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How well is the Dentistry Market working in the UK? Findings from a national survey of practice owners November 2012 By Martin Kemp and Henry Edwards British Dental Association 64 Wimpole Street London W1G 8YS 1 About the BDA The British Dental Association (BDA) is the professional association for dentists in the UK. It represents more than 23,000 dentists working in general practice, in community and hospital settings, in academia and research, and in the armed forces, and includes dental students. Copyright notice Copyright © BDA 2012 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without either the permission of the publishers or a license permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1P 9HE. I Contents List of Tables List of Figures Abbreviations Summary 1 Introduction and background 2 Survey design 3 About the practice owners and their practices 4 Marketing practices 5 Perceptions about how well the UK Dentistry Market is working Appendix I Invitation letter to practice owners Appendix II Practice owner survey schedule Bibliography II III V VI 1 7 10 13 22 42 51 53 63 List of Tables Table 2.1 Outcome of practice owner survey Table 3.1 Demographic profile of survey respondents Table 3.2 Sex and age composition of respondents Table 3.3 UK country where main practice is located: survey population compared with respondents Table 3.4 Profile of respondents‟ practices Table 3.5 Proportion of patients receiving NHS care at main practice Table 3.6 Proportion of patients at main practice receiving NHS care, by country Table 3.7 Percentage of the total turnover from practice owners‟ main practice which came from NHS care in 2010/2011, by UK Country Table 3.8 Employment of dental care professionals by type of patients treated at main practice Table 3.9 Types of patients treated by Dental Care Professionals at main practice Table 4.1 Advertising practices by the proportion of patients at main practice who receive NHS care and practice size Table 4.2 Methods used to advertise dental services provided at main practice Table 4.3 Methods used to advertise, by whether main practice provides NHS, private or mixed care Table 4.4 Methods of booking of booking an appointment at main practice Table 4.5 Method of booking an appointment, by whether main practice provides NHS, private or mixed care Table 4.6 Availability of appointments at main practice, by country, size, location, and the proportion of patients that receive NHS care Table 4.7 Perceptions of patient demand at main practice, by country, location, size, and the proportion of patients who receive NHS care at main practice Table 4.8 Average duration of procedures performed at main practice Table 4.9 Charges made for dental procedures at main practice Table 4.10 Relationship between duration of procedures and patient charges for private treatment at main practice Table 4.11 Methods of setting charges for private dental treatments at main practice Table 4.12 Proportion of practice owners who said that they provide information about fees prior to treatment, by the proportion of patients who receive NHS care at main practice Table 4.13 Methods used by practice owners to communicate private charges Table 4.14 Basis given for complaints policy at main practice III 12 13 14 15 16 17 18 19 20 20 22 23 24 25 25 27 29 31 32 33 34 35 36 37 Table 4.15 How Practice Owners communicate their complaints policies to patients at their main practice Table 4.16 Proportion of practice owners who said they had received a complaint in the past two years at their main practice, by proportion of patients who receive NHS care at main practice Table 4.17 Number of complaints received in past two years at main practice, by proportion of patients who receive NHS care at main practice Table 4.18 Where patients filed complaints (received in past two years), by type of care provided at main practice Table 5.1 Practice owners‟ perceptions of the UK dentistry market Table 5.2 Views about influence of competition on prices and quality among practice owners whose main practice provides some private care Table 5.3 Practice owners‟ views on direct access to DCPs IV 38 39 39 40 42 43 44 List of Figures Figure 4.1 Perceptions of patient demand among practice owners, by the proportion of patients who receive NHS care at main practice Figure 5.1 Level of agreement with the statement “Patients understand which treatments are available on the NHS”, by proportion of patients that receive NHS care at main practice Figure 5.2 Level of agreement with the statement “Patients understand which treatments are available on the NHS”, by UK country Figure 5.3 Level of agreement with the statement “Patients understand what treatment(s) are available privately”, by proportion of patients that receive NHS care at main practice Figure 5.4 Level of agreement with the statement “Patients understand what treatment(s) are available privately”, by country Figure 5.5 Level of agreement with the statement „Patients are well informed about the cost of their treatment before their treatment starts‟, by proportion of patients that receive NHS care at main practice Figure 5.6 Level of agreement among practice owners with the statement “Patients are well informed about the cost of their treatment before their treatment starts”, by UK country Figure 5.7 Level of agreement with the statement “Patients are able to switch to another dentist freely”, by proportion of patients that receive NHS care at main practice Figure 5.8 Level of agreement among practice owners with the statement “Patients are able to switch to another dentist freely”, by UK country V 30 46 46 47 47 48 48 49 49 Abbreviations BDA – British Dental Association BDJ – British Dental Journal CODE - Confederation of Dental Employers CQC – Care Quality Commission DCP - Dental Care Professional DCS – Dental Complaints Service DH – Department of Health GDC – General Dental Council GDS – General Dental Services LHB – Local Health Board NHS – National Health Service NOP – National Opinion Polls OFT – Office of Fair Trading PALS - Patient Advice and Liaison Service PCO – Primary Care Organisation PCT – Primary Care Trust PO – Practice Owner UDA – Unit of Dental Activity VI VII Summary This report describes some of the findings from a programme of research and analysis carried out by the British Dental Association (BDA) to investigate how well the dentistry market is working in the UK. As part of this research programme, the BDA conducted a survey of dental practice owners in the UK in order to explore their views and opinions on a variety of topics relating to the dental market, including: Competition Patient decision making Cost and fees for private treatment Patient complaints and redress. Fieldwork for this survey took place between 15th and 28th November 2011. An online mode of administration was used (using SurveyMonkey). The survey population included all dental practice owners who were members of the BDA and for whom the BDA had current and reliable information. Of the 5396 individuals who were invited to participate in the survey, 1804 responses were received, giving a response rate of 33 per cent. Of these, 1723 were valid cases. The main findings from the survey were as follows: UK practice owners and their practices 1 Practice owners were asked a series of questions about their main practice. We found that: The majority of practice owners are aged over 35 years, with an average age of 50 years. Over three out of every four practice owners are male. On average, practice owners had been the owner of their current (main) practice for 16 years, with the majority (86.6 per cent) being the owner for five years or more. Just under two-thirds reported that their main practice has three or fewer dentists. Less than one in twenty owners said that their main practice is corporately owned. Around one in five practice owners described their main practice as fully private and only seven per cent as fully NHS, with the majority providing a mixture of NHS and private care. 1 „Main practice‟ refers to where you undertake the largest number of clinical sessions each week 1 Respondents‟ main practices in England are more likely to be wholly private than in the other three countries. Nonetheless, they are also more likely to provide care for exclusively NHS patients at their main practice. Marketing practices Those practice owners whose main practice provides care to private patients are more likely to advertise their practice; for example, four out of five owners of exclusively private practices were the most likely to report advertising their practice. Practice owners reported using a variety of media to advertise their main practice. The most popular methods include: advertising via a practice website or the internet; the Yellow Pages or other local directory; signage or billboards. Almost half said that their patients could book via email and 12 per cent via the internet. Those providing private care are far more likely than exclusively NHS practices to accept bookings via email or the internet; for example, only 12 per cent of exclusively NHS practices said that they accept bookings via email. This compares with 72 per cent of practices providing exclusively private care. Levels of patient demand Owners reported that the median number of days before an appointment is available at their main practice is three days (Mean = 6.2 days; SD = 2.5). A small minority of practice owners reported very long waiting times (for example120 days). There is a clear difference between types of practices in appointment availability; for example, practices providing care to higher proportions of NHS patients have, on average, much longer waiting periods before any appointments are available. Over half of the respondents reported a high current level of patient demand for their services compared with around 14 per cent who indicated a low level of demand. There is a greater demand for dental care at NHS practices compared with privateonly practices; for example, over 70 per cent of owners of practices providing exclusively NHS care reported experiencing high levels of demand. This compares with around 40 per cent of those providing exclusively private care. Charging practices Across all procedures and treatments, there is considerable variability in how much practices charge for private care. Among practices providing some private care, just 2 over one-quarter said they set their charges in relation to what other practices charge. Most commonly, practices base their charges on what it costs to run the practice or on the practice owner‟s own judgement. Less than one in ten said that they set their charges relative to NHS charges. Almost all practice owners said that charges are discussed with patients prior to treatment. Around half said that they provide leaflets with information about their charges. Almost half of those who provide some private care said they display private fee information at reception. Only one in five said they provide a cost quotation or estimate within a treatment plan. Duration of treatments There is limited variability in the reported time it takes to complete simple treatments. By contrast, there is evidence of considerable variation in the amount of time respondents said it takes to perform more complex and cosmetic treatments. There is only a moderate positive relationship between how long treatments take and the amount charged for them. However, this relationship is stronger for some treatments than for others; for example, the amount charged for a “hygienist simple scale and polish” is closely related to how long it takes to carry out this procedure where more time is taken, the amount charged to the patient is higher. Responding to complaints Approximately 60 per cent (N=932) of all respondents reported receiving a complaint in the past two years (2010 and 2011), with a median of three complaints per practice during this period. Almost nine out of ten practice owners who have a policy in place at their main practice said that it is based on BDA guidance. Over half said that it is based on NHS requirements. One in five said that they had developed their own in-house complaints policy. Most commonly, practice owners communicate their complaints policy by displaying it in the waiting room or at reception or through patient information leaflets. Only onethird of practice owners said that they discuss the policy with patients and around one in five display their complaints policy on their website. Those providing care to private patients are over twice as likely as those providing NHS care to communicate their policy in this way. Conversely, those practices providing some NHS care are more likely than private-only practices to communicate their policy in the waiting room or via a leaflet. 