International rescue? managing the dental tourist

Dental tourism: those resident in the UK

Within the United Kingdom (UK) the majority of the public will access NHS primary dental services for routine dental care. Others who have the financial means may wish to seek services within the private sector. Over recent years, it has become more evident that many individuals are opting to travel overseas for dental treatment; complex restorative dental care and treatment involving dental implants are amongst the most popular.1

With successive Government reforms to the NHS dental contract, a proportion of dentists have shifted their services from the NHS into either mixed or private dentistry. The primary focus of the new NHS contract rightly strives towards prevention of disease, resulting in a change in the treatment pattern of care provided by NHS dentists. Fewer complex procedures are being carried out in primary care and are now increasingly redirected either to secondary care or to the private sector.

The rapidly expanding field of dental implantology has revolutionized modern dentistry. With greater public awareness and widespread availability, dental implants have become an increasingly desirable treatment option following tooth extraction and, indeed, are considered the gold standard by many. Despite this, restrictive funding criteria for the provision of implants exist within the NHS, meaning that non-eligible patients are redirected to private services, where a single tooth implant and crown may cost in excess of £2,500. With the limitations of NHS dentistry and the cost of UK private dentistry posing a significant barrier in the current economical climate, affordable dentistry available abroad may seem an appropriate resolution for many.

In 2007, the consumer association Which? survey suggested that dentistry is one of the most popular sectors within medical tourism, with a suprising 49% of respondents seeking dental treatment outside of the UK.2 The 2012 Treatment Abroad medical tourism survey, attracting over 1,000 patients, confirmed that 32% of UK residents travelled abroad for dental treatment.2 Central Europe is the favoured international destination for dental tourism, with Hungary being the most popular, closely followed by Belgium. Of respondents, 50% stated that they would be willing to travel to a country that they have never been to before to receive treatment. Levels of patient satisfaction were significantly high, for reasons including, professionalism of staff, cost of treatment and quality of care, with the benefits of combining treatment with a holiday.

A new method of dental tourism has also developed, whereby companies are inviting foreign dentists to provide dentistry in the UK at equally competitive prices.

With readily available access to the internet, many countries invite dental tourism with cheaper quotes, online travel packages and idyllic holiday destinations. There is a wealth of choice dedicated to accessing overseas dentistry, with all-inclusive packages for flights and accommodation at competitive prices. In essence, dental tourism is driven by a combination of factors, including perceived difficulties in registering with an NHS dentist, more affordable charges and a lack of treatment options offered within the NHS; supplemented by extensive internet advertising and competitive airline flights.

At first glance it seems that dental tourism provides financial incentives for members of the public, as an ideal alternative to seeking treatment in the UK.

However, dental tourism is not without its problems. On further inspection, it is prudent to ask the following questions:

Trevor Burke touched on the latter question of who manages post-treatment problems in his editorial ‘The perils of dental tourism, revisited’: ultimately it was the NHS who would pick up the bill for this.3 This is of particular concern when patients choose to split treatment between the UK and abroad. We aim to provide holistic care to our patients, but this can pose difficulties when particular aspects of care have been provided by dentists with whom we have either little or no contact.

At present, there is no legislation in place that oversees the above issues posed by dental tourism. It is at the dentist's discretion whether he or she wishes to manage patients who present with complications originating from treatment executed abroad. We must remember always to respect patient autonomy as each individual is entitled to receive treatment where he/she chooses.

However, we should provide impartial advice for patients who are planning to look further afield for more affordable dentistry. It is wise to inform them of all the risks involved with any treatment, both in the immediate and in the long term. It would be naive to suggest that dental treatment provided anywhere in the world is without complication but, if your dentist is situated overseas, this may incur significant unexpected costs which are not included in the original treatment plan or proposed expenses. Furthermore, if patients are unable to return to the practice that they attended abroad, for any reason, they must be aware that UK NHS dentists are not obliged to undertake the treatment involved to rectify any issues, leaving the onus on the patient to find a willing dentist and pay for the associated costs. There is no time limit to this, resulting in a potential for the patient to face ongoing financial costs for many years, each time further treatment is required, for these teeth and restorations.

The GDC has produced a document called ‘Going abroad for your dental care? – What you need to know before you go’4 (Figure 1). This document is available on the GDC website and neither encourages nor discourages treatment abroad, clearly highlighting important aspects to consider for such treatment. It is comprehensive, recommending patients to research carefully topics including regulatory bodies, complaints procedures, post-treatment care and even qualifications achieved by those carrying out the treatment. The list of questions provided in the leaflet presents ways to make the reader mindful in taking responsibility for deciding who he/she will choose to provide treatment, instead of instinctively basing the decision on cost and holiday destination. This leaflet should be readily available in dental practices and given to those patients who seek advice on dental tourism.

