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What does our work say about NHS dental charging

21 January 2015

This report highlights the confusion surrounding NHS dental charges and is illustrated by summaries from our casework.

Introduction

Last week Which? revealed that its latest undercover investigation found that 'a worrying number' of dentists do not spell out the treatment patients need, give details of NHS and private options or explain the costs of treatment to patients.

The Parliamentary and Health Service Ombudsman (PHSO) exists to investigate complaints that individuals have been treated unfairly or have received poor service from government departments and other public organisations and the NHS in England. PHSO is the final step of the complaints system. It is an independent and last resort to investigate complaints. We receive one in ten of all written complaints about the NHS. We reviewed what our evidence told us about dental charging to provide a more complete picture of the landscape.

PHSO reviewed cases from  September 2012 to September 2014. In that time, we received 36,839 enquiries  related to the NHS; 2,368 of those were about dentists. We looked at 589 dental cases in more  detail, of those we investigated 189. Confusion over dental charging was an issue in 27  cases. The key points we identified were common to all of these.

Key points

  • The current system is confusing for both patients and dentists. Sometimes it can result in incorrect charging by dental practices or failure to understand correctly applied charges on the part of the patient.
  • Sometimes dentists fail to share and communicate clear treatment plans that explain treatment options and associated costs with their patients.
  • Some patients are unsure about entitlement to exemption from charges and fail to understand that it is their responsibility to complete the form correctly.

Clear, effective communication could help prevent many of the complaints we see about this issue.'

- Dentist and clinical adviser to the Parliamentary and Health Service Ombudsman

How NHS England dental treatment costs work

When an NHS patient visits their dentist, the dentist should give them all the treatment clinically necessary to ensure that their teeth, gums and mouth are healthy and pain-free.

There are three standard NHS England treatment charge bands:

  • Band 1: £18.50 covers an examination, diagnosis and advice. If necessary, it also includes X-rays, a scale and polish and planning for further treatment.
  • Band 2: £50.50 covers all treatment covered by Band 1, plus additional treatment, such as non-surgical gum work, fillings, root canal treatment and removing teeth.
  • Band 3: £219 covers all treatment covered by Bands 1 and 2, plus more complex procedures, such as crowns, dentures and bridges.

If a patient needs treatment, they should not be expected to pay privately, although the dentist should explain suitable private options for consideration. Dentists are not allowed to refuse any treatment available on the NHS and then offer it privately. There should only ever be one charge for a single course of treatment, even if the patient visits the dentist several times. If a tooth is repaired as part of NHS treatment, and this repair needs to be corrected or replaced within 12 months, this further work should be carried out without the dentist applying another NHS dental charge as long as the further work is the same as the original treatment. Certain groups of people get free dental care, including those under 18, or under 19 and in full time education, pregnant women, or those entitled to certain income-related benefits. The responsibility for correctly filling in exemption from charges forms rests solely with the patient. 

Insight from our casework  

Mistakes by dentists

Dentists' failure to share with patients clear treatment plans that explain the dental charges involved, despite an obligation to do so.

Mrs S's story

Mrs S had NHS root canal treatment to a tooth at her dental practice, but, during treatment, opted for a composite (white) filling to be provided privately. Mrs S experienced more problems with the tooth and returned to the dental practice later that year. She paid an NHS dental charge to have the tooth filed and subsequently extracted. Mrs S complained that her dental practice failed to fully discuss treatment options with her before it started root canal treatment. She also complained that she should not have been charged for the further NHS treatment to her tooth because she felt it arose from the failure of the original root canal treatment.

Given that private treatment is not covered by the 12-month guarantee, and that the follow-up treatment was different to the original treatment, we did not agree that Mrs S was incorrectly charged for her follow-up NHS treatment. Nevertheless, we said that the rules are clear that dentists should not carry out a mixture of NHS and private treatment to the same tooth over a single course of treatment. We also concluded that there was no evidence that the dental practice acted in line with the rules to discuss Mrs S's private treatment options or obtain her consent on the relevant form before treatment. We therefore recommended that Mrs S's dental practice reimburse her the cost of her private treatment.

