FGDP(UK) Dean Ian Mills reflects on the his experience of returning to work in his mixed NHS/private general dental practice.
It has been some time since I sat down and wrote a blog; which might well be a relief to many of you. The main reason for my literary inactivity has been a pre-occupation with pressing matters at both FGDP(UK) and at my practice. The impact of COVID-19 has been considerable in terms of the workload at the Faculty and the contribution by our remaining staff and our Board Members has been incredible. The majority of our Board Members have practice responsibilities in addition to their many other commitments, and they have done remarkably well to find the time to support the Faculty so effectively. They are certainly better at juggling commitments than I am, as I have had to lean very heavily on the goodwill of my long-suffering practice manager and business partners over the last few months.
Like many of my colleagues in England, I have made a return to practice, albeit a somewhat understated comeback. I am not quite operating at the level I used to, but I am hoping that my return from an enforced retirement is more like Paul Scholes in 2011, rather than Ricky Hatton in 2012! Although I am sort of hoping I will make it beyond the next season!
A lot has happened in the last few weeks, and our four Nations have each taken a slightly different “route map” to re-establishing dental services. At my own practice in Devon, we have taken the first tentative steps in re-opening. It would be inaccurate to state that we “opened our doors” on 8th June, but we did allow patients to enter the building after they had got past our “door staff”. As you can imagine, we have a fairly robust protocol in place to ensure safety for our patients and staff, although this does seem to be straying into the realms of security. Only the most deserving and committed of patients manage to get past our “door staff”, as they battle their way through our new COVID-19 protocols, which appear to be a cross between The Crystal Maze, Mastermind and It’s a Knockout.
I am pleased to say that some of our patients managed to successfully navigate their way through our entry exams. As a reward, they gained admission to our spartan waiting area, where they were welcomed by a greeter clutching an alcohol hand gel dispenser in one hand and a barge pole in the other. Before they are allowed to sit down, they have their bag and coat wrestled from their grasp, are liberally doused in disinfectant, and then quickly ushered into the surgery. Rapid transfer is critical, as we don’t want them touching anything, or worse still, attempting to use our toilet facilities. This would be a challenge in itself, as the current facilities are cordoned off like a scene from The Salisbury Poisonings, which I guess at least prepares patients for the image which will greet them as they enter the surgery!
A visit to a dental practice will often cause the pulse to race, and I’m not just talking about the dentists. You might think the vision of the dental team dressed in gowns, FFP3 masks and visors would make the pulse race that little bit quicker, but surprisingly our patients seem completely relaxed with our new look. In fact, they have been incredibly grateful that we have re-opened and seem reassured by how seriously we are taking infection prevention and control. It would be accurate to state that some of the staff were not quite so relaxed when we first re-opened, and there was considerable anxiety about this new way of working. I am sure it has been the same for many practices, but everyone has been highly professional, and staff stress levels are now reducing… almost as quickly as our bank balance!
It has been a very stressful time for everyone in general practice, and I fear there is more stress and pressure ahead as we navigate our way through this transition period. The return to practice protocols were necessary in order to ensure safe provision of care, but the current approach is unsustainable and will need to change in the near future to allow practices to survive. Whether this change is brought about by increased understanding of the risks of COVID-19 or a decrease in threat levels, is less important than the pace of that change. We cannot afford to continue to work like this, but we cannot afford to simply ignore the risks to ourselves, our staff and our patients.
Our primary concerns over the last few months have been around safety and access to urgent and emergency care for our patients, which has been entirely appropriate. We must now focus our attention on getting practices operating again across the UK, without compromising safety. To do this, we need to rapidly evaluate the risks and ensure that we are applying evidence-based protocols, in order that we can rein back on the precautionary principle which is in danger of paralysing dental practices.
I am aware that a number of organisations and authorities have made a significant and urgent commitment to support research pertaining to the risks of delivery of dental care in relation to COVID-19. This is welcome news, but we need high quality research and we need it now. This is clearly a challenge, but I was encouraged to see that PHE had established a dental academic network to encourage collaboration, and I was particularly delighted to see that general dental practitioners were represented on that group. It is important for the profession to work together at this time, and this must include research where translation of findings across to clinical practice could have such an immediate, profound and wide-reaching impact on the long-term sustainability of general dental practice. It is also important to appreciate that UK dentists are not facing this crisis in isolation. We are a global community and we need to learn from our International colleagues and collaborate as widely as possible on research.