3 The owners of private practices reported on average slightly fewer complaints than those providing high proportions of NHS care. Practice owners whose main practice provides mainly NHS care alongside small amounts of private care reported the greatest number of complaints (a median of three over the preceding two years, compared with a median of two complaints for all other types of practice). Among those who received a complaint(s) in the past two years, almost all (93 per cent) said that it had been dealt with in-house, within the practice. In addition, one in five practice owners said that patients had filed complaints with the PCT/Health Board/Local Health Board and one in ten had filed them with Patient Advice and Liaison Service. Perceptions of the UK dentistry market Respondents were asked about their level of agreement with a series of statements relating to competition in the UK dentistry market. We found that almost half of the practice owners agreed with the view that the dental market is working well in their area (where main practice is located). In addition, over one-third believe that the dental market in their area is overcrowded. But there was some variation depending on the extent of NHS commitment; over one-quarter of owners whose main practice treats exclusively NHS patients agreed with the view that the dental market in their area is overcrowded. This contrasts with almost half of those with no NHS commitment (delivering only private care). Participants were also asked about their level of agreement with a series of statements relating to direct access to dental hygienists and therapists in the UK dentistry market. Practice owners are strongly resistant to the idea that patients should be able to directly access hygienists or therapists without first being examined by a dentist; for example, around 80 per cent of respondents disagree with the view that patients should be able to directly access dental care professionals (DCPs) without being examined by a dentist first. However, around one in five practice owners said that they would not object if patients were able to directly access DCPs at their own dental practice. Finally, practice owners were asked about their level of agreement with a series of statements relating to their perceptions of how well patients understand and are informed about aspects of their treatment. Practice owners are evenly split on whether they believe that patients understand what treatments are available on the NHS. However, as the proportion of NHS care provided increases, they are more likely to believe that patients do not understand 4 which treatments are available on the NHS; in other words, the majority of the owners with practices that have a high NHS demand feel that their patients are not clear about what is available on the NHS. Just under half of all respondents agree that patients understand what is available privately, with around one in five believing that they do not. Owners of practices providing more private care were much more likely to agree with this view compared with those running NHS-only practices. In general, practice owners do not think that patients are well informed about the cost of their treatment before treatment begins: for example, over four in ten agree with this view. The majority (over three-quarters) of practice owners believe that patients are able to switch dentists easily. There are some moderate differences here by practice type, with those providing exclusively private care being more likely to „strongly agree‟ with this statement than those providing care to either mixed or exclusively NHS patients. 5 6 1 Introduction and background This report describes some of the findings from a national survey of dental practice owners which took place in November 2011. This survey was undertaken as part of a programme of research and analysis carried out by the British Dental Association (BDA) to investigate how well the dentistry market is working in the UK. In September 2011, the Office of Fair Trading (OFT) announced its plan to conduct an investigation into the UK market for the provision of dental services (OFT, 2011). This report forms part of a wider contribution of evidence submitted by the BDA to the OFT investigation. Its evidence was based on a programme of research undertaken by the BDA between October and December 2011. 1.1 The OFT investigation of the UK Dentistry market According to the OFT‟s scoping document, the purpose of the investigation was “to examine whether the UK dentistry market is working well for consumers. It will examine how dentistry services are sold and the extent to which there is access to accurate and impartial information to help make informed decisions. It will consider consumers' ability to assess and act on the information that is provided, as well as the nature of competition between providers of dental services”. (OFT, 2011:3) OFT (2010) define a market that is „working well‟ in the following way: “When markets are working well, firms compete to win business by achieving the lowest level of cost and prices, developing better products and services or exploiting their strengths, skills, and other advantages to meet consumers’ needs more effectively than their rivals. This process encourages innovation and provides consumers with increased choice. Competition is enhanced when consumers are empowered to shop around through access to readily available and accurate information about products and services.” (OFT, 2010:2) That is, a healthy market is one that meets “consumers‟ needs”. Competition between firms results in lower costs and better quality services or products for consumers. By contrast, OFT describe the consequences of a market that is not working well in the following way: “Markets that are not working well can result in serious negative effects for consumers, businesses and the economy. For example, consumers may be unable to make informed choices about prospective purchases, 7 businesses may be deterred from improving their products or entering the market and productivity in the sector may be undermined.” (OFT, 2010:2) Here, then, a market that is not working well is one where there is limited competition between firms. When consumers are not well informed and where the choices available to them are limited, this can lead to poorer quality services and products. 2 When this line of thinking is applied to UK Dentistry, it suggests that better informed patients and consumers, together with higher levels of competition and choice, are likely to result in more affordable and better quality dental care for the UK population. 1.2 BDA response to OFT 2011/12 In response to the OFT investigation, the BDA submitted evidence which included relevant economic arguments, research, information, policy positions and recommendations (BDA, January 2012).3 This submission was grounded in the findings from a programme of research and analysis carried out to address the question at the heart of the OFT investigation: how well is the UK dentistry market working? This research programme sought to: examine the extent to which information about dental services is accessible and transparent to consumers, enabling them to make informed decisions about their care assess whether the UK dentistry market supports consumer switching identify whether current mechanisms for complaint and redress are effective assess levels of competition in the UK dentistry market and how this affects quality and cost assess the extent to which there are barriers to entry into and the expansion of NHS dentistry. These objectives cluster around three main themes which were the focus of the research programme: Information and choice Competition Complaints. The research sought to answer the following research questions: 2 An overview of OFT market studies can be found at: http://www.oft.gov.uk/shared_oft/business_leaflets/enterprise_act/oft519.pdf (Accessed 14 May 2012) 3 The BDA‟s submission to the Office of Fair Trading inquiry into the UK dentistry market can be found at: http://www.bda.org/dentists/policy-campaigns/research/oft/OFT.aspx (Accessed 18 July 2012) 8 Is there sufficient transparency of information to enable consumers to make informed choices between dental practices, treatments, private and NHS provision, and different payment methods? Is this information provided in appropriate forms? Are effective mechanisms in place to support consumer switching? What barriers do consumers face when they want to switch dentists? How far are consumers aware of complaints procedures? How do practices compete – service, speed of appointments, etc.? How satisfied are patients with NHS and private dental care? What is the average price of common private treatment and is there a relationship between price and time taken? What are the barriers to entry into the UK NHS dental market? What are dentists‟ attitudes to direct access to dental care professionals? A mixed-method research design was used to investigate these questions (Bryman, 2006) with four main elements: A rapid search and review of the policy and research literature on the themes above An in-depth qualitative case study of the dentistry market in the London Borough of Croydon, which included: three patient focus groups; eight semi-structured interviews with local practice owners; and five interviews with local stakeholders A national survey of 1000 consumers of dental care (commissioned from GfK NOP) An online survey of BDA dental practice owners in the UK. This report describes the main findings from the last of these – the survey of dental practice owners. This first section gives the background to the report. Section 2 gives an account of the survey design and data collection. Section 3 describes the demographic characteristics of respondents and profiles their practices. Section 4 explores how practice owners market or advertise their practice, and how appointments are made at their main practice. The final section examines participants‟ beliefs about and views on how the UK dental market is working. 9 2 Survey design This section describes the design, data collection, and outcomes of the survey of practice owners that took place in November 2011. 2.1 Aims and objectives The aim of the survey was to investigate dental practice owners‟ views about patient choice and competition within the UK dentistry market. In particular, the survey sought to explore the following questions relating to choice and competition from the perspective of practice owners in the UK: To what extent is information about dental services accessible and transparent to consumers, enabling them to make informed decisions about their care? How well does the UK dentistry market support consumer switching? How effective are current mechanisms for patient complaint and redress? What are the levels of competition in the UK dentistry market and how does this affect quality and cost? What are the barriers to entry into the UK dentistry market? 2.2 The survey population The target population included all dental practice owners across all four UK countries: England, Scotland, Wales, and Northern Ireland. This included owners of practices that provide care to exclusively private or NHS patients, and provide a mixture of NHS and private dental care. The target population included corporate dentists, general and specialist dentists, but excluded NHS salaried and community dentists. The effective survey population included all UK practice owners who were also members of the BDA and for whom the BDA had current and reliable information. Respondents were identified using the BDA database, CARE4. 