Patients ultimately need to be aware that the standard of care provided in other countries cannot be guaranteed to be of a similar standard to that set in the UK. In some cases, there will be no regulatory bodies that govern or guide these dentists. In the UK, under The Dentists Act 1984, it is illegal to practice dentistry without valid GDC registration, which incorporates a requirement for continuing professional development (CPD) and high standards of care being provided.5 Similarly, the Health and Social Care Act 2008 established the Care Quality Commission (CQC) as the regulator of all health and adult social services in the UK.6 The GDC registers the individuals and the CQC registers the practices. With governing bodies such as these ensuring patient safety and satisfaction are met, it can be said that treatment in the UK is of a very high standard. However, this being said, patient autonomy is key to the GDC principles, as is respecting our professional colleagues, and a patient's decision on where he/she wishes to have treatment should be respected.7 Patients should be made aware of the fact that any treatment they require may be readily available on the NHS and, if not, as is often the case with dental implants, private referrals can be made allowing them to meet their dental needs in the UK without having to travel abroad.8

Dental tourism: those not resident in the UK

Regarding the subject of access to NHS care, it is also necessary to be familiar with legislation regarding access for patients not residing in the UK.

Considering that dental pain can be spontaneous in nature and can present unexpectedly and unannounced, a patient not normally resident in the UK may attend an NHS dental practice in pain. Dental practitioners must be mindful of the charges they can apply and also must be aware of treatments that they are obliged to perform.

Patients who are non-UK residents, but who have EEA, EU or Swiss nationality, are eligible to apply for a free European Health Insurance Card (EHIC) (Figure 2).9 The EEA stands for European Economic Area and it is a trade-free zone between Iceland, Norway and Liechtenstein and the countries of the European Union. In this regard, a trade-free zone is an area in which goods may be landed, handled, reconfigured, and re-exported without the intervention of the customs authorities. The European Union now consists of 28 member states – Croatia being the newest member since 1st July 2013 (Table 1). The EHI Cards are usually valid for up to 5 years and must be reproducible to the dentist as proof of eligibility for treatment. Ideally, it is beneficial that a patient has valid private travel insurance in conjunction with an EHIC.

In essence, an EHIC presented in the UK will give an individual access to the NHS system in an unrestricted and straightforward manner. It goes without saying that the NHS charges apply as per normal and the band 1, 2 and 3 charges of £18.00, £49.00 and £214.00, respectively, stand payable.10 Band 1 urgent treatment at £18.00 is also allowed.

A valid EHIC permits a patient to the same entitlements as a UK-residing patient. Private healthcare costs are not included. The clinical records made about these patients must include where the patient is visiting from, the cost of the treatment to the NHS, the treatment provided and the EHIC number of that patient. As good standards dictate, these records should be contemporaneous, clear, concise and complete.11

If a patient is an EEA, EU or Swiss national but fails to produce a valid EHIC, he/she is effectively not authorized to receive NHS treatment. The patient must be encouraged to apply to his/her home country for what is known as a Provisional Replacement Certificate that allows for temporary cover. On receipt of this certificate, the same eligibility for NHS treatment is offered as applies with a valid EHIC.12 In a situation where a patient is unwilling to apply for this, emergency or immediately necessary treatment (Band 1) can be offered. The usual Band 1 charges accompany this.

Outside the countries in the EEA, EU and including Switzerland, there are a further 26 countries which have some partial access to the NHS in the UK (Table 2). These 26 countries have a bilateral agreement that gives certain nationals access to some treatment within the UK NHS. Within this agreement, 19 of the countries cover their nationals and UK nationals only.11 The remaining countries cover all residents, irrespective of nationality.11

The Isle of Man's bilateral agreement ended on 1st April 2010.12 These patients, similarly to those who do not have a valid EHIC or a Provisional Replacement Certificate, can receive Band 1 urgent treatment only; charges apply as normal. This treatment is allowed on production of valid proof of nationality, eg via a valid passport.

The final outcome in determining NHS dental care entitlement for non-UK residents is with those patients who are not an EEA, EU or Swiss national and who are also not a resident of one of the 26 countries that hold bilateral agreement with the UK. These patients are such that they are not entitled to ANY NHS dental primary care treatment. This being said, a patient with a life-threatening condition can access the hospital Accident and Emergency department to seek treatment.

Conclusion

In summary, we need to be able to advise our UK patients of the potential problems associated with travelling internationally to receive dental care. We also need to be aware of the legislation relating to access to NHS dental care for patients travelling to the UK from elsewhere. This situation may evolve and the legislation change over time and colleagues should be mindful of this when discussing these matters with patients.