At the risk of stating the obvious, there are significant costs to delivering care during this transition period, and practices are in an extremely vulnerable position as they juggle income, expenses, and staffing. As the owner of a small business, the last three months have had a significant financial impact on our mixed NHS / private practice. Re-opening has offered limited opportunity to derive private income, but has led to a significant increase in costs with a potentially devastating outcome if this is to continue.
The impact of new protocols, physical distancing, fallow times, etc, has had a massive impact on patient throughput, and in our own practice we are currently seeing less than 20% “activity” compared to pre-COVID. This massively reduced activity, coupled with the backlog of patients, means that access is greatly reduced for all. This will undoubtedly translate into an “oral health cost” and as a profession we need to consider how we minimise the impact of reduced access, and in particular how we can protect the most vulnerable in society. I have previously written about my concerns around the impact which COVID will have on oral health inequality and the increased burden which is going to fall on the NHS. This could not happen at a worse time with reduced capacity and little prospect of increased spending on public services. A review of the NHS dental offer needs to be a key priority and we must grasp this opportunity to redesign NHS dental services and ensure that care is provided to those with the greatest need.
Redesign of dental services is not going to happen overnight, so the NHS needs to show courage, conviction and ambition, if we wish to have a sustainable dental service, which is fit for the future. This takes investment both in terms of money, but also in trust. If the devolved Governments fail to appreciate the precarious nature of dental practices, and act to support them over the next 12-24 months, I fear it will have a devastating impact for UK dentistry in the long term.
I have mentioned my concerns about the cost to practices, the cost to patients, the costs to staff, but there are wider implications as we are encouraged to adopt new ways of working during this transition period. We seem to be caught up in the middle of a PPE arms race, with huge quantities of disposable gloves, masks, visors, aprons, and gowns, being used and discarded every day. Social media is awash with images of dental care professionals dressed up as if they are about to decommission Chernobyl, rather than access a pulp chamber. I fully appreciate PPE is a vital aspect of infection prevention control, but we need to ensure that the measures which we are currently adopting are appropriate and proportionate to the threat. In many ways this comes back to the need for evidence-based decision making, and application of common sense.
I was delighted to see that the FGDP(UK) / CGDent guidance took into consideration environmental sustainability and promoted the use of reusable masks, gowns, visors, and mops wherever possible. The decision to promote reusable items may seem like a very small, almost irrelevant, issue to some, but for many practices this can be a significant advantage in terms of cost and ensuring a sustainable supply of PPE. Not to mention the impact on the environment and the cost of waste disposal.
I need to declare an obvious bias, but I believe the FGDP(UK) / CGDent guidance Implications of COVID-19 for the safe management of general dental practice – a practical guide, is an excellent resource to support the dental profession at this very difficult time. The Task Group was chaired by Onkar Dhanoya, Vice Dean FGDP(UK), who did an excellent job in bringing together the disparate views of a large group of contributors. The commitment and contribution of the Task Group over a very short period of time was remarkable, and I would like to take this opportunity to thank each and every one of them. The risk-based approach promoted within the guidance has resonated with many, and it is encouraging to see so many other authorities now embracing this approach.
Faced with a new threat, and a weak evidence base, we have to rely on transferable evidence and expert opinion. This increased degree of uncertainty is far from ideal and artificially elevates the risk threshold. Application of the precautionary principle has been accepted as a sensible approach, but when this is applied for a prolonged period we are likely to witness unintended consequences including irreparable damage to oral health and significant financial difficulties for dental practices.
I am hopeful that a sensible risk-based approach, will maintain a high level of safety, while allowing a reasonable delivery of dental care during this transition period. In the meantime, we must rely on our academic colleagues, working in conjunction with general dental practice, to review the current evidence and rapidly produce high quality, relevant research. This is absolutely vital in order to support evidence-based national policy, which is desperately needed to allow our profession to make sensible, well-informed decisions about the delivery of general dental services.
Read more posts by Ian at www.fgdp.org.uk/deans-blog.