How we kept the diary 80% full through the 2008 crash

There is a particular kind of quiet that comes over a private practice when the economy turns. The phone does not stop. It just slows, in a way you notice about three weeks before it shows up in the figures.

We had co-founded the practice in 1997 and moved it away from the NHS. By 2008 the income was substantially private, which is exactly the position that looks most exposed when patients start deciding what they can defer.

The diary stayed around 80% full through it. Not because we were clever about discounting, and not because we outspent anyone on advertising.

What actually happens to a private diary in a downturn

Patients do not leave. That is the first thing worth understanding, because the fear is that they will.

What they do is defer. The crown becomes a temporary. The hygiene appointment moves from four months to six, then to nine. The treatment plan gets agreed and then quietly sits there. Nobody phones to say they are going elsewhere, because they are not going elsewhere. They are going nowhere.

Which means the damage is not a collapse in patient numbers. It is a slow, invisible lengthening of the interval between visits, across the whole list at once. And because it is invisible, most practices respond to it far too late — usually by cutting prices, which is the one move that makes the following year harder.

The membership plan did the work

We had launched a practice membership plan in 2005. It was not built for a recession. It was built because irregular attenders are bad for patients and bad for a practice, and a monthly payment makes routine care a standing arrangement rather than a decision to be made afresh every six months.

What it turned out to be was the thing that held the base of the diary steady while everything discretionary wobbled.

A patient paying monthly has already decided. There is no fresh purchase to reconsider in a difficult month, because the money has already gone and the appointment is already theirs. The interval does not stretch, because the plan defines it.

By 2008 we had 350 patients on the plan at £12 a month. That gave us a predictable floor of examinations and hygiene appointments every month, booked in advance, largely indifferent to the news.

Everything else moved. That did not.

Why this is not a pitch for discounting

A membership plan is often sold to principals as a way of making dentistry cheaper. That is not what it does, and practices that set it up on that basis tend to be disappointed.

What it does is convert an irregular, deferrable decision into a regular, automatic one. The patient gets predictable cost and a practice that actually recalls them. You get a base of committed patients, a smoother cash position, and — the part that matters most in a downturn — a reason for someone to walk through the door when they would otherwise have put it off.

Set the fee to reflect the care included. If the plan is not sustainable at the price you set, it will quietly become a discount scheme you cannot afford to run.

The three things that mattered, in order

1. A committed base. Plan patients who attend on a defined interval, whatever else is happening.
2. Recall that actually ran. A plan only holds if someone is contacting people and rebooking them. A membership scheme with a broken recall system is just a direct debit.
3. Holding our prices. We did not discount. Practices that did spent the following three years trying to get back to where they had started, with patients who had learned to wait for an offer.

What transfers to now

The specific circumstances of 2008 are not going to repeat in that form. The mechanism underneath it is not really about a credit crisis at all.

Any period where patients feel squeezed produces the same pattern: deferral rather than departure, intervals stretching, treatment plans agreed and not booked. Whether the cause is a banking collapse or a run of expensive years, the practices that hold up are the ones with a committed base and a recall system that works — and the practices that struggle are the ones relying on patients deciding, unprompted, that this is a good month for dentistry.

If you are looking at your own diary and seeing intervals stretch, that is the early signal. It is considerably easier to act on it then than eighteen months later.

The honest caveat

One practice is one practice. I ran this one, I know what it did, and I am not going to claim it proves a general law.

A plan does not rescue a practice with a poor patient experience, and it does not compensate for a location or a fee structure that does not work. It holds a base that is already sound. What I would say with more confidence is the negative version: I have not yet seen a practice regret having a functioning membership plan and a recall system that runs.