Trends in dental complaints 2005–2015 – Did patients complain more during the recession?

Fear of litigation

One area that has changed beyond all recognition is that of complaints/litigation against dentists. In this regard, there has been a significant increase in complaints to the General Dental Council (GDC) over the last 10 years.¹

Fear of litigation is an everyday reality for GDPs. It influences how we practise our dentistry.² Reports of risk-averse treatment planning are commonplace, as practitioners understandably want to avoid becoming another statistic in the GDC Fitness to Practise treadmill. Indeed, the Editor of the British Dental Journal (BDJ), Stephen Hancock, devoted an editorial ‘Defensive dentistry’ to this issue in 2014.³ It is also apparent, from the letters section of the BDJ, that fear of litigation even influences some of our colleagues' decisions in taking early retirement.⁴

This unhappiness within the profession is very much reinforced in the most recent British Dental Association (BDA) survey, published in December of 2016, when over half of the 6000 dentists surveyed stated that they had thought of leaving the profession.⁵

This is hardly surprising when Raj Rattan, the chairman of Dental Protection Ltd (DPL), tells us that every dental practitioner outside Scotland can now expect two dental claims against them in their working careers.⁶

It is therefore worth reflecting on this trend, to inform our colleagues what is happening and also give some understanding as to why. What factors are influencing this? Knowledge, as ever, is a powerful tool and this information should hopefully allow us to be better prepared for what lies ahead.

More cosmetics

Patients worldwide are becoming more concerned about their teeth.⁷ They appreciate more than ever that a healthy mouth contributes to their overall health and well-being. Nowadays an attractive smile influences what other people think of you. If you have a nice smile, people perceive you to be more intelligent, attractive and successful.⁸ This is something that we, as a dental profession, have helped our patients achieve. It is something to be celebrated.

However, the flip side of this is the role of cosmetic dentistry. As healthcare professionals, we often have to balance the patients' requests for cosmetic treatment versus the inherent destruction to tooth structure that this can sometimes involve.7; This can be a challenge as patients may have unrealistic demands that have been driven by other factors. The media have played a role in this over the last couple of decades, with television programmes such as ‘10 years younger’ being particularly guilty of raising expectations.⁹

The challenge is further complicated by the fact that cosmetic treatments generally represent the higher end of the remuneration scale. As a result, dentists have to take care that they are always acting in the patients' best interests and not acting in their own financial interests.¹⁰ The fear is that this is not always the case and some of the drive for cosmetics in dentistry undoubtedly comes from us, the dentists.

More teeth

The population of the UK has increased. From the Office of National Statistics website it can be seen that the population has risen in the UK from 60 million to 65 million over the last 10 years, an increase of 8.3% (Figure 1).¹¹

Furthermore, from the most recent Adult Dental Health Survey in 2009 (Figure 2), we can see that big decreases are evident in the number of edentate patients over the last four decades.¹² There would appear to be almost a 20% decrease with each decade in the 65 and over age group. Of course there will be local variations, but it is fair to say that we can expect this trend to continue with the next Adult Dental Health Survey in 2019. The number of edentate patients in the 65 and over category will drop below 20%.

It is fair to conclude from these two factors that, over the last decade, there are simply lots more teeth to fix in the UK.

More dentists

Logically, as we see the number of teeth increase over the last decade in the UK, you would expect a similar increase in the number of dentists on the GDC register. This is indeed the case. The GDC annual reports show that the number of dentists in the UK has increased from 33,698 in 2005 to 41,095 in 2015. This is an increase of 22%.

There are more patients, more teeth and more dentists, so it is fair to expect more dental treatment.

More spending

From a predominantly NHS service in the 1980s, private treatment has increased significantly. Its biggest growth period was during the 1990s and early 2000s, when it almost reached parity with NHS treatment in 2007/2008. Figure 3 demonstrates this with data taken from the LaingBuisson report Dentistry: UK Summary Market Report.¹³

Despite the 2008 recession and a decrease in private spending, the overall figure for dental spending has continued to rise. This is as a result of the Labour government injecting significant funding between 2004 and 2009/10.

The last substantiated figure in the LaingBuisson report was the 2014 figure, when the annual spend on NHS dentistry in the UK was £3.6 billion while the spend on private dentistry was £2.2billion. The 2017 figure is a 3-year projection from linear regression analysis. It will be interesting to see how those figures pan out in the future. As ever, it is difficult to predict when all the variables come into play, such as the austerity polices of the current Conservative government, the new NHS contracts, the economy and now Brexit.

2008 Recession

Although from Figure 3 it can be seen that dental spending is continuing to rise, it may be worth taking a closer look to ascertain what effect the recession has had. We can see that private spending reduces. Perhaps the most significant figure in all this is the private per capita spend from 2008 to 2014, which is estimated to have dropped by 31% in this period. NHS per capita spending had decreased by 9%. The data in Figure 4 is also taken from the LaingBuisson report of 2014.¹³

So, despite the increase in overall spending, the reality of the situation is that patient spending on dentistry has taken a significant dip in the last decade, in particular between the years 2008 and 2014. Individual patients are spending nearly a third less on their private dentistry and a tenth less on their NHS dentistry. The recession has had a significant effect on dental spending.