2.3 The survey schedule We designed a questionnaire to be administered online based on questions to meet our research objectives. Some of the questions were based on the questionnaire used in a postal survey of dental practice owners carried out in July 2002 in response to an OFT inquiry into private dentistry (BDA, July 2002). The final schedule included mixture of closed and open questions that explored the following themes: patient choice, information and marketing 4 CARE is a contact management system, used by not-for-profit organisations 10 patient switching experience and perceptions of competition attitudes toward „direct entry‟ of hygienists treatment charges barriers to becoming a practice owner patient complaints. 2.4 Data collection The survey was conducted using an online mode of administration and via the online survey tool, SurveyMonkey5. Data were collected between 15th and 28th November 2011. The data collection had to be completed within a two-week period so it was not possible to conduct such a large survey using telephone or postal methods. We therefore chose an online mode of administration because of its advantages in terms of cost and time. A letter was composed explaining the purpose of the research, its rationale, what participation in the study would involve, and assuring respondents of confidentiality and anonymity (See Appendix I). On 15th November, all practice owners included in our survey population (see above) were sent an email with this letter and a link to the online questionnaire in SurveyMonkey. On 22nd November, a reminder letter was sent out to practice owners. The survey was closed on 28th November. Of the 5396 BDA members who were invited to participate, a total of 1804 participants responded. This gave us a response rate of 33 per cent.6 2.5 Managing the data Upon closure of the survey, the data were downloaded from SurveyMonkey and imported into SPSS. Once in SPSS, demographic data stored in CARE were appended to the dataset using the unique identifier. The first question of the survey was a filter question to ensure all participants were practice owners; 63 cases were identified not to be practice owners and were removed from the dataset. In addition, 18 cases were identified as having answered the filter question but not proceeding with the survey; these were removed from the data-set. Table 2.1 sets this out schematically. 5 http://www.surveymonkey.com/ 6 Completed at least one item in the online survey 11 Table 2.1 Outcome of practice owner survey Number of those who responded to survey Of these: Those who said that they were not practice owners Those who identified themselves as practice owners, but did not go on to complete any other questions in the online survey Total valid cases N 1804 63 18 1723 Three attrition points were identified when assessing the data. At each of these points, there was a marked drop-off of respondents who did not go on to complete the remainder of the survey. At each of these points the remaining data were assigned as missing. 12 3 About the practice owners and their practices This section describes the demographic characteristics of respondents and profiles their practices. 3.1 Demographic characteristics of respondents Table 3.1 shows the demographic characteristics of all respondents (N=1723). The majority of participants were aged over 45 years with an average age of 49.9 years and more than three out of every four respondents were male. Table 3.1 Demographic profile of survey respondents Characteristics Age group 21-34 35-44 45-54 55+ Total % Base N Mean age Column percentages 4.3 22.5 45.8 27.4 100.0 1710 49.9 years Sex Male Female Total % Base N 77.8 22.2 100.0 1713 Country England Northern Ireland Scotland Wales Total % Base N 84.2 3.3 8.7 3.9 100.0 1717 Base: All practice owners 13 Table 3.2 shows the sex and age composition of the sample and that almost six in ten respondents were men aged over 45 years. Table 3.2 Sex and age composition of respondents Percentage of cases Sex Male Female Age group 21-34 3.4 0.9 35-44 15.7 6.8 45-54 35.2 10.6 55+ 23.5 3.9 All 77.8 22.2 N All 4.3 22.5 45.8 27.3 100.0 74 383 782 467 17061 Base: All practice owners 1 Missing N=17 It was not possible for us to make a clear judgement about the representativeness of the respondents in relation to the broader population to which they belong (i.e. all UK practice owners who were BDA members). This was because data were not available on key variables related to the purpose of the study for the survey population in the BDA database system, CARE. Nonetheless, it has been possible for us to compare respondents with the wider population using demographic data stored in CARE – specifically, sex, age, and country. The mean age of all practice owners included in the BDA system is 48.9 years (N=5485)7. By comparison, the average age of respondents in our survey is 49.9 years. Overall, then, respondents were marginally older than the wider population from which they were drawn. In addition, around 22 per cent (N=1187) and 78 per cent (4279) of the broader membership population were female and male respectively, which is close to the sex composition of respondents (Table 3.2). 7 This excludes a small number of cases which, according to their reported date of birth, meant they were under 25 years. 14 Table 3.3 compares the UK country where respondents are based with the population of practice owners stored in the CARE database.8 Table 3.3 UK country where main practice is located: survey population compared with respondents Column percentages Country Survey population England Respondents 83.9 84.2 Northern Ireland 3.7 3.3 Scotland 7.8 8.7 Wales 4.6 3.9 Total % 100.0 100.0 Base N 5485 1707* Base: All practice owners *Missing values=16 Table 3.3 shows that respondents were broadly representative of the survey population. However, Scottish practice owners were slightly overrepresented and Welsh practice owners marginally underrepresented among respondents. 8 See note 4 15 3.2 Characteristics of respondents‟ practices Respondents were asked how long they had been the owner of their current main practice. On average, practice owners had been the owner of their current (main) practice for 16 years, with the majority (86.6 per cent) being the owner for five or more years. Respondents were also asked a number of other questions about their main practice. Table 3.4 presents some key characteristics of respondents‟ main practices. Table 3.4 Profile of respondents‟ practices Characteristic Column percentages How would you describe your main practice? General practice Specialist practice Other Total Base N 92.5 6.8 0.7 100.0 1718 Location of practice Rural Urban Total % Base N 25.6 74.4 100.0 1719 Main practice owned by corporate body? Yes No Total % Base N 4.2 95.8 100.0 1703 Number of dentists in main practice* 1 2 3 4+ Total % Base N 20.9 25.2 19.2 34.7 100.0 1703 Mean number of dentists in main practice Base: all practice owners *Includes the respondent 16 3.17 dentists per practice Table 3.4 shows that just under two-thirds of practice owners reported that their main practice have three or fewer dentists, with around one-third reporting four or more. Less than one in twenty said that their main practice is corporately owned and threequarters who said their main practice is based in an urban area. Practice owners were also asked about the proportion of their patients they provide NHS care for (at their main practice). Table 3.5 shows the proportion of respondents who said that their main practice provides private, NHS, or a mixture of private and NHS care. Table 3.5 Proportion of patients receiving NHS care at main practice Proportion of patients that receive NHS care at main practice Column percentages NHS only 7.0 75-99% NHS 33.3 25-74% NHS 17.6 1-24% NHS 20.5 Private only 20.8 Don‟t know * Would prefer not to answer 0.6 Total % 100.0 Base N 1652** Base: All practice owners *Less than 0.5 per cent **Missing cases N=71 Table 3.5 shows that around one in five practice owners described their main practice as fully private and only seven per cent as fully NHS, with the majority providing a mixture of NHS and private care. 17 Table 3.6 examines how the proportion of NHS care provided at respondents‟ main practices varies across UK countries. Table 3.6 Proportion of patients at main practice receiving NHS care, by country Column percentages Country Proportion of patients England Scotland Wales Northern All that receive NHS care Ireland Countries at main practice NHS only 7.2 6.9 6.1 3.6 7.0 75-99% NHS 31.5 50.3 22.7 47.3 33.3 25-74% NHS 16.4 19.3 31.8 27.3 17.6 1-24% NHS 20.5 16.6 27.3 18.2 20.4 Private only 23.5 6.2 12.1 3.6 20.9 Don‟t know 0.9 0.7 0 0 * Would prefer not to say 0.7 0 0 0 0.6 Total % 100.0 100.0 100.0 100.0 100.0 Base N 1382 145 66 55 1648** Base: All practice owners *less than 0.5 per cent **Missing cases N=75 Table 3.6 shows some variation across UK countries in the proportion of NHS care provided at owners‟ main practices; for example, practices in England are far more likely to be wholly private than in the other three countries. In the other UK countries, mixed NHS and private care is more common than in England. 18 This compares with the results of the BDA‟s annual Business Trends Survey (2011) of UK practice owners. For example, Table 3.7 shows the percentage of income which came from NHS care at practice owners‟ main practice, by country. Table 3.7 Percentage of the total turnover from practice owners‟ main practice which came from NHS care in 2010/2011, by UK Country Percentage turnover from main practice by type of care provided 100% Exclusively NHS England Column percentages UK Country Scotland Wales Northern Ireland All Countries 6.3 9.7 2.1 1.1 5.9 75-99% NHS 29.8 39.8 51.0 52.6 32.6 50-74% NHS 12.4 12.9 11.5 10.5 12.3 25-49% NHS 8.7 8.6 17.7 11.6 9.4 1-24% NHS 21.1 19.4 15.6 16.8 20.5 0% Exclusively private 20.9 9.7 2.1 7.4 18.6 100.0 100.0 100.0 100.0 100.0 Base N (Weighted) 598 28 48 29 702 Base N (unweighted) 460 93 96 95 744 Total % Source: Business Trends Survey 2011 Base: Practice owners in the UK Comparing Tables 3.6 and 3.7, the distribution of practice types found among practice owners in this survey is broadly similar to that found in the BDA‟s 2011 Business Trends Survey. The spread found in the UK are within plus or minus three per cent for each category, except for those owners whose practices were reported to fall into the 25-74 per cent NHS category (four per cent more in the Business Trends Survey compared with the survey reported here). However, when comparing the variation of practices by country across the two surveys, some differences are apparent.9 This difference is most notable when comparing the variation in the proportion of patients at the main practice who receive NHS care among practice owners based in Wales; for example, there is proportionately far fewer practice owners with practices in the 75-99% NHS range in the current survey than was reported in the 2011 Business Trends Survey. In 9 It is important to note the smaller base numbers in these disaggregated figures, particularly in Table 3.4. 19 addition, the proportion of practice owners in Wales managing practices where a small percentage of their turnover came from providing NHS care (1-24% NHS) was only 16 per cent in the Business Trends 2011 survey. This compares with around 27 per cent of Wales-based practice owners in the current survey reporting that between one and twenty-four per cent of their patients are NHS. In Scotland, the Business Trends Survey also found a 5.8 lower cent higher proportion of practice that were wholly NHS. Respondents in the current survey were asked a series of questions about the employment of dental care professionals (DCPs) at their main practice. Most practice owners (65.6 per cent, N=1125) said that they employed a hygienist. Just under onethird (28.3 per cent, N=484) reported employing a dually-qualified hygiene therapist and 15.3 per cent (N=262) reported employing therapists at their main practice. Table 3.8 shows the proportion of respondents who said that they employ hygienists, dual hygienist therapist, or therapists at their main practice, by proportion of NHS care provided. Table 3.8 Employment of dental care professionals by type of patients treated at main practice Type of DCP employed Private patients only Hygienist Dual hygiene therapist Therapist 73.8 (254) 31.1 (107) 13.4 (46) Cell percentages (N) Type of patients treated at main practice Mixed NHS NHS patients Don‟t and private only know/would patients prefer not to answer 66.8 (788) 32.8 (38) 61.5 (8) 27.7 (326) 23.3 (27) 30.8 (4) 15.5 (183) 11.2 (13) 30.0 (3) All 1 65.9 (1088 ) 2 28.1 (464 ) Base: all practice owners 1 Missing cases N=37 2 Missing cases N=20 3 Missing cases N=17 Table 3.8 shows that owners whose main practice provide some private care are over twice as likely as practices providing exclusively NHS care to employ a hygienist; for example, almost three-quarters of respondents‟ main practices that provide care to exclusively private patients also employ a hygienist. Those providing a greater proportion of private care are also slightly more likely to employ a dual hygienist therapist, but the difference between practice types is less stark. Practice owners were also asked what types of patients are treated by each type of DCP at their main practice: private patients only; NHS patients only; or both (Table 3.9). 