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PHOTOGRAPHY: EUGENIO FRANCHI RETOUCHING: SPENCER HANNAM FEATURES & INVESTIGATIONS DENTAL TREATMENT COSTS Are we paying too much for our Confused ab...
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PHOTOGRAPHY: EUGENIO FRANCHI RETOUCHING: SPENCER HANNAM

FEATURES & INVESTIGATIONS DENTAL TREATMENT COSTS

Are we paying too much for our

Confused about what your dental treatment should cost and what’s available on the NHS? Our latest undercover research shows you’re not alone

AT A GLANCE

Many dentists are failing to explain treatment options and prices Why you could be paying too much, without knowing what’s available How to ask the right questions and get the information you need

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ou might trust your dentist to give you sound advice and recommend the best treatment – in fact 80% of people we surveyed said they do. But our latest investigation has found that a number of dentists are failing to spell out the treatment you need, provide details of your private and NHS options, and explain exactly what you’ll be paying. To find out whether patients are being short-changed, we surveyed 1,001 dental patients about their experiences, and sent five undercover researchers into the dentist’s chair at 25 mixed (NHS/private) practices. We asked a panel of experts – including two experienced dentists/practice owners and an expert in patient-focused dental research – to assess the visits. They looked at everything from the communication of NHS and private options, to clarity of pricing. Of our 25 visits: 12 were deemed poor or very poor for the clarity of NHS and private options nine were rated poor or very poor for overall treatment and communication on pricing

eight were judged poor or very poor for how treatment options were explained eight were rated poor or very poor for the verbal and written pricing information. The poor communication uncovered in some dental surgeries could well leave patients confused about what they’re paying for, and fearful of unknown costs. This is especially worrying when you consider that nearly a third (31%) of people we surveyed have opted to put off treatments because of the cost. Delaying treatment can ultimately mean losing teeth and, in cases such as undiagnosed oral cancer, have serious health implications. With 29.9 million patients having seen an NHS dentist in the past two years, this means millions of people could be risking their oral heath on the basis of unclear pricing.

Is the price clear?

Despite surgeries being required to clearly display price lists, only four in 10 people we surveyed noticed one on their last visit to the dentist. And 11 out of the 16 price lists we saw FEBRUARY 2015 WHICH? 29

FEATURES & INVESTIGATIONS DENTAL TREATMENT COSTS NHS versus private

at the 25 practices we mystery-shopped didn’t include any private-treatment prices at all. In just under a third of our undercover visits, pricing information was judged poor or very poor by our expert panel. One of our mystery-shoppers – a man in his 40s – needed several fillings and treatment for gum disease, including a scale and polish. On three of his five visits our experts found a lack of clarity on charges, including whether his treatments would be covered on the NHS, with no written treatment plan. In contrast, on one exemplary visit he was taken through the cost of each of his NHS and private-treatment options. Summing up the tough choices some make based on the strength of dental advice, one patient we surveyed said: ‘I had the choice of a root filling or tooth removal. I was told I’d have to pay privately. So I lost the tooth.’ Meanwhile, dental patient Avril Foster, from Colchester, told us that she only found out that her £800 quote for two crowns wasn’t the NHS fee when the receptionist mentioned that she was being charged privately. She said: ‘The surgery’s price list was tucked away out of sight. When I queried it, the dentist said they don’t make money from NHS crowns. I also hadn’t been told the crowns would be gold, although they would be seen when I smiled.’ But our research uncovered some great communication, too, which shows us that best practice is achievable – as well as necessary.

Our undercover visits showed that explaining both NHS and private treatments was the weakest area of communication, with nearly half of our mystery-shopping visits (12 out of 25) rated poor or very poor. The NHS dental system is different from other NHS services, in that dentists can mix NHS and private treatment. Most practices do this, including all 25 practices we visited. If your dentist provides both NHS and private services, they should begin by explaining what NHS options are available. You may also be given a range of private options, for example, to enhance the final cosmetic result, or for treatments not funded on the NHS, such as dental implants. But we found a ‘muddled middle’ where the difference between NHS and private options needs to be clearer. Those we surveyed who received a mix of NHS and private treatment were most likely to say that the treatment was poor value for money (20% compared with 10% NHS-only and 7% private-only). And with only 43% of people feeling well informed about what NHS and private dental treatments offer and how they may differ, the onus is on the dentist to explain. This is vital, given the many options available.

