Covid-19 – What next for primary dental care?
At present Government policy remains that routine dental care should not be provided, urgent care should be delivered predominantly by telephone and aerosol generating procedures (AGPs) – a large part of routine dental practice – should not be conducted outside of NHS Urgent Dental Care centres.
March’s lockdown saw the nation’s dental care put on hold. Practice closure probably brought a degree of reassurance to practitioners given the New York Times rated dental professionals as the occupation at greatest risk of Coronavirus infection. However, as dental professionals realised that many would not benefit from the various financial support packages introduced by the Government, that initial relief was replaced by growing anxiety. The stuttering roll-out of NHS Urgent Dental Care centres reinforced concerns for patients’ ability to access appropriate care. Dramatic media reports of patients extracting their own teeth were only a sentinel for much wider problems created by the lack of access.
The CQC’s announcement
Against that background, the CQC announced this week that “the decision to offer dental care services is one for the provider to take”. There is a danger in reading this announcement that it is an endorsement of the appropriateness of practices re-opening now. In reality, it is merely an acknowledgment of the limitations of the CQC’s powers. The CQC can take action on registration of individual providers for breaches of regulations. It does not have the power to close, or open, whole sectors.
The more important message implicit in the CQC announcement is that there is no wriggle room when it comes to compliance with infection prevention and control [IPC] requirements. Such compliance is a regulatory requirement on practices, and a contractual requirement for NHS contract holders. Compliance with Public Health England and NHS England guidance will have significant cost and service implications for some considerable time. There remains a lack of clarity in respect of the supply chain for PPE and the way in which costs of PPE will be allocated in the medium to long term. When it can be accessed, costs of even basic PPE have soared since the outbreak began with significant implications for overheads per treatment. Though familiar with the use of basic PPE, such as surgical masks, practices will need to get to grips with fit-testing and fit-checking and PPE selection required for AGPs in order to comply with their health and safety obligations.
The surgery decontamination requirements associated with aerosol generating procedures will severely impede practice’s ability to deliver routine volumes of care. It seems inevitable that practices will be unable to deliver their existing UDA activity levels for the foreseeable future. There is talk of an abatement of the NHS contract payments for 2020/21 with little clarity as to the consequences for required activity levels or UDA rates.
All of this coincides with the planned roll out of the new NHS contract(s) in April 2021 and the associated shift to capitation as the primary funding element. Whilst considerable work has been undertaken on piloting the two model contract options, projections of viable rates of capitation pre-COVID are likely to differ significantly from the reality of the post- COVID world. That raises the obvious question as to whether operating at lower consultation volumes, a practice could meet access requirements for their existing practice list size. It seems more likely that maintaining access and commissioning costs at current levels, but with lower daily activity, will mean more dentists are paid less. There is also bound to be upward pressure on the cost of private dental care which may lead to even more demand on the NHS. Pre-COVID, the NHS’s ability to cope with existing demand was already in doubt.
Beyond the uncertainty
Whilst considerable uncertainty remains around financial and contractual issues, practices contemplating a return to the provision of services can be clear about one thing –infection prevention and control requirements will take centre stage in the compliance landscape. A recent, and timely, BDJ report noted that infection control issues featured in less than 1% of fitness to practice hearings.  That seems likely to change.
Practices must be thoroughly familiar with relevant PHE and NHS England guidance and must plan carefully for the local implementation of that guidance. Protocols for local implementation will need to be reviewed very frequently, given the pace of change and the likelihood of some changes to relevant guidance over time. There are clearly elements within the profession, here and abroad, who contest the need for the IPC measures to be as stringent as those demanded by the current guidance. In the context of rapidly evolving understanding of the virus it remains to be seen whether there will be some softening of the requirements. At present practices should be planning ahead for the eventual resumption of AGPs and consider whether structural changes to the practice environment will be necessary or helpful in implementing appropriate IPC measures.
It will be crucially important to plan, implement and document staff training around PPE and to plan arrangements for fit-testing and addressing supply chain issues. Practices will need to develop workable protocols for remote, pre-appointment, COVID-screening of patients and for the allocation of limited appointment slots on the basis of clinical need. A considered assessment of achievable patient volumes will also be crucial. Practices should be realistic about the possibility of further, unplanned, service interruptions due to staff shortages, supply chain issues or a second-wave of coronavirus cases. Practices should also consider the tests which the NHS unions have articulated in their Blueprint for Return. In considering changes in working practices it will be important to consider the related data protection implications. The ICO has recently published guidance for employers on workplace testing.
Whilst there have been promising developments on point of care testing and vaccine development, it is clear that neither will be readily accessible in the short term. Future iterations of the IPC guidance may potentially facilitate higher patient volumes. For the present, practices must plan for what is likely to be a phased return, on the basis that current restrictions in respect of physical distancing, PPE requirements and decontamination will remain for some time. Whilst compliance with relevant guidance is a regulatory and contractual requirement, its objective is the safety of patients and dental staff – a fact which is likely to be reflected in a low tolerance of compliance failures and which must temper the understandable desire for professionals to get back to doing their job and meeting their patients’ needs. At the same time, the profession will be watching anxiously to see how the government responds to their calls for urgent action to protect the financial viability of dental practice on the high street.
 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0282-covid-19-urgent-dental-care-sop.pdf and https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe
This briefing is for guidance purposes only. RadcliffesLeBrasseur LLP accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.