Written Evidence Submitted by the Association of Dental Groups

(CLL0044)

Introduction

This submission from the Association of Dental Groups (ADG) responds to the Health and Social Care Committee and Science and Technology Committee’s joint call for written evidence on Coronavirus: Lessons Learnt.

The Association of Dental Groups (ADG) is the trade association for large dental providers in the UK. Our members include 20 of the largest groups of dental practices in the country, representing over 10,000 clinicians delivering NHS and private dentistry to more than 10 million patients every year. Many of our members staff have either engaged in providing urgent dental treatment centres or have volunteered for wider NHS redeployment during the pandemic period and this submission contains observations from members based on their experiences since March 2020.

The most important lesson learnt from the first pandemic period in March was that dental provision can be safely maintained during future “lockdowns” to suppress the virus and it is in the public health interest to do so. Guidance is now in place from the Office of the Chief Dental Officer (OCDO) and Public Health England which whilst some clinicians dispute the evidence base, allows for more routine dentistry to be carried out in a safe clinical environment. We welcomed the prompt messaging from the CDO (England) ahead of the November lockdown that this was the case.

NHS Dentistry before the Pandemic

Much of the evidence concerning the parlous state of NHS dentistry before the pandemic is available to the Committees from previous written evidence submitted to the enquiry “Delivering Core NHS and Care Services during the Pandemic and Beyond” and the previous call for written evidence on dental services dated 31 July 2019.

To summarise, ADG members reported significant concern with the current NHS General Dental Services (GDS) contract and its inability to deliver a comprehensive NHS dental service before the pandemic, in particular because it does not allow for prevention to be delivered adequately. Our members have experienced significant challenges with the current GDS contract where the use of Units of Dental Activity (UDA) has led to clinicians looking to leave NHS practice for private practice or seeking to considerably reduce the number of hours they practice in the NHS. This has been confirmed by the NHS Confidence Monitor Survey [1]. As current contractual arrangements require patients to pay a contribution towards the cost of their care, we note that this has led to many individuals having difficulties accessing affordable dentistry and therefore resulting in health inequalities. A contract where delivery of care is based on activity as opposed to prevention has been confirmed as inadequate in meeting the populations oral health needs during and beyond the pandemic period.

Dental provision during the Pandemic

By way of background information for the committees, all routine dentistry treatment in England was ceased in the Chief Dental Officer (CDO) letter to the dental profession on 25th March 2020 [2] for the safety of patients and of dentists and their teams during the COVID-19 pandemic. Individual practices were instructed, that unless they had been identified by area commissioners as part of the urgent dental system in a/their regions they should not see patients face to face.

The urgent dental system during the pandemic period can be best described as “work in progress”. Dental practices, as part of receiving ongoing NHSE contractual payments were required to provide telephone, or more ideally, video triage at their surgeries for patients seeking treatment during the pandemic. Only the most urgent/emergency cases would then be referred to their nearest urgent dental centre for face to face care. Many patients were prescribed antibiotics for their treatment remotely which were only alleviating pain and not treating the cause. All the ADG members practices and staff were involved in the triage system and the delivery of the urgent dental centres.

Aerosol generating procedures are required in most dental work and were ceased during the pandemic “lockdown” in March due to the perceived risks of Covid-19 transmission. Only urgent dental centres could undertake aerosol generating procedures where necessary using FFP3 masks, gowns and accompanying PPE for emergency dental work.[3]

The range of conditions outlined by the CDO to be provided for by local UDC systems included but were not limited to

Life threatening emergencies, e.g. airway restriction or breathing/swallowing difficulties due to facial swelling
Trauma including facial/oral laceration and/or dentoalveolar injuries, for example avulsion of a permanent tooth
Oro-facial swelling that is significant and worsening
Post-extraction bleeding that the patient is not able to control with local measures
Dental conditions that have resulted in acute and severe systemic illness
Severe dental and facial pain: that is, pain that cannot be controlled by the patient following self-help advice
Fractured teeth or tooth with pulpal exposure
Dental and soft tissue infections without a systemic effect
Oro-dental conditions that are likely to exacerbate systemic medical conditions

As such, referral to an urgent dental centre was often recommended as a last resort. Routine dental care members of the public would recognise was no longer available. If you had toothache you would have been most likely to be remotely prescribed a painkiller.

At the beginning of May there were estimated to be approximately 308 urgent dental centres [4] in England and some were designated “hot” sites specifically for Covid-19 symptomatic patients. Eventually this figure reached over 650 [5]. Information was not made available to the public on regional coverage (for example it was the case initially that there was only one urgent dental centre for Cornwall but subsequently more were provided). It is understood that there were parts of the country where it was difficult for patients to access a centre.

