Written Evidence Submitted by the British Dental Association
(CLL0074)
Introduction
1. The British Dental Association (BDA) is the professional association and trade union for dentists in the UK. Members engage in all aspects of dentistry: general practice, community dental services, the armed forces, hospitals, academia research, and our membership also includes dental students.
2. We welcome both Committees’ decision to hold this joint inquiry. We have already provided written and oral evidence to the Health and Social Care Committee on the existential challenges facing the service during the current pandemic. Those challenges remain, and it is imperative that lessons are learnt for the next phase of the crisis, and for any future pandemic.
3. Over 19 million fewer courses of treatment have been delivered in NHS dental services since March, when compared to the same period in 2019. While practices resumed face to face care in England on 8th June they did so as a skeleton service, and the majority are still running at under half their pre-COVID capacity. The country has seen what life is like without dentistry, and for the majority of the population now seeking routine care that situation remains.
4. As the UK has confronted a novel virus we have recognised the responsibility of Government to act, sometimes without waiting on a clear evidence base to emerge. Regrettably, choices made since March have often had a devastating impact on both the sustainability of practices, and the patients we treat. The move to a limited Urgent Care model operating at some 600 sites (as opposed to the 10,000 practices currently operating in England) took far too long to implement. The limitations on care at that time, and since practices were allowed to resume face to face care in June, have generated huge backlogs which practices are struggling to manage. Policies such as ‘fallow time’ – the gaps of up to an hour we are still mandated to hold between most treatments – have been taken forward on the basis of the precautionary principle, and remain the main challenge to restoring access.
5. Social distancing, fallow time and other infection control measures have had a huge impact on all practices’ ability to deliver care and maintain their bottom line. Corresponding Government support has been absent or uneven, with welcome help for NHS contract holders but a failure to even recognise the ‘mixed economy’ on which dentistry operates. The private sector now represents 60% of spend on dentistry in the UK, and with the exception of the furlough scheme and access to credit, this part of the service has had to go it alone. There are now real questions as to what level of NHS support is going to be maintained in the medium term, while these policies remain in place.
6. The pandemic has aggravated systemic problems in a service that was already facing a crisis. The target-based NHS contract the Health Committee previously dubbed ‘unfit for purpose’ has proved utterly incompatible with the Government’s wider policy response. ‘Future proofing’ the service requires an urgent move towards a reformed system.
The deployment of non-pharmaceutical interventions like lockdown and social distancing rules to manage the pandemic
7. Ahead of the first lockdown the profession was crying out for clear guidance, to keep staff and patients safe. We accepted the case for lockdown, but choices made at the outset that effectively categorised dentistry as a ‘non-essential’ service must be avoided in future.
8. The approach towards a limited urgent dental care service (operating at around 600 sites in England) appeared to have been largely predicated on a PPE shortage, rather than necessarily the best interests of patients. This decision and on-going restrictions have had wide-ranging impacts on both service sustainability and the nation’s oral health going forward.
9. Between March and June all routine dental care in England was paused, with Urgent Dental Care Centres (UDCs) set up to provide care for a limited number of patients with emergency dental problems. In May just 2-3% of patients were able to access NHS dental care compared to the same period last year, and a recent BDA analysis of Business Services Authority data indicates over 19 million appointments were lost between March and October. As practices continue to operate with a severely reduced capacity, this backlog continues to grow, and it is likely to take years to clear.
10. Pre-existing inequalities in oral health are now likely to become even more marked, as the loss of treatment and preventive services during the pandemic and the severely limited capacity upon resumption of routine care will disproportionately affect people from disadvantaged and vulnerable/shielded groups. With access to dentistry severely limited, many people will continue to experience dental pain and will resort to self-medication and “DIY” dental treatment, with severe implications for their ongoing health.
11. With appropriate standard operating procedures in place and reliable supplies of PPE, we would hope and expect that there will be no suspension of face to face care during further phases of COVID or in any future pandemic.
12. On 8th June high street practices in England were allowed to resume face to face care. However, “business as usual” remains a distant prospect: almost two thirds (64%) of practices surveyed by the BDA in October estimated they could only treat less than half of the patients they saw before the pandemic. Official data shows NHS treatments delivered in October were still just a third of the levels achieved the year before.
13. Social distancing and other interventions like ‘fallow time’ continue to have a significant impact on service delivery. Restrictions on practice require corresponding Government support, given they have undermined the fundamental business models practices operate to.
14. Most courses of dental treatment – for instance any involving drilling or scale and polish – involve Aerosol Generating Procedures (AGPs), which create airborne particles that can contain viruses and bacteria. After each such procedure dentists are required to leave the treatment room empty for up to an hour before it can be cleaned, which dramatically lowers the number of patients they are able to treat.
15. Fallow time could be significantly reduced – and patient throughput increased – by installing high-capacity ventilation equipment. However, such equipment and related ventilation surveys are estimated to cost a typical practice £10,000, and more for larger practices with a high number of surgeries. BDA members’ survey shows that the majority of dental practices in England are not currently able to afford such an investment.