Dentists’ views

Treatment options

After examining you, your dentist should set out what treatment is ‘clinically necessary’ to keep your teeth, mouth and gums healthy. They should explain the risks and benefits, and record what’s agreed in a treatment plan. Yet we uncovered the following problems on some of the new-patient appointments we arranged as part of our mystery shopping: no NHS option for clinically (dentally) necessary gum care, only a private hygienist the dentist saying what he/she thinks necessary, rather than explaining the NHS and private choices available little or no information on the pros and cons of treatment no advice on prevention given. One person we spoke to – 30-year-old Kat Sumner – told us that her dentist performed an NHS root-canal filling which failed. Kat later discovered that one option would have been paying for this complex treatment to be carried out by a specialist (an endodontist). She said: ‘Faced with losing my front tooth, I saw the private specialist, who saved it, but it was trickier to re-do it. This option should have been explained in the first place.’ As one of our expert panel puts it: ‘Every dentist needs to explain each choice – it’s about good communication.’ 30 WHICH? FEBRUARY 2015

In just under a third of our undercover visits, pricing information was judged poor or very poor by our expert panel

We’ve spoken to dentists about the system they’re operating in, to understand their perspective. Since 2006, dental practices have been paid fixed contracts for their NHS work which specify how many ‘units of dental activity’ (UDAs) they are allowed to do a year. For example, all clinically necessary fillings and root fillings earn the practice three UDAs, while a complex necessary treatment involving lab work (such as a crown) earns 12. A practice gets between £15 and £25 per UDA. Most of this is paid by the patient in band charges. This income pays for salaries and practice costs, although the dentists may also do private work. One dentist and practice owner gave his view of the pressures: ‘The NHS system is massively under-resourced and private patients subsidise NHS ones. Practice revenue has dropped by 20%, while regulatory requirements and costs have increased by 30%. It’s harder to spend the time needed on each NHS patient to explain things properly.’ He added: ‘The practice gets paid the same whether you’re offered a root-canal treatment to save your tooth – which could take several hours of skilled work – or a tooth removal taking 15 minutes. A good dentist should give you all the options, but I believe there are disincentives built into the system.’ The dental contract in England is currently under review, and a different system is being piloted at present. which.co.uk

FEATURES & INVESTIGATIONS DENTAL TREATMENT COSTS EXPERT VIEW

KEY PROBLEMS UNCOVERED BY OUR RESEARCH 1  The dentist doesn’t make costs clear One in five (22%) of the people we surveyed who had had dental treatment didn’t feel completely clear about what it would cost before starting. Our mystery-shopping visits were rated poor or very poor for pricing communication on just under a third (eight out of 25) visits.

Verdict You need to understand what you’re paying for upfront, so ask if it’s not completely clear. One of our experts said of one mysteryshopping visit: ‘The treatment plan was vague and gave the patient no idea whether she would be paying band 1, 2 or 3 – which ranges from £18.50 to £219.’

2  You pay privately for treatment you could get on the NHS Only around four in 10 (43%) of people surveyed felt well informed about NHS and private treatments, and how they differ. On our mystery-shopping visits, just under half (12 out of 25) were rated poor or very poor at explaining NHS and private options, and the pros and cons of each.

Verdict On four of our undercover visits, our researchers, who should have been offered an NHS scale (or deep scaling and polish) and advice on looking after their teeth and gums at home, were only offered a private hygienist appointment. While a private hygienist may offer advantages, it should be an explained choice.

3  The dentist doesn’t explain all your treatment options One in seven of people surveyed (15%) did not have the pros and cons of different options explained. On our mystery-shopping visits, nearly a third (eight out of 25) were rated poor or very poor for the dentist explaining the dental problems, options and risks and benefits.

Verdict Patients don’t know their options unless they are explained in clear language. On one mystery-shopping visit our experts said: ‘Very few options and little explanation given, including how her extensive gum problems will be treated, and no explanation of the risks and benefits of the fillings offered.’

4  There’s nothing written down Only 52% of people surveyed who should have got a treatment plan (for more complex treatment such as fillings or crowns) were given one, although 87% think it’s important. On our undercover visits, fewer than half (eight of 20) of those eligible were given a treatment plan after their visit.

Verdict It’s a legal requirement that any patient who has more than a band 1 course of treatment, and is not exempt from charges, must be given a treatment plan. This plan should set out the proposed treatments, give a realistic cost estimate and list whether each treatment is NHS or private.

5  There’s no price list on display Just 43% of people surveyed saw a price list in the reception or waiting area, although 88% think this is important. On our undercover visits, our researchers saw a price list on 16 out of 25 visits. Only five of these 16 price lists contained any private prices, yet this is part of the General

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Dental Council standards to which practising dentists must adhere. Verdict It’s a legal and professional requirement to display a price list. On five out of 20 visits no price list was displayed and no treatment plan provided. We believe that makes it hard for patients to be really clear on what they’re paying.

