Hidden costs

A TRIP to the dentist is challenging enough for most people – but being hit with an unexpectedly high bill afterwards can only make matters worse.

General dental practitioners earn their living principally through collection of fees from patients and, as a result, they are perhaps more likely to be faced with disputes in relation to money than other healthcare professionals.

In recent years, MDDUS has been asked by its members for assistance in an increasing number of fee-related complaints. And while this could be partly blamed on the current economic climate, a more immediate cause may be publicity surrounding the 2012 Office of Fair Trading report on UK dentistry. Amongst the findings were significant levels of dissatisfaction in dental patients regarding the clarity, accuracy and punctuality of costing information.

This dissatisfaction was related largely to alleged misinformation about the range of treatments that can be provided under the NHS. However, concerns were also raised over “the failure by some dentists to provide basic, requisite information to dental patients regarding proposed dental treatment, including the cost, prior to the dental treatment being provided.”

Transparency

Knowledge of treatment availability and potential costs are essential components of the consenting process and the conduct flagged up by the OFT, if deliberate, could scarcely be condoned. The fact is, however, that most practices are careful to maintain transparent costing policies, not only as a reflection of high professional standards, but also because it makes good commercial sense. Even so, there may be occasions where administrative errors, time pressures or even a reluctance to broach the tricky subject of fees leads to patients being presented with bills which are unexpectedly high or simply unexpected. In many such instances, a complaint will follow and MDDUS will always endeavour to support our members who seek assistance in providing a response.

The fact is that both private and NHS dentists are compelled to provide clear, written guidance to patients regarding the recommended treatment, the basis on which it is being provided and the likely costs. Failure to comply will not only undermine any attempts to rebut a patient’s complaint, but may also lead to investigation by the member’s NHS board or PCT and/or the General Dental Council.

Necessary forms

Considering NHS treatment first, patients must be provided with a standard estimate form (FP17DC; GP17DC), or equivalent, before treatment commences. This shows diagrammatically which teeth require treatment and the anticipated costs.

The estimate form rule is relaxed only in very specific circumstances, usually when the proposed care is very simple. Therefore, in England, if no items from Bands 2 or 3 are clinically indicated, an FP17DC estimate form is not required. In Scotland, the cut-off is slightly more complex. Put very simply, where treatment is limited to less than three permanent fillings, periodontal visits or extractions, production of a GP17DC is not obligatory. However, these exceptions do not apply to the first course of treatment - all new patients must receive an estimate form. An estimate and plan must also be produced at the specific request of a patient and should be updated if the proposed treatment plan is to be varied. Perhaps most importantly, a separate section must be completed and signed by the patient where the plan, however straightforward, includes any private dentistry.

Obviously, this final caveat clarifies for the patient the basis on which certain treatment items are being provided and therefore also helps to provide a record that consent to non-NHS treatment has been secured. However, the patient’s signature does not completely obviate subsequent challenge. Firstly, private and NHS treatment cannot be provided on the same tooth. This is of particular relevance in Scotland, where items such as bonded molar crowns and posterior composites are generally not available on the NHS. For example, recording an NHS root filling and private crown on an upper first molar might render the GP17DC invalid.

NHS or private?

Secondly, patients cannot be misled as to the availability of NHS treatment. In Scotland, a patient who insisted upon a posterior resin, having been given all relevant information on which to base this decision, could quite correctly be advised that a private fee applied. This would be recorded in the notes and on the countersigned GP17DC. However, in England, treatment items are not restricted by a Statement of Dental Remuneration. All that is required is that the patient’s oral health is secured which could, quite conceivably, involve placement of non-amalgam restorations for a Band 2 fee. The private/NHS distinction only becomes completely clear once services such as bleaching or implants are considered.

Thirdly, agreement to private treatment cannot be secured by denigrating the quality of care which is available on the NHS. In fact, to do so would be contrary to reason, as practitioners would effectively be casting aspersions on their own clinical standards. Great care must be taken at the consenting stage if entanglement in these regulations is to be minimised. If practitioners wish to avoid their clutches altogether, they must work completely outside the NHS.

Private practitioners are not required to provide forms like GP17’s and FP17’s which, apart from saving a few trees, relieves them of a significant administrative burden. Yet, since private treatment tends to involve higher costs, many practitioners would agree there are even stronger business and ethical arguments for providing an initial estimate, perhaps accompanied by details of payment plans.

This notwithstanding, the results of the OFT survey suggest that some patients commence treatment without sight of an itemised treatment estimate. Private practitioners may explain, quite truthfully, that costs had been agreed verbally. However, this argument is always torpedoed by the GDC’s consenting guidance, which requires that all patients are given a written treatment plan and cost estimate after an examination or assessment has been completed. Without such a document, defending a financial complaint against a private dentist is often very difficult (see box).

While the findings in the OFT sparked furious public debate, they are not revelatory. The need to set out expected costs has, for some time, been subject to very prescriptive regulatory and legislative rules, the contravention of which may limit the defence of a subsequent complaint or even lead to third party investigation. It is therefore critical that patients not only understand the financial implications of their treatment, but that this is documented in the notes and on the requisite estimate form.

Doug Hamilton is a dento-legal adviser at MDDUS

GDC guidance on contractual consent

1.5 Always make clear to the patient:

• the nature of the contract, and in particular whether the patient is being accepted for treatment under the NHS or privately; and
• the charge for an initial consultation and the probable cost of further treatment.

1.6 Whenever a patient is returning for treatment following an examination or assessment, give them a written treatment plan and cost estimate.

1.7 If, having agreed an estimate with the patient, you think that you will need to change the treatment plan, make sure you get the patient’s consent to any further treatment and extra cost, and give the patient an amended written treatment plan and estimate.

From Principles of Patient Consent. General Dental Council 2005