20 3 14.8 (245 ) Table 3.9 Types of patients treated by dental care professionals at main practice Type of DCP employed Hygienist Dual hygiene therapist(s) Therapist Row percentages Type of patients treated by Dental Care Professional Private Both NHS and NHS patients Total Total N patients only private only patients 55.7 41.2 3.1 100.0 41.5 48.5 10.0 100.0 24.5 60.9 14.6 100.0 1 1122 2 480 Base: varies according to DCP – includes all practice owners whose main practice provides treatment from each type of DCP 1 Missing cases N=12 2 Missing cases N=18 3 Missing cases N=14 Among those practice owners whose main practice had at least one hygienist, over half reported that they only see private patients, with four in ten employing hygienists who provide care to a mixture of NHS and private patients (Table 3.9). Very few practice owners reported employing hygienists to provide care to exclusively NHS patients. A similar, though less accentuated pattern is observable for dual hygiene therapists, though one in ten practice owners employ this type of DCP to provide care to exclusively NHS patients. Finally, Table 3.9 shows that therapists are most likely to treat NHS patients than the other two types of DCPs, with three out of every four providing treatment to NHS patients. 21 3 261 4 Marketing practices This section explores how practice owners market or advertise their practice, and how appointments are made at their main practice. It also looks at perceptions of the demand for dental care, and then goes onto discuss cost issues - how much practices charge and how they inform their patients about these costs. This section also examines how practices deal with patient complaints relating to the care they provide. 4.1 Advertising the practice Practice owners were asked about how they advertise their main practice. Around seven out of every ten respondents (N=1195) reported advertising their main practice. However, the likelihood that practice owners advertised their main practice depended on the characteristics of the practice (Table 4.1). Table 4.1 Advertising practices by the proportion of patients at main practice who receive NHS care and practice size Row percentages Advertises main practice? Proportion of patients that receive NHS care Yes No Total % N NHS only 47.3 52.7 100.0 112 Mixed 75-99% NHS 62.6 37.4 100.0 545 Mixed 25-74% NHS 62.6 37.4 100.0 290 Mixed 1-24% NHS 79.5 20.5 100.0 337 Private only 82.3 17.7 100.0 344 Don‟t know 66.7 33.3 100.0 3 Would prefer not to answer 70.0 30.0 100.0 10 All cases 72.1 27.9 100.0 1641 1 64.4 36.0 100.0 344 2 71.8 28.2 100.0 418 3 74.4 25.6 100.0 320 4+ 75.6 24.4 100.0 569 All cases 72.0 28.0 100.0 1651** * Size of practice (number of dentists) Base: all practice owners *Missing N=82 **Missing N=72 As Table 4.1 shows, the likelihood of a practice owner reporting that they advertise their practice depends on the size of the practice and the proportion of NHS care 22 performed by that practice; for example, there is a definite gradient visible in Table 4.7, with the likelihood of advertising increasing with the share of private patients treated. Those practice owners whose main practice provides care to private patients are more likely to advertise their practice; for example, four out of five owners of exclusively private practices were the most likely to report advertising their practice. In stark contrast to this, just under half of those who own a practice that provides care to exclusively NHS patients reported advertising their practice. The propensity to advertise increases with the size of practice, with owners of larger practices (four or more dentists) being the most likely to report advertising their practice (Table 4.1). Those owners who said they advertise their practice were then asked about the different methods they used (Table 4.2). Table 4.2 Methods used to advertise dental services provided at main practice Method of advertising Multiple responses included Percentage of cases 64.8 63.5 59.5 30.2 22.9 6.1 3.6 2.3 2.3 1.2 1.0 * 2.1 1194** Internet/website Yellow Pages/Thomson/other directory Signage/billboards Leaflet/flyer Newspapers Magazine/newsletter/brochure TV/radio adverts Word of mouth Local shops/supermarket Local GP/Doctors surgery Social Media Via Referral Other methods of advertising Base N Base: all practice owners who said that they advertised their main practice *less than 0.5% **Missing cases N=1 Table 4.2 shows that practice owners reported using a variety of media to advertise their main practice. The most popular methods are: advertising via a practice website and the internet; the Yellow Pages or other local directory; and signage or billboards. For example, among respondents who advertise their main practice, between 59 and 65 per cent reported using these methods (Table 4.2). 23 Table 4.3 shows the range of methods used to advertise practice owner‟s main practice, by type of care provided (exclusively NHS, mixed, or exclusively private care). Table 4.3 Methods used to advertise, by whether main practice provides NHS, private or mixed care Multiple responses included Per cent of cases Type of care provided Method of advertising Newspapers NHS only Mixed private and NHS Private only 17.0 20.5 29.7 0 3.0 5.3 Leaflet/flyer 22.6 29.4 33.9 Internet/website/webpage 35.8 61.3 80.2 Signage/billboards 28.3 59.8 63.6 Yellow pages/other directories e.g. Thomson 64.2 65.3 59.4 Word of mouth 5.7 1.9 3.2 Magazines/Brochure/Newsl etters 1.9 5.7 7.4 Local shops/supermarket – e.g. windows 0 2.1 3.5 Via Referrals 0 * 0.7 Local GP/Doctors surgery 0 1.3 1.1 Social media 0 0.8 1.8 Other 5.7 1.7 2.8 Base N 53 838 283 TV/radio adverts Base: All practice owners who advertised their practice *Less than 0.5% 24 4.2 Booking an appointment Practice owners were asked how patients are able to book an appointment at their main practice. Around 96 per cent (N=1655) of respondents gave information in response to this question. Table 4.4 shows the frequency of the different methods that patients are able to book an appointment at respondent‟s main practice. Table 4.4 Methods of booking of booking an appointment at main practice Method of booking an appointment* Multiple responses included Percentage of cases Telephone 99.8 Face-to-face 96.2 Email 45.7 Internet 11.8 Other means (e.g. text message, SMS) 2.1 Base N 1655* Base: all practice owners *Missing N=68 Almost all practice owners said that patients are able to book appointments at their practices by telephone or face-to-face. By contrast, almost half said that patients could book via email and 12 per cent via the internet (Table 4.4). Most of those who used „other‟ methods of booking an appointment did so via text messaging/SMS. Table 4.5 shows method of booking an appointment at practice owner‟s main practice by whether main practice provides NHS, private or mixed care. Table 4.5 Method of booking an appointment, by whether main practice provides NHS, private or mixed care Multiple responses included Per cent of cases Type of care provided Method of booking an appointment NHS only Mixed private and NHS Private only All Book by telephone 99.1 99.8 99.7 99.8 Book face-to-face 95.7 96.2 97.1 96.3 Book by email 12.1 41.2 72.0 45.6 Book on the internet 1.7 8.8 24.8 11.7 Other means of booking (e.g. text/SMS) 4.3 1.9 2.0 2.1 Base N 116 1179 343 1638* Base: All practice owners *Missing N=72; Excluded from this table are practice owners who said responded either „don‟t know‟ (N=3) or “Would prefer not to answer” (N=10) when asked about the proportion of NHS/Private patients their main practice provides care for. 25 Table 4.5 shows a clear relationship between the type of care provided at respondent‟s main practice and the methods available for booking an appointment. Almost all practice owners said that patients can book by telephone or face-to-face, but only 12 per cent of NHS practices compared with 72 per cent of private only practices accepted bookings via email, with mixed practices intermediate between these two. In addition, a few owners of practices that provide care to exclusively NHS patients said that they accept bookings via the internet compared with almost one in four of those providing exclusively private care. 4.3 Patient demand Respondents were asked two questions relating to the demand for services at their main practice. The first question sought to gauge level of demand for dental care at owners‟ main practice – respondents were asked „How far ahead is the first available appointment with a dentist in your practice?‟ Table 4.6 shows average appointment availability times by practice size, UK country, and the proportion of patients at main practice who receive NHS care. 26 Table 4.6 Availability of appointments at main practice, by country, size, location, and the proportion of patients that receive NHS care How far ahead (in days) is the first available appointment with a dentist in your practice? Mean SD Median Min Max N Country England 5.7 7.8 3.0 0 120 1394 Scotland 8.5 11.8 5.0 0 90 146 Wales 7.2 8.7 5.0 0 40 65 Northern Ireland 9.5 9.7 5.0 0 42 55 NHS only 7.8 7.9 5.0 0 30 114 Mixed 75-99% NHS 8.0 10.7 5.0 0 120 545 Mixed 25-74% NHS 6.3 7.9 3.0 0 60 288 Mixed 1-24% NHS 5.0 6.7 2.0 0 50 336 Private only 3.9 5.1 2.0 0 40 341 1 7.0 4.4 5.0 0 120 346 2 6.4 9.5 3.0 0 60 418 3 6.1 8.2 3.0 0 50 316 4+ 5.7 7.6 3.0 0 90 566 Rural 7.0 9.3 3.0 0 90 431 Urban 5.9 8.0 3.0 0 120 1231 All 6.2 8.4 3.0 0 120 1664* Proportion of patients that receive NHS care Practice size Location of practice (self-categorised) Base: All practice owners *Missing N=59; the number of cases in this column do not always sum to the total because of variable missing data for practice size, practice type, and country SD=Standard Deviation 27 As Table 4.6 shows, owners reported that the median number of days before an appointment is available at their main practice is three days (Mean = 6.2 days; SD = 2.5 days). The gap between these two measures is partly due to the fact that some practice owners reported very long waiting periods resulting in a high degree of positive skew in the underlying distribution. A small minority of practice owners reported appointment availability times of 120 days. There is a clear difference between different types of practices in appointment availability times (Table 4.6). Owners of practices providing care to higher proportions of NHS patients reported, on average, much longer periods of time before an appointment becomes available. This finding could have been driven by a number of factors – for example, there may be greater demand for NHS care than for private care among patients. Alternatively, there may be constraints on the amount of NHS care that practices provide, which force up availability times in the face of high patient demand for NHS care (see Table 4.7). The availability of appointments increases with practice size, with single-handed practices reporting a median five-day period for appointment availability compared with a median of three days for larger practices. Table 4.6 also shows considerable variability in next appointment availability at main practice by UK country and rural/urban location. For example, practice owners in England reported having appointments available within a median of 3 days. This compares with practice owners in Northern Ireland, Scotland and Wales who all reported a median of five days. This may reflect variation in the amount of NHS care provided at dental practices in these latter countries compared with England. In addition, practice owners who said that their main practice are based in rural locations reported a greater mean next appointment availability time than those in urban locations, whilst the median values were identical. This is caused by a greater degree of positive skew in the distribution of availability times for practices in rural locations compared with those in urban locations. Practice owners were asked to rate current levels of patient demand, from „very high demand‟ to „very low demand‟. Over half (54.4 per cent, N=901) reported that the current level of patient demand is high at their main practice („very high‟ or „moderately high‟ combined), compared with only around 14 per cent who reported that current demand is „low‟. Table 4.7 shows practice owners‟ perceptions of patient demand by the proportion of patients at main practice who receive NHS care, country, location and size of practice. 