Scottish Government

Modernising NHS Dental Services in Scotland: Analysis of Responses

CHAPTER 7: HOW SHOULD PATIENTS CONTRIBUTE TO THE COST OF THE SERVICE?

The consultation stated:

The current system of patient charges for NHS dentistry requires individuals (who are not exempt or qualify for help) to pay 80% of the treatment costs, subject to a current maximum of 378. Because a course of treatment may comprise a number of individual items, each with a different fee, the system is extremely difficult for patients to understand (and complex for dental practices to manage). There is also some limited charging for services provided through CDS (and the hospital dental service).

Changes to the remuneration system for contractor dentists and greater integration of GDS and CDS into primary care dental services would mean changes to the patient charging system. Successive administrations since the early 1950s have taken the view that patients - unless exempt for specific age, condition or income reasons - should contribute to the cost of dental treatment. Income from dental charges is currently over 50m in Scotland.

Consumer groups and professionals have pressed for simpler charging arrangements which are also seen to be as fair and equitable as possible.

The consultation paper posed a number of specific questions about how patients should contribute to the cost of the service. This chapter is structured to present the responses to each question in turn.

7.1 WHAT PRINCIPLES SHOULD BE PURSUED IN DETERMINING A SYSTEM FOR PATIENT CHARGES?

The topic of patient charging produced a substantial volume of responses relative to other topics. Around 110 respondents provided views on the rationale for a system for patient charges. Interestingly, comments from the public were slightly under-represented amongst these, suggesting, perhaps, some lack of understanding of the current framework of patient charges on which to base comments.

Views provided were a mix of those based on idealism and those based on pragmatism. Indeed, some respondents gave 2 versions of their views - one of which related to an ideal situation, the other, relating to what they thought would be workable in the real world. Because of this, the quantification of views below should be treated as indicative only, with some degree of double counting inevitable.

Free Dental Care?

Fifteen respondents, representing five of the sector groups, argued that the principle of NHS dental treatment, free at the point of delivery, was valid. One view was that people who have paid national insurance should expect free treatment (Pub 13, Pat Rep 18, Pat Rep 2). Another was that charging for dental treatment was out of step with the rest of primary health care (Dent 21, Dent 79, Pat Rep 18). Ways of funding free dental care were suggested. Ideas comprised general taxation (Dent 58, Educ 2, Bod 19, Pat Rep 11) or through some form of sugar tax (Bod 23, Pat Rep 14). One comment was that if the government was really serious about oral health, then NHS dental treatment would be free for all (Pub 21).

Important to Retain Charging

An opposing view was that charges should be kept in order to better regulate supply and demand, and to provide an incentive for people to look after their teeth. Overall, twelve respondents stressed the importance of retaining charges.

Taking these in turn, one concern was that if all dental treatment became free then demand for treatment and expectations relating to accessing treatment could not be met (Dent 7, Dent 65, Dent 72). Charging for treatment was viewed as a means by which those who did not look after their oral health could subsidise those with better oral hygiene (Prof Rep 19), make people look after their teeth (Dent 7, Dent 80) and make people less likely to miss appointments (Dent 83).

Partial Charging

Between these 2 extremes lay a host of suggestions for a mix of free, subsidised and charged dental treatment. These are summarised here.

Free Dental Check Ups

Amongst the 18 respondents who commented, 13 found favour with the plans for free dental check ups. Amongst the remainder, questions were asked about how these would be funded (Dent 3), who would deliver them (Dent 46, Bod 17) and the perceived lack of impact this would have on oral health, with the comment that those on low income do not pay for check ups anyway (Dent 44).

Free "Core" Treatment

Nine respondents suggested that a "core" of treatment (core to be defined) could be provided free or subsidised by the NHS with the rest to be paid for by the patient. One respondent (Dent 35) articulated what they perceived would be the main benefits of this:

• reduction in time consuming collection of monies and administration

• reduce fraud and bad debts

• almost eliminate complex monitoring systems of Dental Estimates Board

Reduced Charges for Good Oral Health

A small group of respondents considered that if a person was seen to maintain good oral hygiene then they should be rewarded with free or reduced charges (Dent 19, Dent 21, Dent 74, Bod 16). Likewise, one consultee suggested free care where a patient displayed regular attendance at the dentist (Bod 15). The notion of strategic pricing was favoured by several consultees with recommendations that charges be set to support good oral hygiene amongst patients, rather than favouring oral neglect (Dent 78, Prof Rep 3, Dent 78, Dent 81). The view of 5 respondents was that all preventative work should be free or be charged at a low rate (Dent 21, Educ 2, Bod 26, Bod 17, Pat Rep 14).

