NHS Dentistry – Resumption of service but not as usual
As dental practices across the country begin to re-open their doors, they face significant challenges and uncertainty. We look at some of the most recent guidance for dental practices and address some of the biggest hurdles that lie ahead.
The guidance now available includes a Standard Operating Procedure published jointly by the Chief Dental Officer and NHS England [“the Guidance”], as well as earlier guidance from the Faculty of General Dental Practice (FGDP). The various guidance documents are not entirely aligned and the Guidance makes a point of stressing that their guidance is the one which must be followed, and which sets the standard which regulators will expect to be followed. So, practitioners do not have a free hand to choose the guidance which best aligns with their preferences. NHS contract holders will also be under a contractual obligation to follow the Guidance.
Many practitioners will have welcomed the guidance published by the FGDP last week, in particular the Faculty’s advice that FFP2 masks could be used interchangeably with scarcer, more expensive, FFP3 masks. The Guidance differs, albeit that aspects of the guidance are ambiguous. Although the Guidance states “FFP3/FFP2/N95 applies where FFP3s are referred to throughout this text” a later appendix sets out detailed guidance which notes –
“The HSE has stated that FFP2 and N95 respirators (filtering at least 94% and 95% of airborne particles respectively) offer protection against COVID-19 and so may be used if FFP3 respirators are not available.”
This distinction suggests that, in order to comply with the Guidance, those using FFP2 or N95 masks will need to be in a position to demonstrate that they were unable to obtain FFP3 masks.
Staff with Household Contacts – Self-isolation
The Guidance has an unhelpful ambiguity in the advice in relation to how staff who have infected household contacts should behave. The first reference to this issue in the guidance states that such staff members may return to work if they have a negative test. That makes no sense. The position is correctly stated later in the guidance:
“Staff living in a household where someone has symptoms should stay at home for 14 days from the onset of household contact’s symptoms. However, if the member of staff becomes symptomatic during the 14 days isolation, they should isolate for 7 days from the date of symptom onset.”
However, that paragraph does not specifically mention the implication of a negative test taken by the staff member. On its face the document can be read as advising that a negative test permits staff to attend work despite having a known infected as a current household contact. The ambiguity is unhelpful.
Minimally Invasive dentistry and activity related remuneration
The Guidance explicitly endorses deferring functional and reconstructive care with an emphasis on stabilisation:
“Following an oral health care assessment, care planning should focus on achieving stabilisation, with care limited, where judged suitable, to non-AGPs (non-Aerosol Generating Procedure). Deferring functional and reconstructive care remains a viable treatment option under current circumstances… Practitioners should exercise their clinical judgement to manage the associated risks with the unique clinical proximity and AGPs involved in dental care.”
The Guidance states that “the focus on stabilisation should be delivered in line with the principles outlined in the Avoidance of Doubt: Provision of Phased Treatments”. We note that the document does not describe a generalized approach to the breadth of the patient population. Rather it is directed at a small subgroup of patients – “patients who will not usually have accessed and completed routine dental care in the previous 24 months.” The unusual nature of the approach is clear from the observation –
“Normally patients who regularly attend your practice should not require phased treatment spanning a number of CoTs. However, there may be a very small number of patients where there has been a significant and unexpected decline in dental health where this approach may be appropriate.”
The Avoidance of Doubt document acknowledges the significant implications for patients including the multiple patient charges which result. An issue which is not acknowledged in the Guidance. Indeed, dentists face the challenge of reconciling the references to the Avoidance of Doubt document with the Guidance’s recommendation to complete treatment in as few visits as possible and the contractual requirements to provide all treatment necessary to secure oral health in a single course of treatment.
The Guidance expressly advises: “Keep intervention to a minimum, to reduce exposure risk” (our emphasis). It does not disguise the fact that it is advocating one “option”, amongst a number of others. That clearly has implications in relation to consent. The choice between available treatment options lies with the patient, not the clinician. Patients are entitled to make choices which do not align with the advice or recommendations of their dental professional.
The law of informed consent has not changed as a result of COVID-19. Dentists are still required to explain the range of available treatment options and their risks and benefits and the associated costs, including NHS patient charges. The fact that a particular treatment option may present a risk to staff, or may not be available at your practice (e.g because of a lack of access to PPE) is information which is relevant to the patient’s decision about whether to select from the options available at your practice or look elsewhere. The Guidance notes:
“In appreciating that the clinical treatment options and approaches to care may be unfamiliar to some patients, fully informed consent will be important, as will any decision by the professional not to offer a particular treatment because of a wider risk assessment. Recording valid consent and detailing any risk assessment supporting a treatment plan remains a high priority.”
If not currently offering AGP it will be important to advise patients in advance of attendance that a normal range of services is not available at your practice and this may have implications for the availability and timing of interventions and total cost, including the number of NHS patient charges.
The challenges of explaining an additional layer of considerations, arising from COVID, which affect patient choice will only be exacerbated by the communication difficulties resulting from wearing masks. Care will be required in checking and confirming patients have properly understood the information communicated to them.
Interestingly, the Guidance fails to mention Human Factors, a topic which is addressed in the FGDP guidance. Personal Protective Equipment can impact peripheral vision, hearing, non-verbal cues and speech creating challenges for communicating with colleagues. This makes strategies such as “repeat back” even more relevant to mitigating the risk of communication errors.
On the cusp of a new NHS dental contract, which has been years in the making, practitioners are being encouraged to deploy a treatment philosophy which is not a good fit for the mode of remuneration under the existing contract. Whilst activity related remuneration is on hold at present there is little clarity as to when it will resume. The shift to mixed capitation/remuneration models under the new contracts is still some way off. The Guidance does not engage with the issue of patient charges save that the reference to “Avoiding Doubt” implicitly acknowledges that many patients will end up paying repeat patient charges for what would normally be a single course of treatment. It seems almost certain that there will be disputes around these issues in at least some cases.
Perhaps one of the greatest challenges emerging from the Guidance will be for practitioners to handle the tension between the Guidance, which implores them to limit AGPs and postpone functional and restorative treatments and then need to afford patients a free and informed choice of treatment options. This will include expressly inviting patients to postpone treatment not because it is in their own best interests but in the interests of limiting risk to practice staff and other service users. It will be more important than ever to keep detailed records of the consent discussions.
 Citing the following guidance in support: 10
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.