28 Table 4.7 Perceptions of patient demand at main practice, by country, location, size, and the proportion of patients who receive NHS care at main practice Row percentages How would you rate current levels of patient demand at your practice? Very high Demand Moderately high demand Neither high nor low Moderately low demand Very low demand Total % Base N Country England 15.1 37.5 32.3 12.9 2.2 100.0 1388 Scotland 13.1 44.8 35.2 5.5 1.4 100.0 145 Wales 33.8 41.5 16.9 6.2 1.5 100.0 65 Northern Ireland 20.0 43.6 25.5 9.1 1.8 100.0 55 NHS only 30.2 41.4 22.4 6.0 0 100.0 116 75-99 NHS 25.8 44.3 23.6 5.1 1.1 100.0 546 25-74 NHS 14.1 33.8 35.2 14.1 2.8 100.0 290 1-24 NHS 5.4 37.5 37.5 16.4 3.3 100.0 336 Private only 6.7 32.0 40.7 17.7 2.9 100.0 344 0 80.0 10.0 10.0 0 100.0 10 1 13.9 36.8 29.9 16.8 2.6 100.0 345 2 15.5 36.3 33.2 12.9 2.1 100.0 419 3 14.4 36.1 39.2 7.8 2.5 100.0 319 4+ 18.2 42.5 27.4 10.3 1.6 100.0 565 Rural 13.5 42.2 28.7 13.5 2.1 100.0 429 Urban 16.6 37.3 32.8 11.2 2.1 100.0 1226 Proportion of patients who receive NHS care would prefer not to answer Practice size Location of practice (selfcategorised) All 15.9 38.5 31.7 11.8 2.1 100.0 1657* Base: All practice owners *Missing N=66. The number of cases in this column do not always sum to the total because of variable missing data for practice size, practice type, and country 29 Table 4.7 shows some variation by UK country in self-reported demand. For example, practice owners who work or live in Wales reported a very high level of demand compared with those based in England or Scotland. Practice owners in England and Northern Ireland were more likely than those in the other two countries to report „low demand‟ for their services. For example, around 15 per cent of practice owners in England reported experiencing a low demand for their services, compared with around 7 per cent of Scottish practice owners. Figure 4.1 shows a clear relationship between amount of NHS care provided and level of self-reported demand, with owners of practices providing high levels of NHS care reporting a much higher level of demand than those whose practices provide more private care. There is a particularly stark difference between owners of NHSonly and private-only practices in their likelihood of reporting „very high demand‟ (30.2 per cent versus 6.7 per cent). Figure 4.1 Perceptions of patient demand among practice owners, by the proportion of patients who receive NHS care at main practice Finally, across all countries and types of practice, self-reported demand among practice owners is slightly higher among large practices compared with small practices (e.g. single-handed practices); around six of ten owners of large practices reported high levels of demand, compared with around half of owners of singlehanded practices. However, there is only marginal variation in levels of self-reported demand across rural-urban locations. 30 4.4 Patient charges and duration of dental procedures Those practice owners who do some private work were given a list of twelve private treatments and asked to provide the prices they charge for a private adult patient and the average time it takes to perform the treatment. The treatments were split into three broad categories: simple, complex and cosmetic (see Table 4.8). 4.4.1 Duration of procedures Participants were first asked the average time (in minutes) it takes to perform each dental procedure on a private adult patient. Table 4.8 shows the average duration and standard deviation for each of the procedures. Table 4.8 Average duration of procedures performed at main practice Type of procedure Duration (minutes) Mean Median SD Base N Missing N Simple New patient examination 29 30 9 1450 73 Recall examination 16 15 5 1432 91 Simple scale and polish 17 15 6 1289 234 Hygienist simple scale and polish 25 30 6 1057 466 Extraction (1 tooth) 25 30 8 1390 133 Small composite filling 25 25 8 1392 131 Large posterior composite filling 41 40 11 1394 129 Large amalgam filling 31 30 9 1250 273 Medium sized upper metal partial denture 90 80 65 1330 193 Bonded molar crown 77 75 39 1384 139 Veneer (per tooth) 66 60 43 1355 168 Tooth whitening (both arches) 65 60 48 1188 335 Complex Cosmetic Base: All practice owners that provide some private treatment (N=1523). Exclusions include: practice owners with fully NHS main practices (N=116) and those who did not provide NHS commitment data (N=84). SD=Standard Deviation Table 4.8 shows that there is only limited variability in the reported time it takes to complete simple treatments. By contrast, there is considerable variation in the amount of time respondents said it takes to perform more complex and cosmetic treatments. For many complex treatments, the mean exceeds the median by around 10 minutes. This is caused by some very high values at the upper end of each distribution. 31 4.4.2 Charges made for procedures Respondents were then asked about the private fees they charge at their main practice for each procedure for an adult patient. Table 4.9 shows the average fee and the standard deviation for each of the treatments. Table 4.9 Charges made for dental procedures at main practice Type of procedure Amount charged (£) Mean Median SD Base N Missing N Simple New patient examination 55.39 50.00 21.30 1260 263 Recall examination 34.32 30.00 11.33 1235 288 Simple scale and polish 35.97 32.00 12.20 1099 424 Hygienist simple scale and polish 42.60 40.00 10.51 949 Extraction (1 tooth) 69.18 60.00 25.66 1231 292 Small composite filling 64.15 60.00 22.70 1238 285 111.25 98.00 39.17 1237 286 79.90 75.00 31.60 1073 450 Medium sized upper metal partial denture 558.31 500.00 222.42 1192 Bonded molar crown 407.76 375.00 113.74 1238 285 Veneer (per tooth) 369.88 350.00 122.01 1196 327 Tooth whitening (both arches) 348.75 340.00 102.58 1164 359 574 Complex Large posterior composite filling Large amalgam filling 331 Cosmetic Base: All practice owners that provide some private treatment (N=1523). Exclusions include: practice owners with fully NHS main practices (N=116) and those who did not provide NHS commitment data (N=84). SD= Standard Deviation Across all procedures and treatments, there is a high degree of variability in how much practices charge (Table 4.9). For most procedures, the mean and median are broadly similar, though in all cases there is evidence of skew in the distribution of fees towards higher values. 4.5 Relationship between duration of procedures and charges made for private treatment In order to learn more about the relationship between the duration and charges for each treatment, the correlation coefficient was calculated for each item. Table 4.10 examines the correlation between duration of treatment and the charges for each item. 32 Table 4.10 Relationship between duration of procedures and patient charges for private treatment at main practice Type of procedure r* Base N Missing N Simple New patient examination 0.573 1254 269 Recall examination 0.511 1223 300 Simple scale and polish 0.530 1081 442 Hygienist simple scale and polish 0.648 923 600 Extraction (1 tooth) 0.476 1222 301 Small composite filling 0.424 1229 294 Large posterior composite filling 0.519 1230 293 Large amalgam filling 0.478 1067 456 Medium sized upper metal partial denture 0.283 1162 361 Bonded molar crown 0.339 1126 397 Veneer (per tooth) 0.316 1178 345 Tooth whitening (both arches) 0.331 1066 457 Complex Cosmetic Base: All practice owners that provide some private treatment and provided both time and costs data. Excluded those fully NHS N=116); and those that did not provide NHS commitment data (N=84). *r = correlation coefficient, indicating the degree of association between two variables. In all cases, there is a moderate10 positive relationship between how long treatments take and the amount charged for them (Table 4.10). However, this relationship is stronger for some treatments than for others; for example, the amount charged for a “hygienist simple scale and polish” is closely related to how long it takes to carry out this procedure – where more time is taken, the amount charged to the patient is higher. In comparison with many other procedures, the relationship between duration and the amount charged is particularly weak for cosmetic and some complex treatments; for example, the amount a practice charges for a „medium sized upper metal partial denture‟ is only weakly related to how long it takes to complete the procedure. 4.6 Setting fees/charges As already noted, almost all practice owners (92.2 per cent, N=1523) said that their main practice has some private patients (including those that provide care to mixed 10 A strong relationship is where the correlation coefficient is ±0.7-1.0; a moderate relationship is ±0.3-0.69; and a weak relationship is ±0.0-0.29 (Jackson, 2009) 33 NHS and private patients). These practice owners were asked how they set the fees for their private work. Table 4.11 shows the popularity of various methods. Table 4.11 Methods of setting charges for private dental treatments at main practice Multiple responses Method of setting charges included Percentage of cases Use an hourly rate for time taken, and then add the average 66.9 laboratory fee Charge what I feel is correct 46.5 Finding out what neighbouring practice are charging 27.0 11 Using the BDA advice on private practice 23.0 Seek advice from an accountant 12.6 Based on NHS fees 9.1 Denplan 1.4 Based on costs of running surgery/cost of materials 1.3 Level of complexity/type of care 0.7 Historical reasons given for charges 0.5 Competition with other practices * To give enough profit” * Set according to practice plan * Other 1.5 Base N 1500** Base: Practice owners providing some private dental care *less than 0.5% **Missing data: there were 23 participants whose main practice provides some private care but who did not give any information about how they set charges As can be seen from Table 4.11, some practices are sensitive to the prices charged by other practices with just over one-quarter saying that they set their charges in relation to what other practices charge. Most commonly though, practices calculate their charges based on the costs of running their service or they depend on their own judgement. Less than one in ten set their charges in relation to NHS fees. It is the dentist‟s responsibility to ensure that patients are given information on charges for treatment before it is provided. For those providing care to NHS patients, it is a contractual requirement in all four countries to display an NHS dental charges poster. We therefore asked practice owners whether they inform their patients of the fees or charges prior to treatment. Almost nine out of ten (N=1483) of respondents claimed that they inform patients of their charges prior to treatment, but around 12 per cent (N=204) said that they inform patients only “sometimes”. Table 4.12 shows 11 See Appendix II 34 practice owners‟ propensity to inform patients of fees prior to treatment by the proportion of patients who receive NHS care at respondent‟s main practice. Table 4.12 Proportion of practice owners who said that they provide information about fees prior to treatment, by the proportion of patients who receive NHS care at main practice Row percentages Do you inform your patients of your fees or charges prior to treatment? Proportion of patients who receive NHS care NHS only Always Sometimes Never Would prefer not to say Total* N 87.8 12.2 0 0 100.0 115 Mixed 75-99% NHS 85.5 14.1 * 0 100.0 546 Mixed 25-74% NHS 86.3 12.7 1.0 0 100.0 291 Mixed 1-24 NHS 86.6 13.1 0 * 100.0 337 Private only 91.3 8.7 0 0 100.0 343 Don‟t know 66.7 33.3 0 0 100.0 3 would prefer not to answer 90.0 10.0 0 0 100.0 10 All 87.2 12.4 * * 100.0 1645** Base: all practice owners *less than 0.5 per cent **Missing N=78 Table 4.12 shows that, among those who provide all or some NHS care, there is little variation in the propensity to inform patients prior to treatment by proportion of NHS care provided. However, owners who provide exclusively private dental care are slightly more likely than those who provide NHS care to say that they „always‟ inform their patients of their fees. Those practice owners whose practices provide some private care were then asked an open question about how they communicate their private fees or charges to patients, with 94.7 per cent (N=1442) giving information about how they communicate fees. Table 4.13 shows the most common methods used to communicate fees,12 with respondents being free to identify more than one. 12 Some questions (e.g. Q27) had a set of closed categories together with an open „other‟ box. A coding frame was developed on the basis of these free-text data, which was then recoded to generate new categories. In some cases responses were recoded back into one of the existing response categories. 