Members of the committees will have had complaints from constituents unable to access the urgent dental centre for emergency treatment. As reported by the BBC [6] and confirmed in an answer to a parliamentary question given by the Public Health Minister access to appropriate PPE was a factor in site opening:

“Dentistry does not usually require FFP3 masks or other higher-level PPE. However, the heightened risks presented by COVID-19 mean that this is required for any aerosol generating procedures. We are aware that there have been delays for a number of urgent care dental hubs in getting all the PPE now required and that this is still an issue for some hubs. The Department and NHS England and NHS Improvement are working urgently to resolve this. As an immediate measure emergency dentistry has been placed on the list of priorities areas to receive supplies from Local Resilience Forums.”[7]

The availability of appropriate PPE, for the safety of the dental team and the patient alike was an ongoing issue which constrained some urgent dental centres from opening. Shortages of PPE are no longer as acute and the NHS has established a “PPE portal” for providers to access stock. A dialogue has also been established with providers over their PPE requirements which should go some way to alleviate the difficulties experienced over the requirements for “fit testing” of PPE.

Due to the PPE, ventilation and social distancing requirements the number of patients that an urgent dental centre could see in one day was limited to approx. 8. Before the pandemic, a dentist might be expected to undertake 30 appointments a day.

As an entirely predictable consequence of the “lockdown” of dental provision a huge backlog of open cases, cancelled routine appointments and unmet need has now built up. The British Dental Association (BDA) estimates that 19 million fewer treatments [8] were offered between March and October 2020 compared to the previous year. The ADG polled members of the public and found that 49% of households had a member who had missed or decided against making an appointment with their dentist since March.[9]

Dental provision now and lessons learnt

The re-opening of dental services on 08 June was made through media on 28 May shortly followed by a letter confirming the resumption of services from the OCDO [10]. Dental professionals like many others, have been disappointed that communications have often been through media channels. This announcement gave practices just over a week to remobilise for re-opening which was compounded by the delay in issuing the Standard Operating Procedures under which practices could reopen. This was published on 4th June 2020 meaning many practices were not able to fully re-open on 8th June.

NHS dental services is a devolved matter for the four nations and the differences of opinion between the Chief Dental Officers of the administrations in the early stages of the pandemic added an additional burden to the profession. For example, In Wales, dental practices could remain open for patients on an urgent basis for face to face assessment if deemed appropriate.[11] It should be noted that co-ordination between the four nations improved over time, in particular through the work of the Scottish Dental Clinical Effectiveness Programme (SDCEP) which led the “Rapid Review into the Mitigation of Aerosol Generating Procedures”[12] forming the basis for all four nations to review their guidance on the “fallow time” requirements for ventilation between AGP treatments.

Upon reopening of services guidance recommended a “fallow time” of 60 minutes between AGP treatments to allow potentially infectious droplets and aerosols to clear from the air. Following the work by SDCEP referenced above this has been reduced by several ventilation mitigations and the current “fallow time” requirement can be lowered to 10 min with 10 air changes an hour or 30 minutes without additional ventilation with a range of times between depending on ventilation and additional mitigating factors such as high volume suction or rubber dam [13](Figure 1). However, even this has considerably curtailed the capacity of the NHS estate and is likely to continue to inhibit recovery of the backlog of outstanding care. It should be noted that compared to many other countries the UK’s requirements for ventilation and fallow time remain at the higher end of the scale and many clinicians challenge the limited evidence base.

However, as the Chair of the Health and Social Care Committee has already identified on numerous occasions a greatly increased testing capacity [14] is the best route for ensuring that the NHS does not become a Covid only service and other treatments can be undertaken more routinely again. The provision of testing for dental teams and point of care testing for dental patients would be the biggest step forward for the recovery of routine care until a vaccine has become widely administered within the UK population.

The closure of face to face services during the lockdown in England has caused a spike in patients remotely prescribed with antibiotics up 22% in England during April to June 2020 compared to previous year’s figures. Many patients are returning with pain or further swelling as the cause of the problem has not been able to be treated during the period of the pandemic, contributing further to the overhang of oral healthcare. There is a clear link between over prescription of antibiotics and the rise of anti-microbial resistance and whilst remote triage has a role to play whilst social distancing remains a requirement its role is limited. The inability to access face to face services during the lockdown has also resulted in a rise in “DIY dentistry”. A poll carried out by the ADG found that someone in 7.6% of households [15] has attempted to extract a tooth since lockdown started. The extent of further treatment needed due to patients taking matters into their own hands is still yet to reveal itself. The Oral Health Foundation have also warned that detection of mouth cancers have fallen by up to 65% since the beginning of lockdown.[16]

Recovering the overhang of oral healthcare arising from the pandemic will be limited by ongoing social distancing measures, patient confidence and the considerable additional costs now associated with providing dental treatment (PPE and ventilation requirements). An ADG survey estimated that 20% of pre pandemic dental surgeries will have to be refitted to meet the current guidance on ventilation requirements.

