What cost to us, dental tourism?

This limited investigation concerned the possible costs to the UK taxpayer generated by nationals going abroad for dental care. At present, 60% of the General Dental Services (NHS) is funded from taxation.

Data for the investigation was severely hampered by confidentiality issues. In February 2011, there appeared in the three most popular dental titles and the website, www.gdpuk.com, an appeal for leads: ‘I should like your help. I am involved in a survey looking at the economic impact of dental tourism. Beyond anecdotal reports and speculation in the popular press, relatively little is known about the implications to the NHS of dental tourism. The survey will require comments from both tourists and general practitioners.’

The appeal must have been seen by many of the UK’s high street practitioners. There was one response.

Popular destinations
There are no figures available from any source for those seeking dentistry abroad. The most common destination is Hungary where a figure of 35,000 per year is quoted. Slovakia, Poland and the Baltic countries are not far behind.

In April 2011, the Hungarian Prime Minister, speaking to his parliament, referred to dentistry generating 227 million euros to the Hungarian economy. He went on to say that his government would finance the sector’s development to multiply by threefold in five years.

There are a number of factors in play. The first is the cost of UK private contract dentistry. The second is the internet. The industry is entirely internet driven. Put in the word ‘dental’ into any search engine and you will find a promotion on dental tourism. The third factor is low-cost airlines such as Ryanair and Easyjet. The fourth and the main driver is the government’s reform of NHS dentistry that occurred in 2006.

Destructive system
From now on, dentists with NHS contracts were to be paid by courses of treatment. The new currency was the unit of dental activity (UDA). A more destructive system for both patients and dentists could not be devised. A dentist, working under a NHS contract, is either credited with UDAs worth between £15-£30 each, with even the most complex treatments worth a maximum of 12 UDAs. Within each of these three bands all treatment necessary for dental health is required. For an unlimited amount of crown, bridgework, root fillings and extensive gum treatment the maximum credit is still £180-£360. You can understand the explosive growth after 2006 of dental tourism. Many high street practitioners refuse buy into the NHS system. Those who do, carry out the minimum amount of work on as many patients as possible, often spreading treatments over an extended period of time. It is known as gaming and can be reasonably justified.

Cost and legislation
Reference was made to the first factor in dental tourism being the cost of UK private dentistry, which an increasing number of patients have been resorting to since 2006, either by choice or manipulation. There are many reasons for this: cost of student debt, price of property or rent, staff, employment legislation, health and safety legislation, indemnity insurance and duplicated regulation from both the GDC and CQC.

It is a matter of regret that practitioner and patient leads had to be made through personal contacts. There simply was no alternative. It is admitted that it was not random and not Cochrane compliant.

The BDA, the BDTA, the BDHF are largely hostile to dental tourism, waving the shroud of continuity of care and/or legal redress if things go wrong.

It may be worthwhile remembering that treatments go wrong in the UK, too. The job of these organisations is hardly one of encouraging globalisation. The government’s chief dental officer, who is obliged to support health ministers, also makes mild noises of the dangers of unsatisfactory outcomes and the difficulty of continuity of care. However, there is a feeling that his officials think dental tourism may be a good thing.

Case studies
The sample used was 42 mixed-practice dentists and 31 patients. Four patients were interviewed but not examined. Each one of these 31 patients had to be contacted through their practitioner for consent. For such a small sample, it was a disproportionate amount of work. The restorative departments of 15 dental schools were also contacted, of which seven responded.

Also asked were three tabloid journalists who had written newsworthy articles about dental tourism. However, none responded. Of the 42 dentists mixed-practice dentists, the following was found:
•    30 had some feelings of upset or anger that patients with whom they had a satisfactory relationships in the past had gone abroad and then just returned to them for maintenance work
•    37 said that the work that their patients had either told them or had admitted that it was done abroad was either ‘very good’ or ‘good’
•    Only five said the work was ‘very poor’ or ‘poor’. This was quite surprising, given that these 42 dentists could be expected to be rather critical
•    Two of these mixed practice dentists would only do emergency work under NHS contract for unsatisfactory work completed abroad. This was irrespective of whether or not they had seen the patient before
•    Three of the dentists had done some remedial work for unsatisfactory work completed abroad but under private contract. The other 39 said if they were faced with having to carry out remedial work for unsatisfactory work completed abroad they would only do it under private contract
•    40 of the 42 dentists said that any continuing care for a patient who had had satisfactory work completed abroad would be done under private contract irrespective of the treatment or its urgency.

Half the story
This is only half the story because it was impossible to identify the patients who had gone abroad, had unsatisfactory treatment and refused to disclose the fact or were economical with the truth when faced with a practitioner who they had never seen before.  

The seven restorative departments of the 15 dental schools all said that there was a statutory obligation for their NHS Hospital Trusts to treat all patients who presented in pain or with life-threatening conditions.

None of them would commit themselves further.

Regarding the 31 patients:
•    27 described their dental outcomes as ‘very good’ or ‘good’. What was interesting is that over half gratuitously commented on what is now termed patient experience or customer care.

This was without being prompted. It included detailed treatment plans, price lists, transportation from the airport, hotel arrangements, restaurant reservations, VIP treatment and general professionalism.
•    15 of the patients said that since going abroad they had some sort of continuing care, minor care to the work done abroad or work unrelated to the work done abroad.

The 15 said they had no difficulty in obtaining it and seven of them had gone back to the dentist they has seen before. What is significant is that all 15 said they were seen under private contract
•    Two described their treatment as having been unsatisfactory but both had the opportunity of having remedial treatment, albeit not as they had originally expected. One had it done by the same clinic with offices in London and one had to return to Budapest at their own expense
•    Two others described their treatment as unsatisfactory or had not had their expectations met. Neither of these two had informed the clinics concerned or had any intention to seek further treatment.

The conclusion of this rather limited non-randomised review is that there are no cost implications of dental tourism on public expenditure or on the UK taxpayer.

The vast majority of dentists surveyed said that when patients sought treatment to remedy dental work done overseas they did so on a private basis with no cost to the NHS.
 

Summary of a paper given at the 9th International Dental Ethics and Law Congress, Louvain, in August 2012 by Edgar Gordon.

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