Following a 30-year career in general dental practice, Simon Hearnshaw MFGDP(UK) is currently Chair of the North Yorkshire and the Humber LDN, and Training Programme Director for Dental and Dental Therapy Foundation Training. In this blog, he reflects on the challenges of providing urgent dental care during the pandemic and implications for the future.
The Covid pandemic has posed huge challenges to Primary Dental Care. NHSE Commissioning Teams and Local Dental Networks (LDN) have had to make multiple decisions to keep patients and teams safe and at the same time provide prioritised urgent care. So what have we learned from the dental response to Covid and does this provide a roadmap for the future?
In North Yorkshire and the Humber (NY&H) we had a small but important head start. The LDN was set up around seven years ago following the restructuring of the NHS to commission the entire dental pathway and in the years since, the Network has slowly become a cohesive forum for problem solving and the progressive development of services. People are absolutely correct when they say that the strength of any Network is the representation on it and the relationships developed over several years. For example, the Local Dental Committees (LDCs) in our area are very active and aligned with LDN priorities, mainly because they have had input into these and share ownership. Equally, thanks to relationships developed across secondary care and the Community Dental Services, there are well-established lines of communication and an understanding of the challenges in our diverse and very large area. The LDN has already successfully driven the “In Practice Prevention” programme in response to the very poor oral health of the communities we work within and worked hard as a group to shape and develop the new NY&H Flexible Commissioning Programme. As a result of this collaborative work, we had an existing platform from which to respond to the Covid threat. For example, because of the local programmes and the learning gained from them, we understood the value of clear communication, working collaboratively and evaluating approaches and adapting. What wasn’t clear was whether we could respond so rapidly and so well as a co-ordinated system
The answer is yes we could, not perfectly, and we are still discussing the lessons learned but, within a short period of time, the LDN, working with commissioners, LDCs, Public Health England (PHE), Health Education England (HEE) and the Community Dental Services built networks to deliver essential urgent dental care (UDC) during the lockdown. Primary care practices were divided into simple care networks with one and sometimes two UDC hubs delivering urgent care within a group of between two and 12 practices, depending on geography. Simple and effective communication and referral pathways were rapidly set up and implemented. This system was communicated to practices through email, secure messaging platforms and webinars, assisted by HEE. In addition, HEE locally supported a central, one-stop-shop information webpage and organised fit testing courses. The system performed remarkably well with referrals peaking at week 3.
Analysis showed our UDC hubs:
• received over 700 referrals in peak weeks
• provided 5,500 episodes of face-to-face care including around 1,000 aerosol generating procedures
• reported a 90% appropriate referral rate.
Meanwhile, the Community Dental Services and Specialist Secondary Care Services reported excellent quality referrals, and the PHE-trained fit-testing team, tested over 500 front-line staff.
This networked system of UDC delivery used pooling of workforces between practices, which resulted in teams outside the hubs learning to work within the protocols. In addition, a strong element of informal peer review, backed up by regular webinars, appeared to help compliance and quality improvement. This system also appeared to result in a more rapid return to recovery post June 8th, possibly because of the strong communication channels within the cluster networks, the sharing of experience and information and the fact that most practice teams had some experience of working within the UDC hubs to fall back on when they opened as treatment centres themselves.
So, what does this tell us?
I think it tells us that if you empower established clinical networks and ask them to work together to build systems for care delivery, they can do this rapidly and effectively. If LDNs can work in partnership with all stakeholders supported by Commissioning Teams, Public Health Teams and HEE Teams with an agreed vision, this network can plan, develop, implement and evaluate. Also, objectives were met without an activity target as such – just an outcomes target of meeting urgent dental care need.
I think it also tells us that the solutions to improved commissioning, and ultimately improved care systems, are already within the networks. We simply need to decide on commissioning priorities and empower the networks to develop frameworks that can target care appropriately moving away from activity targets towards outcomes-based commissioning.
What does the future hold?
I am not sure, but what Covid has taught us is that in terms of dental care provision, even a small period of constraint results in serious problems, so oral health is critical for general health. We also know that the system can manage change, so why not harness this to develop a better NHS to work within and a better NHS for patients? And could this period also strengthen the value of public health and the importance of programmes like supervised brushing programmes, care homes programmes and community water fluoridation that build prevention resilience? I hope so.
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