Exploring the unseen risks of providing dental care in times of economic turmoil.
In difficult economic times, the financial pressures faced by our patients may make them less willing to embark upon complex or expensive courses of treatment. It is also well-recognised that healthcare complaints and litigation tend to increase in times of recession or economic downturn, perhaps because patients are less willing to accept and tolerate a sub-optimal outcome for which they have paid money that (in their view) could have been put to better use. Very often, however, the trigger is simply that patients want someone else to pay for treatment that they might well have needed in any event.
Thanks, but no thanks
A patient's caution may well be fuelled by financial concerns, but they won't always tell you this, and these underlying concerns can manifest themselves in a variety of ways.
(a) Declining recommended treatment outright.
(b) Postponing treatment.
(c) Declining a referral (to a specialist, for example, if this might mean additional costs) or pressing a practitioner to provide treatment against his/her better judgement or beyond his/her competence, in order to keep costs to a minimum.
(d) Attending less often.
(e) Failing to attend appointments, or ignoring recall reminders.
(f) Imposing constraints upon treatment - perhaps, staging treatment or opting for a simpler or cheaper option. Each of these possible scenarios have the potential to cause dento-legal problems in different ways, and the risks of each need to be anticipated and steps taken to address them.
Commercial pressures
The problem for the clinician who is trying to hold a practice together in the midst of an economic downturn, is that s/he may not wish to lose a patient, even when constraints are being imposed that are making it difficult - or impossible - to treat the patient safely and to an acceptable standard. Consequently, the clinician can be tempted to jump through one hoop after another at the patient's behest, in an attempt to please and satisfy them. This often involves accepting comprises which the dentist would be unwilling to tolerate in most other circumstances.
NHS v private
Many complaints result from a practitioner's refusal to provide certain treatment under the terms of the NHS, instead offering to provide the treatment for the patient on a private basis only. All it takes is for the patient to learn that what appears to be similar treatment, has been provided for another patient on the NHS (perhaps by another dentist) and the seeds of conflict are sown. When declining to provide certain treatment on the NHS, an NHS practitioner does need to be very careful how they explain this to the patient and especially in the terms they use to explain their decision. Other members of staff must be similarly aware of the dentist's contractual obligations. In these situations, patients need to understand that what would be proper, reasonable and necessary treatment for one patient, in one clinical situation, might be unnecessary or otherwise inappropriate for another patient, in another situation. The particular danger to avoid is that of misleading a patient into believing that a particular treatment cannot be provided within the NHS, when in fact it can. The GDC makes it very clear that patients should be told the basis upon which they are being treated (i.e. NHS or private) and any suggestion that the patient has been misinformed or deliberately misled, is likely to incur the wrath of the GDC.
Referrals
There will be occasions when the complexity of the patient's treatment, or the experience (or lack of it) of the treating clinician, is such that a referral to a specialist or a more experienced colleague is indicated. When this can be done without additional costs to the patient, problems are unlikely to arise. But if this referral involves the patient in additional expense, there is an ever-present risk that this will precipitate a complaint.
Documentation
In all of the above situations, it is crucial to ensure that all the explanations given to the patient are fully documented in the clinical records. At the very least, the notes should demonstrate that every effort had been made to explain the situation to the patient in a fair and balanced way. Of course, it is always open to the patient to argue that although some explanations were given, they had never properly understood the full significance of these discussions. In today's unforgiving healthcare environment there is no shortage of complaints pathways ready and willing to investigate such a suggestion. But a comprehensive, detailed set of clinical records will be a powerful asset for any dentist in defending any such allegations.
Response to complaints
In times such as these, many of our patients will be suffering acute stress, financial hardship or other pressures either in their domestic or in their working life. Some patients will be fearful about keeping their job - others may be worried about their ability to meet their financial commitments and to make ends meet for themselves and their family. However frivolous or unreasonable a complaint might appear to be, and however much you and your staff are convinced that the complaint is simply a 'try on' designed to avoid or delay payment, it is important to separate (wherever possible) the issue of the complaint itself, from the issue of the money owed to you. Even in an economic downturn, not every complaint is about money - although it is easy to jump to the conclusion that it must be. The tone of any correspondence or exchanges with a patient should be measured and supportive. Any dental fees owed to us by a patient might be just a small part of a much bigger picture of debt, and there is a fine balance to be struck between being firm enough to let the patient know that you do expect to be paid for treatment that you have provided for the patient in good faith, but also reasonable enough to avoid provoking a complaint where this can be avoided.
The reality of a professional relationship - especially in healthcare - is that we are not expected to engage in the kind of heavy-handed debt collection techniques that other people, in other fields, might find it appropriate (and necessary) to use. In one sense this places us at a commercial disadvantage, but in another sense it is worth remembering that every action and every step we take in our dealings with patients can end up being viewed by others at a later date, not in the context of a business transaction, but in the context of our ethical and professional conduct.
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