Dentist or dental practice confused about appropriate charging for dental treatment and then missing opportunities to correct mistakes.

Mr A's story

At an appointment with his dental practice, Mr A and his dentist agreed that Mr A should have all his teeth extracted and he should have dentures. He was referred to a local hospital for the extraction. When Mr A went back to the dental practice to be fitted with the dentures, he and dental practice staff disagreed about whether this should be considered as a new course of treatment.

We concluded that, according to the rules, the extraction, the appointment where this was discussed and the fitting of the dentures, should all have been charged as one single course of treatment, regardless of whether Mr A was referred to a different practitioner during the course of treatment. We also concluded that the dental practice missed a chance to correct the mistake when Mr A challenged it. We asked the dental practice to apologise and make a payment to Mr A to recognise its failure to apply the NHS dental charge correctly. We also asked it to review the rules about NHS dental charges.

Patients' confusion 

Patients did not understand that they would incur two NHS dental charges for what they considered to be one course of treatment.

Mrs G's story

Mrs G's dentist extracted four teeth from the front of her mouth and fitted an immediate (temporary) denture. Mrs G says that at a later appointment, the dentist told her that her gums would shrink and she would need to pay for a replacement denture once that had happened. She was unhappy about this because she felt that she was being asked to pay twice for a single course of treatment. We concluded that, according to the rules, an extraction and fitting of immediate dentures, and the provision of permanent dentures, count as two, separate courses of treatment.

Mr Y's story

After Mr Y had an NHS scale and polish (cleaning to remove plaque from his teeth) at his dental practice, he arranged for a more thorough cleaning procedure to be carried out there the following month. Mr Y complained that the dental practice's NHS scale and polish was sub-standard, and that he was not told that the follow-up cleaning procedure would be charged privately.

We concluded that, according to the rules, dentists are only required to remove plaque from around the gum line to combat disease during an NHS scale and polish. A more thorough clean would be cosmetic, and could be charged for privately.  

Patients paying for NHS treatment and/or incurring fines because they have completed the exemption from NHS dental charges form incorrectly.

Mr R's story

After a full dental extraction, Mr R's dental practice fitted him with dentures. At his appointments, Mr R completed the relevant forms, stating that he was exempt from NHS dental charges because he was receiving income-based jobseeker's allowance. Mr R was not receiving that specific benefit at the time. The form that Mr R signed states 'I understand that I will have to pay a penalty charge of up to £100 if it is not correct and I am not entitled'. Mr R was later charged for his treatment and given a penalty charge because he was not entitled to free NHS dental care.

Mr R complained that his dental practice did not help him to complete the forms and this meant that he incorrectly stated he was eligible for free NHS dental care. We concluded that the dental practice acted in line with the NHS Business Service Authority's guidelines because dentists are not allowed to help patients complete the forms.

What happens next?

In light of the confusion about dental treatment costs for both practitioners and patients, PHSO welcomes the current review of the dental contract and the pilot of a different system, as well as the CQC's 'fresh start for the regulation and inspection of dental care services'.

Improving communication

Our evidence shows patients' confusion about dental charging. Therefore, it is more important than ever that dentists meet their obligations. Dentists should try to clearly communicate treatment options and associated costs with their patients. Options and costs should be written in a treatment plan, particularly for band two and three treatments, which is shared with the patient, in line with the terms of the NHS Dental Contract.

Dentists should be clear about what constitutes one course of treatment, what charges apply when a patient fails to complete a course of treatment, charging protocol when a patient is transferred to a different practitioner over the course of treatment; and when the 12-month guarantee does not apply.

Something useful for patients

The Which? publication has lots of top tips for patients to help them understand dental treatment costs and get the most out of their visit to the dentist. If, as a patient, you have experienced similar problems and have already spoken to your dental practice or NHS England and are not satisfied with the response, please get in touch with us as we may be able to help.