CLEAN UP DENTAL COSTS Helen McKenna, Which? principal health policy adviser At Which?, we are disappointed that dentistry patients continue to experience problems, despite the Office of Fair Trading (OFT) making a number of recommendations in 2012. The sector promised to deliver, but we have found that some recommendations still haven’t been acted on.

New campaign We have launched a campaign, Clean Up Dental Costs, to ensure that dentists are upfront with patients on costs. We want the Department of Health, NHS England, the Care Quality Commission and the General Dental Council to comply with the OFT recommendations that are still outstanding, and take action to ensure all dental practices, whether NHS, private or mixed: prominently display prices in practices and on websites give a treatment plan in advance of treatment to each patient who is entitled to one clearly provide treatment options so patients can make an informed choice explain to NHS patients, and state in plans, whether treatment is NHS or private. Patients should expect oral healthcare that is appropriate, easily accessible and of a good quality. Whether care is NHS or private, all options should be made clear, and patients should be given transparent information about costs before starting their treatment. Here’s how you can get involved in our campaign: 1 Sign up to the campaign at which.co.uk/dentistry – the more supporters, the greater the pressure for change. 2 Spread the word by telling others about the campaign. FEBRUARY 2015 WHICH? 31

FEATURES & INVESTIGATIONS DENTAL TREATMENT COSTS

Dental pricing guide To give you an idea of what you could pay for your treatment, we collected prices from leading dental chains BUPA, Dentalcare Group, Integrated Dental Holdings, Oasis and Rodericks*. Below, we show you a range of private prices they gave (rounded to the nearest £5), plus NHS prices

New patient consultation and assessment (adult)

Simple x-rays (radiographs)

Hygiene clean (scale and polish)

NHS band 1  £18.50 Private £15-£65

NHS band 1 £18.50 Private £5-£30

We say Ask how long your private consultation will last, and whether any x-rays are included with it (including the type) as it varies between practices. Subsequent routine appointments are usually cheaper, but do ask for ongoing prices so you know what you’re paying in the long term.

We say As a new patient, you will usually have simple x-rays of the back teeth (called bite-wings). But you may need more complex specialist x-rays to get a view of the whole mouth from ear to ear; the latter may well be more expensive if done privately.

Scale and polish in NHS band 1 if clinically necessary £18.50 Deep scaling NHS band 2 £50.50 Private £35-£100

Amalgam (metal) filling

Composite filling (known as tooth-coloured or white)

NHS band 2 £50.50 Private £40-£190 We say The cavity in your tooth is drilled so it can be filled with a mixture of metals. Private prices for all types of filling depend on the size and complexity of the treatment you need, for example, how many tooth surfaces it covers. Amalgam is hard-wearing and good for the back chewing teeth.

Simple extraction (tooth removal) NHS band 2 £50.50 Private £55-£250 We say Some teeth will be routinely extracted in the dentist’s surgery – known as a simple extraction. Others will need referral to a dentist with advanced skills in surgical treatments because they’re awkwardly shaped or placed, and surrounding bone may need to be removed to free them.

NHS band 2 £50.50 Private £40-£260

We say Check if it’s with a dentist or hygienist, how long for (private hygienist appointments generally last 20-45 minutes), what’s included and the treatment plan. See Which?, Feb 2014, p29 to review the evidence for scale and polish.

Root canal treatment NHS band 2 £50.50 Private £95-£700

We say Composite fillings are trickier to do (the tooth surface must be dry as the resin gel is bonded on) and can be less hard-wearing for back teeth that chew and grind. More expensive private ones are lab-made for you. On the NHS, you’re more likely to get them on front teeth, but your dentist decides what you need.

We say If decay gets deep into your tooth and affects the root, a root filling (known as root-canal work) can save the tooth. It’s a technically demanding treatment and you may be referred to a specialist endodontist. Private prices depend on the complexity, tooth size and position (back teeth tend to be more expensive).

Crown (any material)

Dentures (full)

NHS band 3 £219 Private £350-£1,100

NHS band 3 £219 Private £220-£1,300

We say Crowns are shaped like natural teeth and fit like a cap over teeth. Private prices depend on materials used and time taken. Crowns are lab-made of materials including porcelain (most expensive for a very natural tooth look), porcelain bonded on to precious metal, or all-metal (generally less expensive and used on back teeth).

We say The private price of a full or partial denture will vary depending on what it’s made of, the number of teeth missing and the condition of remaining teeth. Cobalt chrome dentures rest on the teeth, not the gums, and can fit better than acrylic, although you can have acrylic bonded on to chrome.