More litigation

The dental indemnity companies are generally unwilling to provide the public with sensitive figures for litigation. In the process of researching this article, the author contacted both MDDUS and DPL requesting the statistics on dental claims over the last decade. Both declined to give this information citing commercial sensitivities.

However Raj Rattan, the chairman of DPL, shared some helpful information⁶such as:

More complaints

Then comes the outlier: all our other variables, such as population, dentists and patient spend, private spend per capita and even litigation have increased or decreased by circa 10%, 20% or even 30%.

However, in the same period we have watched complaints to the Fitness to Practise Panel of the GDC increase 5-fold, a staggering 500%. The data is collated in Figure 5 and is readily available online in the GDC annual reports.

This figure peaked in 2014 when the GDC triaged 3222 cases.

How do we explain this rise? Where did it come from? And, in particular, why did it spike sharply in the years 2008 to 2014 when individual patient spending was contracting in the region of 20%?

We cannot blame the infamous GDC advert in The Telegraph when the GDC advertised to the general public to complain directly to the Dental Complaints Service if they were not completely satisfied with their dental treatment. That went out in July 2014 (Figure 6).

When these data were first collated, it was thought that there would be a straightforward linear increase in all variables. The number of complaints would roughly follow the increase in population, the increase in numbers of teeth and the increase in dental spending fuelled by the increase in cosmetic demand from our patients. The working title was ‘More teeth, more spending, more complaints and more litigation’. So where has the huge surge in complaints to the GDC come from? The GDC, in its recent publication Shifting the Balance,¹⁵ suggested that the increase is due to:

While these changes are undoubtedly happening within society, these are gradual changes that have been ongoing for decades. They do not explain the surge of complaints in 2008. Perhaps there are other factors at work here, something else outside dentistry?

The year 2008 was, of course, the worse recession since the Great Depression of 1928. What was the effect of the recession? Did our dental patients complain more during the recession?

Other healthcare professions

To gain further insight into this, it was decided to check the annual reports from the General Medical Council and the General Pharmaceutical Council. The data from the GMC was readily available from the online GMC annual reports (Figure 7). Interestingly, the figures for complaints to the Fitness to Practise Committee doubled from 2008 to 2012.

The figures for the pharmacists were a little more complicated, as the General Pharmaceutical Society only came into existence in 2010. Prior to that the Royal Pharmaceutical Society of Great Britain both regulated and represented the profession. This was split into two separate bodies in 2010, with the renamed Royal Pharmaceutical Society representing the profession and the newly formed General Pharmaceutical Society regulating it.

The figures were available from the GPhC's online annual reports from 2011 onwards but the Royal Pharmaceutical Society has only been able to provide one report from the previous era, the 2008 report. However, it was possible to piece bits of information together from other reports to produce the graph in Figure 8.

The figures for the pharmacists follow the same trend as those for the dentists and doctors. A marked increase was evident during the recession. There may be other factors at work here, such as the change in regulatory body in 2010 that also encouraged patients to complain. However, the GPhC figures clearly show a three-fold increase from 2011 to 2014.

Post recession consumerism

Recessions have an impact on our behaviour as a society. The depth of the recession also determines this effect. Thankfully, most recessions are shallow and brief but the 2008 recession was the worst one since the Great Depression, and the effects of the Great Depression lasted for a whole generation. The people who lived through it were deeply affected by it. Increases in alcoholism, depression and suicide¹⁶ are well documented.

However, more subtle changes are also described. Flatters and Willemot detail this in their 2009 article ‘Understanding the Post-Recession Consumer’ in the Harvard Business Review.¹⁷ They describe how, in times of recession, people seek to punish sources of their dire circumstances. In good times disciplining bad business is less of a priority. They also describe a declining deference in society that is driven by a mounting scepticism about the quality of information provided by traditionally trusted professions, such as doctor, clergy and businessmen.

They said, of the 2008 recession, that:

So, like our great grandparents before us who lived through the Great Depression, we have been affected by the 2008 recession. Our behaviour will be modified as a result. We will tend to hold people more accountable than, for example, our parents' generation. This increase in complaints may therefore last for an entire generation. This is a sobering thought for us in the healthcare professions.

Conclusion

The figures show that patients in the UK complained more about their healthcare in the years after the 2008 recession.

This increase would appear to be in part due to the post-recessional effect on the consumer. This is a well-understood phenomenon in the business world and we, as modern healthcare providers, should not expect to be immune from its effect.

We should educate and inform our fellow professionals regarding this phenomenon. A better understanding of this helps us to manage our patient complaints better. This ultimately improves our patient care and, of equal importance, helps the morale of the profession.