Cases where Oral Health Impacts Negatively on General Health

Four respondents recommended free dental care in cases where general health suffers as a result of poor oral health (Bod 22, Bod 20, Prof Rep 28, Prof Rep 20).

Standardised Charging

A recommendation was that any system of charging for dental care should be consistent nationwide (Dent 19, Bod 29). Another urged consistency of charging for treatment across primary care (Prof Rep 31, Bod 11 - " why is a person not required to pay for treatment to an abscess on the leg but is required to pay for treatment to an abscess in the mouth?"). Ten respondents wished to see consistency in charging across GDS, CDS and hospital treatment.

Improving the Charging System

Around one-quarter of those who commented on patient charges raised the issue of simplifying these. (One dissenting voice, however, cautioned that simplification could lead to unfairness (Dent 11)). Again, one-quarter of those commenting requested charges which were more easily understood, transparent and clear for both patient and practitioner. Particular issues which were seen to be in need of addressing were the perceived confusion over what elements of a charge were NHS supported and what the patient had to cover (Prof Rep 23). Other requests were for more transparency in providing itemised bills (Pat Rep 4) with prices clearly displayed (Prof Rep 14), and ensuring that patients received a receipt after treatment (Pat Rep 11).

Five consultees recommended a charging system which made the collection and the administration of charges more straightforward for dental practices (Dent 68, Bod 4, Prof Rep 1, Prof Rep 5, Dent 79).

Maximum Charges

Of the 10 respondents who commented, there was an even split between those who wished to see the maximum patient charge scrapped (all were dentists) and those who thought it should be maintained (mix of other categories). One view was that it should be " radically reduced" (Pat Rep 17).

Affordable Charges

Six respondents called for an "affordable" or "reasonable" pricing structure which did not serve as a disincentive to attend for treatment (Pub 2, Pub 18, Bod 26, Bod 17, Pat Rep 14, Pat Rep 15).

Exemptions

There was much discussion of the categories of patients which deserved to be exempt from future dental charges. Many consultees simply stated that they agreed with the current exemption categories. Views on specific categories of patient or treatment type are summarised in Table 2 below.

The view of 5 consultees was that the time was now ripe for a review of the current list of exemptions (Dent 78 - " may be too generous", Dent 80 - revoke if patients fail to keep appointments, Bod 6, Pat Rep 11, Prof Rep 14).

7.2 WHAT ARE YOUR VIEWS ON THE OPTIONS FOR PATIENT CHARGES LISTED IN THE CONSULTATION DOCUMENT?

Around one-quarter of all respondents provided comment on the options for patient charging listed in the consultation document. An overarching concern which emerged in a small number of responses was that whatever options were selected, they should try to avoid contributing to any patient/practitioner conflict. Payments should be transparent with the rationale for charging unambiguous and not open to different interpretations or disputes between dentist and patient (e.g. Dent 5, Prof Rep 34).

Taking each option in turn:

Single (simple) charges for specific procedures

There was much support for this option. Its advantages were seen as patient focused - e.g. helping them feel that they were getting something for their money (Dent 19); making it easier for them to understand the charges (Bod 24); and practice focused - e.g. being easier to administer (Pub 16).

Suggestions were made for the delivery of this option. These included ideas for prices - in units of 5 with, say, 20 for a small filling (Bod 23); standard prices for "all fillings" or "all crowns" (Dent 15); or the provision of a "menu" with charges clearly set out (Dent 65).

However, one dissenting voice envisaged this option giving rise to inequalities in provision with lower socio-economic groups having to pay the same fees as those as others (Educ 4).