35 Table 4.13 Methods used by practice owners to communicate private charges Method of communicating charges Multiple responses included Percentage of cases Discuss costs prior to treatment 96.8 Provide patient information leaflets 49.7 Display charges in waiting room/reception 43.5 13 19.8 Quotation/estimate/treatment plan/FP17 Website/online 10.5 Display charges in surgery 10.1 New other category 3.6 Display charges in the window 1.6 Base N 1442* Base: practice owners with private patients only 14 *Missing N=81 As Table 4.13 shows, charges are discussed with patients prior to treatment, and around half said that they provide leaflets with information about charges. Almost half of those whose main practice provides some private care reported displaying private fee information at reception. 13 FP17 is the form that dentists complete to make a claim for UDAs. It gives details of the patient and how much they pay. 14 Of all private owners that had some private patients (N=1523), 81 cases did not respond to this question on how charges were set. So table below is based on N=1442 cases. 36 4.7 Dealing with patient complaints Almost without exception, respondents said that their main practice has a written complaints procedure or policy. Respondents were asked an open question about what their policy is based on? Each respondent was free to identify as many sources as apply. The results are shown in Table 4.14. Table 4.14 Basis given for complaints policy at main practice Complaints policy is based on… Multiple responses included Percentage of cases BDA guidance 87.8 NHS requirements 55.3 Own policy 19.3 Denplan 3.4 15 1.8 CODE CQC/RQIA 1.0 GDC 0.6 Other 1.4 Base N 1568* Base: all respondents with a complaints policy *Missing N=11 cases who said that they had a written complaints policy but then gave no information about its basis. As Table 4.14 shows, almost nine out of every ten practice owners who had a policy in place said that it is based on BDA guidance. Over half reported that it is based on NHS requirements and one in five said that they had devised their own in-house complaints policy. Practice owners were then asked to identify the ways they communicate this policy to their patients.16 The distribution of responses is shown Table 4.15. 15 Confederation of Dental Employers 16 The question about how the practice complaints policy is communicated to patients (Q31) was a closed multiple response question with an open „other‟ box. The free-text responses given were recoded to either existing categories or new categories. The categories listed in Table 4.15 are a combination of these. 37 Table 4.15 How Practice Owners communicate their complaints policies to patients at their main practice How complaints policy is communicated to patients Multiple responses included Percentage of cases Display policy in waiting room/reception 77.5 Patient information leaflets 69.6 Discuss with patients 32.7 Display on website 18.8 Display policy in surgery 5.4 Available on request/when they ask 1.0 Notice in waiting room 0.8 Welcome letter/introduction pack * Comments box * Given to patient when they make a complaint * Other 0.9 Base N 1567** Base: All practice owners with a complaint policy *less than 0.5 per cent **Missing N=12 cases who said that they had a written complaints policy but then gave no information about how they communicate that policy Table 4.15 shows that, most commonly, practice owners communicate their complaints policies by displaying it in the waiting room or at reception, or through patient information leaflets. Only one-third of practice owners said that they discuss the policy with patients and around one in five said that they display their complaints policies on their websites. There were some differences here in how practices communicate their policy depending on whether the proportion of NHS care provided. For example, those providing care to private patients are over twice as likely as those providing NHS care to communicate their policy in this way. Conversely, those practices providing some NHS care are more likely than private-only practices to communicate their policy in the waiting room or via a leaflet. Around 60 per cent (N=932) of all respondents said that they had received a complaint in the past two years, with on average three complaints per practice. Table 4.16 compares the probability of receiving a complaint by type of care provided at main practice (Table 4.16). 38 Table 4.16 Proportion of practice owners who had said they had received a complaint in the past two years at their main practice, by proportion of patients who receive NHS care at main practice Row percentages Received a complaint in last two years? Proportion of patients that receive NHS care Yes No Would prefer not to say Total % Base N NHS only 62.1 37.9 0 100.0 116 Mixed 75-99 NHS 72.5 26.2 1.4 100.0 516 Mixed 25-74 NHS 65.0 32.9 2.2 100.0 277 Mixed 1-24 NHS 48.3 50.5 1.3 100.0 319 Private only 45.2 53.0 1.9 100.0 321 Don‟t know/Would prefer not to say 46.1 46.1 7.7 100.0 13 All 59.6 38.9 1.5 100.0 1562* Base: all practice owners *Missing N=161; of these, 157 cases did not answer the question about complaints; the remaining 4 missing cases did not give information about proportion of NHS/Private patients. Table 4.16 shows that owners of practices doing more NHS work were more likely to report receiving a complaint compared with those providing mainly private care. Less than half of the latter reported receiving a complaint in the previous two years. This compares with around three-quarters of those whose main practice provides mainly NHS care alongside a small amount of private work. Those respondents who said that their main practice had received a complaint over the past two years were asked how many complaints they had received during this period. Table 4.17 shows the average number of complaints they reported receiving over the past two years, by proportion of NHS care provided at main practice. Table 4.17 Number of complaints received in past two years at main practice, by proportion of patients who receive NHS care at main practice Proportion of patients that receive NHS care Mean SD Median Min Max N NHS only 3.29 3.90 2.00 1 25 64 Mixed 75-99% NHS 3.63 3.67 3.00 1 31 337 Mixed 25-74% NHS 3.18 2.75 2.00 1 25 172 Mixed 1-24% NHS 2.63 1.81 2.00 1 10 145 Private only 2.56 2.18 2.00 1 15 131 All 3.18 3.08 2.00 1 31 853* Base: all practice owners who received a complaint during the past two years *Missing N=157 cases were not asked this question because they did not respond to the previous question relating to whether or not they had received a complaint in the past two years; in addition. There were also 79 respondents who said that they had received a complaint in the past two years but then did not give a non-zero number. SD=Standard Deviation 39 Table 4.17 shows that the median number of complaints received over the past two years among all those who said that they had received a complaint is just two, with a mean of just over three complaints (SD=3.08). The average number of complaints reported varies by the proportion of private or NHS care provided at respondents‟ main practice. The owners of private practices reported on average slightly fewer complaints than those providing high proportions of NHS care. Practice owners whose main practices provide mainly NHS care alongside small amounts of private care reported the greatest number of complaints (a median of three over the preceding two years, compared with a median of two complaints for all other types of practice). Practice owners were then asked about how complaints are dealt with (Table 4.18). The complaint process and the organisations involved are different for NHS and nonNHS dental care, so Table 4.18 shows how complaints were dealt with at main practice disaggregated by type of care provided at main practice.17 Table 4.18 Where patients filed complaints (received in past two years), by type of care provided at main practice Type of care provided Multiple responses included – per cent of cases Organisations/agencies that patients filed complaints with NHS only Mixed Private only All “In house” 90.3 93.7 90.9 93.1 By PCT/Health Board/Local Health Board 45.8 21.9 0.7 20.5 By PALS 13.9 11.1 1.4 9.8 By DCS (Dental Complaints Service) 2.8 2.7 9.1 3.8 By GDC 2.8 2.7 7.0 3.4 By Ombudsman 4.2 3.3 1.4 3.0 Solicitor/lawyer 1.4 1.6 1.4 1.5 Dental Protection 0 * 0.7 0.8 Denplan 0 0.6 2.1 * Via another organisation not mentioned above 2.8 1.7 0.7 1.6 Base N 72 703 143 924* Base: all practice owners who received a complaint *Missing N=157 cases were not asked this question because they did not respond to the previous question relating to whether or not they had received a complaint in the past two years; of the 932 respondents who said that they had received a complaint in the past two years, N=8 did not give information about how the complaint was dealt with. Among those who had received a complaint(s) in the past two years, almost all (93 per cent) said that these had been dealt with „in house‟ within the practice. In 17 A summary of the NHS complaints procedure and the role of the Dental Complaints Service and GDC in dealing with complaints relating to non-NHS dental care can be found in D‟Cruz et al (2010). 40 addition, one in five practice owners said that patients had filed complaints with the PCT/Health Board/Local Health Board and one in ten had filed them with PALS. There are some clear differences by type of practice (Table 4.18). For example, just under half of owners of NHS-only practices filed their complaints with the PCT/Health Board/Local Health Board and an additional 14 per cent filed them with the Patient Advice and Liaison Service (PALS). This compares with a negligible proportion of owners of non-NHS practices with patients who filed their complaints to local NHS agencies. Compared with NHS-only or mixed practices, complaints with private practices are more likely to be filed with the General Dental Council (GDC) or Dental Complaints Service (DCS). In addition, one in five practice owners said that patients had filed complaints with the PCT/Health Board/Local Health Board and one in ten had filed them with PALS. 41 5 Perceptions about how well the UK Dentistry Market is working The final section examines participants‟ beliefs about and views on how the UK dental market is working. 