I don’t believe they realised the evidence in front of them. Julie struggled with her role, not with getting the work of practice manager done but with any allowance for the way that she worked and how challenging she found working with the partners.

To go back to the addition of the associate. She initiates in Fact Finder, add that to the same scores from Sharon & Julie, could well result in there being a tendency for the clinical & management team to fall into “Perfection Paralysis”.

Here’s a quick look at the team synergy;

Fact Find Follow Through Quick Start Implement Team Synergy Ideal
0-3 Prevent 0 50% 50% 25% 31% 25%

+/- 5%

4-6 Respond 25% 25% 0 75% 31% 50%

+/- 10%

7-10 Initiate 75% 25% 50% 0% 38% 25%

+/- 5%

They score above 30% in the Initiate and Prevent Zones this can lead to Polarization which in an organisation is like conflict between individuals. Productivity is blocked because energy is sidetracked in internal tugs-of-war.

Their energy is turned inwards and this results in “on again, off again” efforts culminating in a self-destructive team.

The solutions?

  • Appoint people to “bridge” the gaps for selective projects – not necessarily easy for a small set up.
  • Break into project teams, this was tried on an informal basis but as soon as the partners got to talking across the dinner table the efforts were undermined.
  • Work independently towards shared goals, within a small organisation not that easy.
  • Look for an associate with a complimentary Kolbe MO

There was no simple answer to this one and most of my time was spent supporting the practice manager who, in spite of her efforts, felt repeatedly let down by her employers and was planning her long-term exit strategy.

Ironically although she was, at least on the face of it, regarded as a highly valued employee and a cornerstone of the practice, it was possible that she had come to the end of her time in terms of the use of her skills. Her instinctive initiation in Fact Find and Follow Through had been invaluable during a period of change and growth (coinciding ironically with Debbie’s maternity leave) but now in a time of building on those changes her skills MO wasn’t as applicable.

There also came into this, obviously, the practice owners whose emotional relationship overrode most other things although it was frequently to the detriment of the smooth running of the practices. So if you’re going into business with your spouse / partner or you’re already there your Kolbe score may explain a huge amount.

PS There was a coach’s dilemma, I was employed by the partners to coach the manager, to whom was my duty? In this and every case, to the individual who was being coached.

The Monday Morning Quote

“Never complain. Never explain.

Benjamin Disraeli

Exactly. (Thanks to Hugh Macleod)

NASDA Goodwill survey reflects rising dental practice values

Time for an exit policy?

The latest NASDA survey in which Alan Suggett, partner in charge of the unw Dental Business Unit and editor of the quarterly survey, comments on the continuing rise in the goodwill value of dental practices.

NASDA goodwill survey reflects rising dental practice values

The goodwill value of dental practices continues to rise according to the figures gathered in the quarterly survey of deals and valuations by NASDA, the National Association of Specialist Dental Accountants. The average figure for both valuations and deals is now back near 100 per cent, the kind of level last seen before the recession struck in 2008.

Alan Suggett, a partner in unw LLP and the NASDA technical committee member responsible for gathering the figures, said that while the figures were snaking back up, the amounts achieved by dental practice vendors lacked consistency. It would be difficult to draw any conclusions on regional trends or on the merit of private versus NHS as an income source.

“As always,” he said, “this is very much a snapshot in time which reflects the general trend of the marketplace. The corporate chains are still buying, which helps keep dental practice values buoyant, although the big groups are more interested in NHS or mixed practices.”

The average goodwill valuations as a percentage of turnover during the quarter ended 30 April 2010 was 99.6%, while the percentage for actual deals done was slightly lower at 99.2%. This compares with valuations at 92% and deals at 86% in the last quarter of 2009 and a year ago, in the first quarter of 2009, the figures were as low as 71% and 75%.

If you would like to speak to Alan about the above or any other related matters, he can be contacted as follows:

Alan Suggett

Direct Dial: 0191 243 6009
Mobile: 07860 246718
E‐mail: alansuggett@unw.co.uk

Free Advice from Chris Guillebeau

From the excellent Chris Guillebeau’s blog The Art of Non-Conformity

Free advice is often worth less than the price. Much of the time, you already know what you need to do about something—you just need to do it.
Nevertheless, I hear a lot of things being repeated, and I get asked a lot of the same questions… so here’s my less-than-$0.02 for anyone who cares. As the saying goes, take it or leave it.

“The customer is always right.”

Actually, sometimes the customer is dead wrong. Sometimes you don’t want the customer, and if you go out of your way to please one of them, you’ll disappoint the others.

I recently received my first PayPal buyer complaint in more than two years of doing business with Unconventional Guides. Two years! A great streak. Then one guy comes along with an axe to grind and tells PayPal I owed him money despite all evidence to the contrary.

It depressed me. My PayPal rep said I could dispute the claim and I would win, because my account was in such good standing. But in the end I just gave up, sent the money to the axe-grinder, and said goodbye. That customer wasn’t right, but if I kept stressing out about him, my ability to help anyone else that day would have been negatively impacted.

“You should ask people what they want when developing a project.”

Who said that? Oh, it was me. Oops. Well, here’s the thing: sometimes this is true. I’m the first to say that it can be helpful to run your ideas by people, get feedback, etc.

But it’s also true that if what you’re doing is truly innovative, not everyone will understand in the beginning, and maybe you should just go for it. Lately I’ve been thinking about what Henry Ford said: “If I had asked people what they wanted, they would have said ‘faster horses.’”

“Never check email in the morning.”

I’m on a one-man crusade to say that it’s OK to check email in the morning, or whenever you feel like. If you read blogs about productivity, you know it’s a lonely crusade, but I think I’m on to something. You don’t have to feel guilty if you like checking to see what people have to say to you.

Who knows—maybe that’s even the most important work of the day? OK, I’ll duck now.

“Don’t waste time with Twitter when you could be doing real work.”

What if 25% of your business comes from Twitter? That’s how it works for me, even though in the past 30 days I’ve mentioned my actual business work a total of once. Therefore, I think I’ll keep hanging out on Twitter. And you can too if you want, or not if you don’t want. Oh, and one more thing about this –

“To build a following on Twitter, you should share interesting links and reply to people.”

It’s good to do those things, but they won’t help you build a following on Twitter. The best way to build a following is by doing stuff away from Twitter, and encouraging people who find you elsewhere to add you on Twitter. Yep, that’s how it works.

“You must have a local support team to succeed.”

I think a support team can be very helpful. But what if you’re on your own and no one around you believes in your mission? Those people sound like a non-support team to me. If you have to choose between a non-support team and going it alone, I suggest going it alone.

“Slow and steady wins the race.”

What race are we talking about? It’s probably a good idea to know which race one has in mind before making blanket statements. Some races go to the slow and steady; others go to the fast and furious. See Mario Andretti: “If you think that you’re in control, you’re not going fast enough.”

Maybe that isn’t your style, but I think there’s a time and a place for it. Speaking of that:

“Good things only come to those who wait.”

Some good things come to those who wait; others come to those who go out and get them. If what you want is in the second category, what are you waiting for?

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