Dental care in the UK is a mixed economy with nearly half of spend on private dentistry which meets much of the population need that is not met by the NHS. Both the ADG and BDA (British Dental Association) have raised with Ministers that because of the “lockdown” of dentistry private practices had no revenue and they were ineligible for most HM Treasury support schemes [17]. The failure by policy makers to ensure fair and equitable support to the private sector may well lead to the failure of smaller independent practices which could result in further pressure to NHS budget. A stakeholder working group put forward proposals to Government for consideration [18]. ADG members were particularly aggrieved that no exemption was granted to high street private dental practices for business rate relief.
The current UDA contract system has already been shown to inhibit innovation due to its inflexibility and inability to effectively use all the dental team. It will certainly not allow dentistry to address the post Covid-19 challenges with the current restrictions on routine treatment.

Specifically, the UDA system will not allow the profession to:

Address the significant inequalities of access which have been exacerbated by the Covid-19 shutdown.
Recover and treat the significant patient need which has built up over the shutdown period.
Provide a service which addresses the expected anxiety in the population about many treatments – including face to face dental work.
Adequately address the expected increase in time to deliver face to face treatment.
Use the full dental team to deliver dental services to address pent up patient need.
Treat large volumes of patients with capacity reduced by the additional infection control requirements.
Delivery of previously contracted levels of activity due to the inflexibility of the UDA measure will not be possible to be met (This is already recognised by NHSE with a lower activity requirement being set since reopening).

For these reasons, a different contracting solution is needed for the provision of dentistry post Covid-19. Since reopening NHSE has continued contractual payments to providers on a monthly basis, however it would be undesirable to return to a purely “activity” driven UDA model and consideration should be given to introducing more flexible commissioning aimed at hard to reach groups such as children and care home residents. A move to more flexible commissioning with a greater emphasis on prevention would be widely welcomed by the profession.

The impact on professional morale of current working conditions should not be underestimated. In order to comply with evolving guidance many practices have had to undertake physical and costly changes to their premises, and members of the dental team have had to be “fit tested” individually with PPE more associated in the public’s mind with an intensive care ward during the pandemic. Anecdotally this has led to indications that experienced professionals are considering early retirement or leaving NHS dentistry. Coupled with uncertainty about NHS contractual payments on a month by month basis and previous dissatisfaction with NHS dentistry this is hardly surprising. Workforce difficulties are likely to be exacerbated by the suspension of the Overseas Registration Examination (ORE) the main route for overseas professionals to qualify to practice in the UK by the General Dental Council throughout 2020.

These additional challenges overlay on the pre-existing problems facing dentistry. We already know that there has been a particularly acute access issue in remote and deprived communities. In areas such as Cornwall, parts of Wales and Yorkshire where there have been so few clinicians that practices have had to close. Practice closures lead to further accessibility issues which further increase health inequalities as outlined above.

One of the recommendation from the Health and Social Care Committee enquiry into “Delivering Core NHS and Care Services during the Pandemic and Beyond” was an invitation to Sara Hurley, Chief Dental Officer (England) to set out her assessment of the challenges facing dentistry and a plan for the restoration of dental services in England. In order for providers to recover patient care and address the widening oral health inequalities in the UK such a plan would have to address:

Point of care testing to raise access to care which is plateauing at about 40% of pre pandemic activity.
Consideration of a financial grant for ventilation improvements where necessary.
Utilisation of the full dental team (within their scope of practice) and a new workforce strategy to improve long term recruitment and retention.
Transformation of current contracts to deliver more “preventative work”.

In addition to the above, we welcome the recent comments by the Lords Health Minister, Lord Bethell [19] that the Government’s proposals for water fluoridation would be announced shortly. A national programme for water fluoridation is the single biggest preventative measure that could be taken to protect the nation’s oral health in the future. Water fluoridation requires no behaviour change and the evidence shows it is highly effective in reducing dental decay and delivers the most benefit to the deprived.

In conclusion, the dental profession has seen a wave of unmet and rising demand for care as a consequence of the three month cessation of provision which due to the nature of oral healthcare provision is going to be difficult to meet over the next 12 months. The NHS will have to take a fresh approach to its model of provision to ensure that providers can try and meet the population’s needs in the future.

(November 2020)