16. Capital funding for dental services has been non-existent for decades. While point of treatment lateral flow testing and access to a vaccine could reduce these challenges, investment is required to future proof the service.
17. Government has singularly failed to recognise the mixed economy on which the service is based. Private practices – which represent the majority of spend on UK dentistry – have had negligible support, while providing vital access to patients. The return of VAT to PPE in November has been viewed as a tax on safety for private colleagues ineligible to access free PPE via the Government’s NHS hub.
18. These interventions have proved entirely incompatible with the target-based contract on which NHS services operate, where dentists are remunerated for achieving Units of Dental Activity (UDAs). Contract holders have been provided with their former contract value on the condition they maintain the same pre-pandemic NHS/private split. The low remuneration for time consuming urgent care (1.2 UDAs) relative to a quick routine check-up (1 UDA) now means any move to reimpose the system would force dentists to deprioritise those most in need in order to meet arbitrary targets, to avoid steep financial penalties. This perverse model of care has no place now, in a post-COVID environment, or in any future pandemic.
19. Since the first lockdown remote consultations and remote triaging have increased significantly, and would reasonably be expected to form part of the response to any future pandemic. However, the long-term failure to address the lack of effective digital integration among NHS providers has become even more acute. Dentists’ inability to access electronic prescribing and summary care records has reduced time available for direct patient care. Development of appropriate, integrated digital infrastructure is essential going forward.
20. The impact of these interventions has also been felt across community services and secondary care. Frontline intelligence gathered by the BDA across the English regions suggest many general anaesthetic (GA) services have yet to resume treatment since the start of lockdown, and where they have the capacity it has been significantly reduced to meet social distancing and additional infection control procedures.
21. England already had a significant problem with waiting times for patients requiring GA dental treatment in England, leaving many vulnerable adult and child NHS patients in immense pain and distress. Pre-COVID some people waited over a year for GA procedures. The impact of COVID and the restricted access to general anaesthetic means many adults and children will now face significantly longer waits. Urgent action is required to ensure appropriate access to GA lists for community and hospital dental providers.
The impact on the social care sector
22. The limited provision of dentistry to care residents has been well documented by the Care Quality Commission, who found residents left unable to eat, drink and communicate as a result of widespread failure by homes to implement appropriate policies, alongside limited access to dental services.
23. Pre-COVID levels of commissioning for domiciliary care were low and falling. Freedom of Information requests undertaken by the BDA indicated domiciliary care provision was equivalent to providing coverage to under 1.3% of the population whose activity is significantly limited by disability or ill health.
24. The full impact of COVID on the oral health of care home residents has yet to emerge. However, access will likely have followed the same patterns seen across primary and secondary care, taken to greater heights owing to the necessity of shielding these vulnerable residents. Long term progress will hinge on appropriate commissioning of domiciliary services, underpinned by a robust needs assessment.
Government communications and public health messaging
25. Government communications with regard to dentistry – whether addressing the profession or the public - have been unacceptably poor. Messages have been late or open to interpretation. The result has been widespread frustration: dentists working against the clock following an eleventh hour call to reopen on 8th June, and patients left unclear on what levels of service they might be able to access.
26. Failure to manage patient expectations has been the single greatest criticism of the Government’s COVID record among dentists. 73% of practices surveyed UK-wide expressed dissatisfaction with the Government’s performance in this area, ahead all other measures, including PPE availability, access to financial support and quality of guidance.
27. Dentists remain justifiably troubled that they first heard the news about practices reopening on 8th June via a BBC news ticker during a Downing Street news conference. Subsequent official messages implied a return to “business as usual” that still remains far removed from reality. Similarly, clarity that practices could remain open during the second lockdown were not immediately forthcoming.
28. Going forward, and in any future pandemic, the Government has a duty to keep this profession in the loop.
The UK’s prior preparedness for a pandemic
29. Dentists alerted authorities to the shortage of key PPE in early February, as key supply chains from China began facing widespread disruption. While commercial UK suppliers were given access to strategic stockpiles, our concern that dentists would soon have to ‘down drills’ were viewed as an overreaction. Little over a month later that is precisely what transpired.
30. We welcome moves to create a more robust, home grown supply chain for PPE. Failure here in future would result in a return to an unacceptably limited urgent care model in any future pandemic.
The development of treatments and vaccines
31. Dentists welcome the prospect of a rapid rollout of a COVID vaccine, and the Joint Committee on Vaccination and Immunisation (JCVI) recommendation that all health professionals should be near the front of the queue for vaccination. That is a logical approach, which will support continuity in provision across healthcare services.
32. We remain concerned that dentists – in both NHS and private settings – will not be given priority, given that NHS contractors have been excluded from the free flu vaccination programme in England.
33. Given volunteers are being sought from among the workforce to deliver the vaccine, we need to avoid a surreal situation where dentists administering the vaccine will be ineligible to receive it.
34. Crucially, the failure to prioritise dental teams in the COVID vaccination programme will further hinder access to dental services for patients.