5.1 Perceptions of competition in UK dentistry Respondents were asked about their level of agreement with a series of statements relating to competition in the UK dentistry market. Table 5.1 shows practice owners‟ views on how well the dental market is working and how „overcrowded‟ it is. Table 5.1 Practice owners‟ perceptions of the UK dentistry market Row percentages “The dental market* in my area is working well” Strongly disagree 5.7 Somewhat disagree 16.9 Neither agree nor disagree 27.2 Somewhat agree 30.4 Strongly agree 17.6 Don‟t know Total % 2.1 Total N* 100.0 1656 Total % Total N* 1 “The dental market in my area is overcrowded” Strongly disagree 4.9 Somewhat disagree 20.4 Neither agree nor disagree 35.7 Somewhat agree 23.0 Strongly agree 14.4 Don‟t know 1.6 100.0 1663 2 Base: All practice owners 1 Missing cases N=67 2 Missing cases N=60 Table 5.1 shows that almost half of practice owner respondents agreed with the view that the dental market is working well in their area (where main practice is located). There were some differences between countries; for example, in England and Scotland, almost half of the respondents thought that the dental market is working well (48.5 per cent and 51.0 per cent respectively). By contrast, a smaller proportion of practice owners in Northern Ireland (35.2 per cent) and Wales (41per cent) agreed with this statement. As Table 5.1 shows, over one-third of respondents felt that the dental market in their area is overcrowded. However, there was some variation depending on the extent of NHS commitment. Over one-quarter of respondents whose main practice provided care for exclusively NHS patients agreed with the view that the dental market in their area is overcrowded. This contrasted with almost half of those with no NHS commitment (only private care). 42 There was some variation between UK countries in the likelihood that respondents felt that the dental market in their area is overcrowded. Respondents in England and Northern Ireland were slightly more likely to agree with this statement compared with those in Scotland and Wales. Table 5.2 shows the extent to which practice owners whose main provided some private care agreed with statements relating to the influence of competition on the cost and quality of the dental care they provide. Table 5.2 only includes those practice owners whose main practice provided some private dental care, and so excludes exclusively NHS practices. Table 5.2 Views about influence of competition on prices and quality among practice owners whose main practice provides some private care Row Percentages “The prices charged for private services by my practice are influenced by competition with other practices” Strongly disagree 14.9 Somewhat disagree 20.5 Neither agree nor disagree 16.7 Somewhat agree 30.6 Strongly agree 16.1 Don‟t know 1.2 Total % Total N 15121 100.0 “The quality of service my practice provides is influenced by competition with other practices” Strongly disagree 39.7 Somewhat disagree 21.4 Neither agree nor disagree 13.9 Somewhat agree 13.5 Strongly agree 10.7 Don‟t know 0.8 Total % 100.0 Total N 15072 Base: practice owners whose main practice provides some private care 1 Missing N=11 2 Missing N=16 It is clear from Table 5.2 that practice owners whose practices provide some private dental care were ambivalent about the influence of competition on the prices they charge for dental services. Almost half felt there is some influence of competition on the prices they charge for private treatment, but more than one-third thought that they did not. Respondents perceived the influence of competition on quality differently; among practice owners whose main practice provides some private dental care, six out of ten disagreed with the view that the quality of the care they provide is influenced by competition (Table 5.2). 43 5.2 Practice owners‟ attitudes towards direct access to DCPs Participants were also asked about their level of agreement with a series of statements relating to direct access to dental hygienists and dental therapists in the UK dentistry market. Practice owners‟ views on direct access to dental care professionals (DCPs) are displayed in Table 5.3. Table 5.3 Practice owners‟ views on direct access to DCPs Row Percentages "In my dental practice, I would not object if patients could directly access dental hygienists or dental therapists without first being examined by a dentist” Strongly disagree 42.2 Somewhat disagree 24.5 Neither agree nor disagree 8.3 Somewhat agree Strongly agree 13.0 Don‟t know 9.6 2.5 Total % 100.0 Total N 16591 “Outside a dentist owned practice, I would not object if patients could directly access dental hygienists or dental therapists without first being examined by a dentist” Strongly disagree 56.1 Somewhat disagree 24.5 Neither agree nor disagree 8.0 Somewhat agree Strongly agree 6.9 Don‟t know 3.4 1.2 Total % 100.0 Total N 16642 “Patients should be able to directly access dental hygienists or dental therapists without first being examined by a dentist” Strongly disagree Somewhat disagree 57.5 22.9 Neither agree nor disagree 6.8 Somewhat agree Strongly agree Don‟t know Total % Total N 8.0 4.1 0.7 100.0 16653 Base: all practice owners 1 Missing N=64 2 Missing N=59 3 Missing N=58 Less than one-quarter (22.6 per cent) of practice owners agreed with the view that patients at their main practice should be able to access dental hygienists or therapists without prior examination by a dentist (Table 5.3). By comparison, the majority, or around two-thirds of practice owners, indicated that they would object to direct access being provided at their own practice. In short, practice owners mostly felt that, at least at their own practice, patients should first undergo an examination by a dentist before seeing a hygienist or therapist. However, practice owners were even more resistant to the view that patients should be able to directly access hygienists or therapists outside of a dental practice - that is, without reference to a qualified dentist. Around four out of every five practice 44 owners disagreed with the view that patients should be able to directly access DCPs outside of a dentist-owned practice without first being examined by a dentist. 5.3 Practice owners‟ perceptions of how well patients understand aspects of their treatment Practice owners were asked about their level of agreement with a series of four statements relating to their perceptions of how well patients understand and are informed about aspects of their treatment. They were asked how well they agreed or disagreed with a series of statements relating to patient knowledge and awareness of aspects of their treatment. Figures 5.1 and 5.2 examine levels of agreement with the statement “Patients understand which treatments are available on the NHS”, by proportion of NHS patients and UK Country. Figure 5.1 shows an even balance between the proportions of practice owners who agreed or disagreed with the view that patients understand what treatments are available on the NHS. However, a clear gradient is visible – as the proportion of NHS care provided increased, respondents were more likely to believe that patients do not understand which treatments are available on the NHS; in other words, the majority of the owners of practices with a high NHS demand felt that their patients are not clear about what is available on the NHS; for example, almost two-thirds of the owners of NHS-only practices and well over half of those providing care to small numbers of private patients agreed with this statement. Figure 5.2 shows that practice owners in Northern Ireland and Scotland were slightly more likely to disagree with the view that patients understand what treatments are available on the NHS. However, the numbers surveyed in these countries is small, so these proportions need to be treated with some caution. This pattern of response may also reflect the higher proportion of NHS care provided at practices in these countries (see Table 3.6). Respondents were also asked whether they agreed or disagreed with the view that „Patients understand what treatment(s) are available privately‟. Figures 5.3 and 5.4 examine levels of agreement with the statement “Patients understand what treatment(s) are available privately”, by proportion of NHS patients and UK country. Overall, just under half of all respondents agreed that patients understand what is available privately, with around one-in-five believing that they do not. The proportion of NHS or private care provided at main practice had a strong influence on responses to this item, with the likelihood of disagreement increasing with the amount of private care provided – for example, around half of those practice owners whose main practice provided care to exclusively private patients strongly agreed with this view, compared with only around 18 per cent of those whose practices provided exclusively NHS care. 45 Figure 5.1 Level of agreement with the statement “Patients understand which treatments are available on the NHS”, by proportion of patients that receive NHS care at main practice Figure 5.2 Level of agreement with the statement “Patients understand which treatments are available on the NHS”, by UK country 46 Figure 5.3 Level of agreement with the statement “Patients understand what treatment(s) are available privately”, by proportion of NHS patients Figure 5.4 Level of agreement with the statement “Patients understand what treatment(s) are available privately”, by country 47 Figure 5.5 Level of agreement with the statement „Patients are well informed about the cost of their treatment before their treatment starts‟, by proportion of patients that receive NHS care at main practice Figure 5.6 Level of agreement among practice owners with the statement “Patients are well informed about the cost of their treatment before their treatment starts”, by UK country 48 Figure 5.7 Level of agreement with the statement “Patients are able to switch to another dentist freely”, by proportion of patients that receive NHS care at main practice 100% Percentage of practice owners 90% 80% Strongly agree 70% Somewhat agree 60% Neither agree nor disagree Somewhat disagree 50% 40% Strongly disagree 30% Don't know 20% 10% 0% NHS only Mixed 75- Mixed 2599% NHS 74% NHS Mixed 1- Private only All practice 24% NHS owners Proportion of NHS/Private patients Base: all practice owners; N = 1,640 Figure 5.8 Level of agreement among practice owners with the statement “Patients are able to switch to another dentist freely”, by UK country 49 Figures 5.5 and 5.6 examine levels of agreement with the statement “Patients are well informed about the cost of their treatment before their treatment starts”, by proportion of NHS patients and UK country. They show that, in general, practice owners did not believe that patients are well informed about the cost of their treatment before their treatment starts – for example, over four in ten agreed with this statement across countries. However, practice owners in England and Wales more likely to agree than those in Scotland and Northern Ireland. Again, caution should be exercised in interpreting these proportions because of the low number of respondents involved. Figures 5.7 and 5.8 examine levels of agreement with the statement “Patients are able to switch to another dentist freely”, by proportion of NHS patients and country. They show that the majority (over three-quarters) of practice owners agreed with the view that patients are able to switch dentists easily. There were some moderate differences here by practice type, with those providing exclusively private care being more likely to „strongly agree‟ with this statement than those providing care to either mixed or exclusively NHS patients. For example, 61.8 per cent exclusively private practice owners strongly disagreed with the view that switching is easy, compared with 45.7 per cent of those providing exclusively NHS care. Practice owners in England and Scotland were marginally more likely to agree with this statement compared with those in Wales and Northern Ireland. Wales stands out in this respect. Whilst the numbers here are small and therefore these results need to be treated with some caution, over one in four practice owners in Wales felt that it is not easy for patients to switch easily, compared with 12 per cent across all countries. This may indicate that there are some significant barriers to patients‟ ability to change dentists in Wales which are not present to the same degree in the other UK countries. Further analysis and research is needed here on barriers to patient switching in the Welsh context. 