Change to the percentage (or amount) charged depending on the nature of the service

There was less support expressed for this option, although it was difficult to interpret responses as it may be that, in the main, only those who wished to object have made their views known. Reasons for not supporting the option included the perceived complexity of operating the system (e.g. Dent 19, Prof Rep 28, Pat Rep 17) and the concern that if charges were weighted to support prevention rather than treatment, then people may be put off their initial dental visit (Bod 4).

Change to the percentage (or amount) charged depending on the patient's characteristics

Very little comment was made on this option (although relevant views on exemptions depending on patient characteristics were made in relation to the previous section of this report). Again, the balance of comments received was against this option largely due to the perceived complexity of the system. One other concern was that dentists may find that this option led to disputes with patients over charging (Anon 1).

Fixed charge for each visit to the dentist, which could be related to time in practice

Of the 20 responses which addressed this option, 13 were against the suggestion with 7 for.

Reasons against fixed charging included:

• could lead to abuse - difficult to regulate (Bod 5, Prof Rep 30)

• too dependent on characteristics of individual practices (Bod 8)

• difficult to administer (Dent 49)

• could result in dentist/patient conflict (Dent 5, Pat Rep 6)

• too similar to a private practice model (Prof Rep 23)

• disadvantages those requiring more time in surgery on account of a disability (Pat Rep 17)

• does not fit with notion of free check ups (Dent 19)

Separate payment arrangements for dental appliances (dentures, bridges, crowns) rather than through the fee related system

Of the 12 responses which related directly to this option, 9 appeared in favour of such a scheme. Where arguments were specified those against were based on perceived administrative difficulties (Dent 49) and a concern that it may discourage some people from having necessary treatment (Bod 8).

Insurance type system (similar to some private dental plans) with or without assessment of dental health and status

Of all the options outlined, this one attracted the most comment (24 responses). Out of these, 15 responses favoured some form of insurance, with the remainder against or not certain. Reasons for favouring the option included:

• attractive to public (Dent 33)

• helps dentists with cash flow (Dent 34)

• could target it to insure against emergency treatment and trauma (Dent 5)

• would facilitate a better relationship between dentist and patient (Prof Rep 34)

Arguments against the option included:

• not acceptable to the public to pay 10 per month (Dent 2)

• it already exists in the form of National Insurance (Dent 19)

• difficult to administer without a suitable IT system (Dent 49)

• too expensive, with insurers just out to make money (Pub 21)

• should wait and learn from lessons from elsewhere first (Bod 8)

• discriminatory against those on low incomes (Pat Rep 5, Dent 78)

• might be problems if a patient wished to change dentist (Pat Rep 17)

7.3 ARE THERE OTHER APPROACHES THAT MERIT CONSIDERATION?

A small number of recommendations were made which related largely to modes of payment for dental treatment. There are summarised below:

Voucher Scheme

Around 9 respondents recommended that some form of voucher scheme be tried which provided the patient with some flexibility over use and perhaps was designed to reflect the patient's income and the Scottish Executive's priorities (Prof Rep 35, Bod 16, Bod 4, Bod 23, Bod 22, Bod 20, Bod 27, Prof Rep 28, Prof Rep 20).

Smart Card

The idea of a smart or swipe card for payment purposes was advocated by 7 respondents (Dent 50, Bod 4, Bod 22, Bod 20, Prof Rep 28, Prof Rep 20, Dent 80). A further suggestion was for dental practices to have facilities to accept switch cards and standing orders (Pat Rep 14).

Regular savings

One respondent suggested the introduction of a "health card" which could be used for payment and topped up at various locations such as post offices (Dent 34).

Proof of Exemption

Calls were made by a few respondents for clearer systems of establishing the exemption status of patients. Suggestions were for an "exemption card" (Dent 49, Prof Rep 14) or documentation which put the onus on the patient to show their exemption qualification (Dent 62).

Handling of Bad Debts

One theme which emerged throughout several responses was a desire for dentists to be protected against bad debts. Several respondents suggested that these be more appropriately dealt with centrally by health boards, the Scottish Executive or a debt collection agency.

Compensation to Patients in cases of lack of access to NHS Dental Care

One final comment came from several members of the public who argued that should a patient have to seek private treatment in the absence of any available NHS care, then they should be entitled to some form of reimbursement from their respective health board (Pub 3, Pub 7, Pub 19, Pub 20, Pub 23).