* Genix Healthcare and Southern Dental declined to provide information. 32 WHICH? FEBRUARY 2015

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FEATURES & INVESTIGATIONS DENTAL TREATMENT COSTS

How NHS dentistry works If you visit your dentist as an NHS patient, you are entitled to receive the NHS treatment you clinically need to keep your teeth, gums and mouth healthy and pain-free There are three standard NHS treatment bands: band 1 (£18.50), 2 (£50.50) and 3 (£219). Band 1 Includes examination, diagnosis (including x-rays), scale and polish (if needed), application of fluoride or fissure sealant and preventative advice. Band 2 Includes everything in band 1, plus further treatment such as non-surgical gum treatment, fillings, root canal work and tooth removal. Band 3 Includes everything in bands 1 and 2, plus treatments made in a lab, such as crowns, dentures and bridges. If you need a treatment you should not be expected to pay privately, although your dentist should explain suitable private options you can consider. Dentists are not allowed to refuse any treatment available on the NHS but then offer it privately, or to suggest that NHS treatment is inferior. You should only pay one charge for a course of treatment, even if you visit the dentist a few times – so three fillings and a crown recommended on the same treatment plan would all be covered by the £219 charge. Certain people get free dental care, including those who are pregnant; those under 18 (or under 19 in full-time education); and those entitled to certain income-related benefits.

THE BOTTOM LINE

Checklist Find a dentist See the NHS Choices website in England to search for a dentist (or NHS Wales, NHS24 in Scotland, and Health and Social Care in Northern Ireland). There are patient ratings for dentist surgeries on the NHS Choices website and on Which? Local at which.co.uk/local.

Questions to ask Before the appointment How much will it cost? Will x-rays be included (if you’re paying privately)? During the appointment What are my dental problems? Can you explain my treatment options? What are the pros and cons, or risks and benefits, of each option? What are my NHS and private options – and costs associated with each? What would happen if I don’t have the treatment? When do I have to pay? How long will it take? Is the work guaranteed for a length of time? If I’m unhappy with the results, who pays for the work to correct problems? If there are complications and I need more treatment, will there be extra charges? What can I do to prevent further problems? What can you do to help me prevent further problems?

Many dentists aren’t explaining what patients will pay, the treatment options and whether they’re NHS or private. They’re also not meeting legal/professional requirements, including giving written treatment plans and displaying price lists. Which? is calling on the regulators to take action to make sure you get the information you need. In the meantime, use the guidance in this article to make sure your dentist explains the options, and that you’re clear on the costs. which.co.uk

Things to expect There should be a price list on display at your dentist – ask if there isn’t. You should get a written treatment plan (estimate) before any work begins if you need treatment in band 2 or above. This includes more complex treatment such as fillings or crowns. Contact details for advice after treatment. If your dentist claims to be a specialist – for example, in orthodontics – you can check the General Dental Council’s specialist list to make sure.

How to complain if things go wrong If you’ve got concerns or complaints about NHS or private treatment, as your first step ask your dentist or dental practice to investigate. They are required to have a complaints procedure and should take it seriously. If you’re an NHS dental

FIND OUT MORE On Which.co.uk l 18 dental insurance policies compared for both NHS and private treatment: which.co.uk/ dentalinsurance l Advice on what to do if you receive poor dental treatment, whether it’s

patient, you can complain to NHS England (or the national equivalent in Wales or Scotland), as it commissions dental services. See nhs.uk. If the NHS is not able to resolve your concern, contact the independent Parliamentary and Health Services Ombudsman in England (each UK country has an ombudsman). If you’re a private patient, contact the free UK-wide Dental Complaints Service on 020 8253 0800; dentalcomplaints.org.uk If your complaint is about a dental professional’s ability, behaviour or health, contact the UK-wide regulator the General Dental Council on 020 7167 6000; gdc-uk.org. The Care Quality Commission also regulates dental practices in England (separate regulators in UK countries), but doesn’t deal with individual complaints – although it encourages patients to feed back issues.

with an NHS or private dentist: which.co.uk/ dentalrights Previous related articles in Which? l ‘Budget brushes clean up’, December 2014, p65 l ‘What seems to be the problem?’, April 2013, p22 l ‘How good is your

dentist?’, November 2011, p58 Other useful contacts l Search for a dentist and see patient ratings for dental practices at nhs.uk l Get info on the standards to expect at gdc-uk.org l Get advice on treatment from dentalhealth.org FEBRUARY 2015 WHICH? 33