50 Appendix I Invitation letter to practice owners 30 October, 2011 Salutation, OFT investigation - Practice owner survey I am writing to invite you to participate in a survey we are currently conducting of practice owners. We are conducting this survey as part of the BDA‟s response to the Office of Fair Trade‟s (OFT) study into the UK dentistry market. Last month, the (OFT) decided to undertake a market study into the market for the provision of dental services. They are aiming to assess how well the UK dentistry market is working for consumers. The OFT previously looked at the dental market in 2003, when they carried out a study into private dentistry. That report generated a number or recommendations and subsequently the GDC revised its guidance to dentists regarding choice, pricing of information and systems of redress. The British Dental Association (BDA) plans to respond to the market study with a submission of evidence including relevant economic arguments, information, policy positions and recommendations. This will require that we conduct new research into the dental market and, as part of this research, we have decided to survey practice owners about their views and experiences. The survey will look to understand patient information, choice and methods of redress across the UK. The findings from this survey will be invaluable for the BDA and the evidence submission to the OFT market study. Every response we receive helps to ensure the results are representative of all dentists. You will shortly receive an email inviting you to participate in this survey. I would be most grateful if you would follow the link in the email and complete the questionnaire. It should take you no more than 10 minutes to answer the questions and all information gathered will be kept strictly confidential. I have also attached to this letter an information sheet which gives you more background to the research. Due to the time restrictions placed upon us we would be grateful if you could complete the survey by the XXX November. If you are interested the scope of the investigation and OFT press release they can be found by following this link (http://www.oft.gov.uk/OFTwork/markets-work/marketstudies-further-info/current/dentistry/ ). Thank you in advance for any assistance you are able to provide and for taking the time to participate. If you have any questions, comments or concerns regarding this 51 survey, please do not hesitate to contact Martin Kemp or Henry Edwards, BDA Research Unit, on 020 7653 4135 or at [email protected]. Yours sincerely, Dr Susie Sanderson Chair of the BDA‟s Executive Board 52 Appendix II Practice owner survey schedule BDA Practice Owner survey, November 2011 This survey is for practice owners assessing their perception of choice and competition in the UK dentistry market. 1. Are you a practice owner? Yes No Section A. About your practice In this first set of questions, we would like to ask you a few questions about your own practice. 2. How would you describe your main practice*? General practice Specialist practice Other *„Main practice‟ refers to where you undertake the largest number of clinical sessions each week 3. How would you describe the location of your main practice? Rural Urban 4. How long have you been the owner of your current practice? [ ] years 5. Which of the following groups are you taking on as new patients in your practice? (Please select as many as apply) NHS children NHS exempt adults NHS non-exempt adults Private children Private adults 6. Is your practice owned by a corporate body? Yes No 53 7. Including yourself, how many dentists work in your main practice? [ ] No. of dentists 8. Do you employ/engage any hygienists in your practice? Yes No 9. Which sets of patients does your hygienist(s) treat? Private patients only NHS patients only Both NHS and private patients 10. Do you employ/engage any dually qualified hygienists/therapist in your practice? Yes No 11. Which sets of patients does your dually qualified hygienist/therapist(s) treat? Private patients only NHS patients only Both NHS and private patients 12. Do you employ/engage any therapists in your practice? Yes No 13. Which sets of patients does your therapist(s) treat? Private patients only NHS patients only Both NHS and private patients Section B. Competition The next set of questions relate to your perceptions and experience of the local dental market in the area where your practice is located. 14. Please read each of the statements below and indicate how strongly you agree or disagree with each statement *The „dental market‟ is defined as the market for the provision of dental services. This includes the dental services provided by both NHS and private practices in the UK. 54 Strongly disagree Somewh at disagree Neither agree nor disagree Somewh at agree Strongly agree Don‟t know a) “The dental market* in my area is working well” [ ] [ ] [ ] [ ] [ ] [ ] b) “The dental market in my area is overcrowded” [ ] [ ] [ ] [ ] [ ] [ ] c) “The prices charged for private services by my practice are influenced by competition with other practices” [ ] [ ] [ ] [ ] [ ] [ ] d) “The quality of service my practice provides is influenced by competition with other practices” [ ] [ ] [ ] [ ] [ ] [ ] e) “In my dental practice, I would not object if patients could directly access dental hygienists or dental therapists without first being examined by a dentist” [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] f) “Outside a dental owned practice, I would not object if patients could directly access dental hygienists or dental therapists without first being examined by a dentist” g) “Patients should be able to directly access dental hygienists or dental therapists without first being examined by a dentist” 55 15. Do you advertise your practice? Yes (please specify below how you advertise your practice) No 16. How do you advertise your practice? (Please select as many as apply) Newspaper adverts TV/radio adverts Leaflet/flyer Internet Signage Yellow pages Other (please specify): 17. How far ahead is the first available appointment with a dentist in your practice? [ ] working days 18. How would you rate current levels of patient demand at your practice? Very high demand Moderately high demand Neither high nor low demand Moderately low demand Very low demand Don‟t know 19. Did you experience any barriers or difficulties in becoming a practice owner? Yes (please specify below) No Don‟t know Please tell us more about the barriers or difficulties that you experienced in the space below: 56 Section C. Patient decision-making Next we would like to ask you some questions about patient decision-making. Thinking about dental patients in general… 20. Please read each of the following statements and indicate how strongly you agree or disagree with each statement. Strongly disagree Somewh at disagree Neither agree nor disagree Somewh at agree Strongly agree Don‟t know a) “Patients understand which treatments are available on the NHS” [ ] [ ] [ ] [ ] [ ] [ ] b) “Patients understand what treatment(s) are available privately” [ ] [ ] [ ] [ ] [ ] [ ] c) “Patients are well informed about the cost of their treatment before their treatment starts” [ ] [ ] [ ] [ ] [ ] [ ] d) “Patients are able to switch to another dentist freely” [ ] [ ] [ ] [ ] [ ] [ ] Now, thinking about your own practice… 21. How are patients able to book an appointment at your practice? (Please select as many as apply) Telephone Face-to-face Email Internet Don‟t know Other (please specify) 57 22. Do you inform your patients of your fees or charges prior to treatment? Always Sometimes Never Would prefer not to say 23. What approximate proportion of your patients do you provide NHS care for? 100% (Exclusively NHS patients) 75-99% 50-74% 25-49% 1-24% 0% (Exclusively private patients) Don‟t know Would prefer not to answer Section D. Fees and charges Now we would like to ask you some questions about the fees that you charge at your practice. 24. How do you set charges for private dental treatment in your practice? (Please select as many as apply) Use the BDA advice on private practice Find out what other neighbouring practices are charging Seek advice from an accountant Based on NHS fees Use an hourly rate for time taken, and then add the average laboratory fee Charge what I feel is correct Other (please specify below) 25. Please specify the average time (in minutes) it takes to perform the following treatments on and adult patient? a) New patient examination [ ] minutes b) Normal recall examination [ ] minutes c) Simple scale and polish [ ] minutes 58 d) Hygienist simple scale and polish (if appropriate) [ ] minutes e) Extraction (1 tooth) [ f) ] minutes Small composite filling [ ] minutes g) Large sized amalgam [ ] minutes h) Large posterior filling [ i) Medium sized upper metal partial denture [ j) ] minutes ] minutes Bonded molar crown [ ] minutes k) Veneer (per tooth) [ l) ] minutes Tooth whitening (both arches) [ ] minutes 26. Please tell us what private fees you would charge for the following items for an adult patient. a) New patient examination [ ] (£) b) Normal recall examination [ ] (£) c) Simple scale and polish [ ] (£) d) Hygienist simple scale and polish (if appropriate) [ ] (£) e) Extraction (1 tooth) [ f) ] (£) Small composite filling 59 [ ] (£) g) Large sized amalgam [ ] (£) h) Large posterior filling [ i) Medium sized upper metal partial denture [ j) ] (£) ] (£) Bonded molar crown [ ] (£) k) Veneer (per tooth) [ l) ] (£) Tooth whitening (both arches) [ ] (£) 27. How do you communicate your private fees or charges to patients? (Please select as many as apply) Display charges in waiting room/reception Display charges in the window Display charges in surgery Provide patient information leaflets Discuss costs prior to treatment Other (please specify) 28. Do all the dentists within your practice charge out at the same rate? Yes No Not applicable Don‟t know 60 Section E. Complaint and redress The following section asks questions about the complaints and redress systems in your practice. 29. Does your practice have a written complaints procedure or policy that is available to patients? Yes No 30. What is your policy based on? (please select as many as apply) BDA guidance NHS requirements Own policy Other (please specify) 31. How do you communicate this policy to your patients? (please select as many as apply) Display policy in waiting room/reception Display policy in surgery Display on website Patient information leaflets Discuss with patients Other (please specify) 32. Has your practice received any complaints in the past two years? Yes No Don‟t know Would prefer not to say 33. How many complaints have you received in the past two years? [ ] no. of complaints 61 34. Which organisation(s) did your patients file complaints with? (please select as many as apply) Dealt with within the practice PCT/Health Board/Local Health Board Ombudsman General Dental Council Dental Complaints Service Patient Advice and Liaison Services (PALS) Would prefer not to say Other (please specify below) That was the last question! Thank you for sharing your views with us and for giving up your time to take part in this study When you press „Done‟ your answers will be submitted to us. Thank you 62 Bibliography British Dental Association. 2012. Submission to the Office of Fair Trading Inquiry into the UK dentistry market. Available at: http://www.bda.org/dentists/policycampaigns/research/oft/OFT.aspx [Accessed 18 July 2012] British Dental Association. 2010. Omnibus Survey British Dental Association. 2011. Business Trends Survey. Available at: http://www.bda.org/businesstrends. Bryman, A. Ed. 2006. Mixed Methods. Four-Volume Set. London: SAGE Publications Ltd. D‟Cruz et al. 2010. Understanding NHS Dentistry. London: Dental Publishing Ltd. Jackson, S. 2009. Research Methods and Statistics: A Critical Thinking Approach. Belmont: CA, Thomson Wadsworth. Office of Fair Trading. 2010. Market studies Guidance on the OFT approach. Available at: http://www.oft.gov.uk/shared_oft/business_leaflets/enterprise_act/oft519.pdf [Accessed: 10th July 2012] Office of Fair Trading. 2011. Dentistry Market Study: Statement of Scope/Q&A. Available at: http://www.oft.gov.uk/shared_oft/market-studies/Dentistry/QandAs.pdf [Accessed 10 July 2012] Office of Fair Trading. 2012. Market studies - further information. Available at: http://www.oft.gov.uk/OFTwork/markets-work/market-studies-further-info [Accessed 10th July 2012] 63 British Dental Association 64 Wimpole Street London W1G 8YS 020 75634563 www.bda.org