Written evidence submitted by Bupa Dental Care (CLL0085)

Bupa Dental Care

• We are one of the UK’s largest dental providers, with over 480 practices across the UK and Ireland providing access to both private and NHS dental care for around 2.4 million patients. The UK market is highly fragmented, and while we are one of the largest providers, we still account for around only 4% of the market.

• Our services and treatments are available to everyone and around 60% of all Bupa Dental Care customers across the UK are treated as NHS patients.
• We also provide dental services through insuring more than 162,000 employees through employer dental health plans.

How we, and other dental providers, have responded

• Throughout the crisis we’ve worked closely with the NHS across all 4 devolved nations.
• While our practices were closed for face-to-face care in some areas, in line with government advice, our practices and teams supported around 300,000 patients throughout the UK with remote triage advice, prescriptions and treatment, and in Wales, Northern Ireland and some parts of Scotland, emergency face-to-face care.

• Dental providers stepped up to provide triage services and there was a willingness from dental teams to volunteer to support Urgent Dental Care hubs (UDCs) and wider NHS redeployment. The competence and professional nature of the dental industry has been a big contributing factor in our ability to respond to this crisis efficiently. The industry is supported by already excellent standards and understanding of Infection Prevention and Control (IPC) procedures, and we are used to working with patients with other viral disease such as hepatitis C or HIV, or even seasonal flu.
• Once allowed to return to providing face-to-face care everywhere, dental providers developed clear cascade and communication plans to practices, clinicians and other staff to ensure everyone understood the new guidelines and changing expectations.

• Once Bupa Dental Care practices were able to recommence full face-to-face treatments, we followed national guidance from the Chief Dental Officer to prioritise patients with emergencies and urgent dental needs, and those who are mid-treatment. Where possible (most of our practices) we have recommenced routine appointments for NHS patients, with our team working hard to reduce the backlog of patients seeking dental care.

Challenges with COVID-19 regulations

• The complete shutdown of face-to-face dental care in England, and parts of Scotland, left the population with no or very limited access to care, which led to huge problems for people in need and forced them to use other NHS resources. In Wales,Northern Ireland and some parts of Scotland, emergency face-to-facecare could be provided, which provided an escape valve for the population, even though they still relied on UDCs. This took place while dentists were desperate to return to work but were only able to redirect their patients to UDCs (in the most urgent cases). These were however insufficient in capacity and many lacked appropriate PPE.
• This failed to acknowledge dentistry as an essential healthcare service, with long experience in dealing with viruses and other diseases, also in addition to the critical role the private sector plays in providing half of the dental care in the UK.

• Now we are reopened for full face-to-face care and are working hard to reduce the backlog of patients, however, the hours that we can provide to treat NHS patients are limited by our NHS contracts, which pre-date the pandemic. This is challenging, as there are now several factors that restrict how many patients we can see for NHS treatments in a day due to the time they take. For example, we now need to triage all patients by telephone before an appointment and undertake additional infection control measures for each patient. We also have at least a 25-minute fallow period (the time gap between procedures designed to reduce the risk of viral transmission) between patient appointments. Until last month, this fallow period was 60 minutes which greatly reduced productivity. Since then we have been working through a series of requirements to reduce this. As a global provider, we operate dental clinics around the world, and in no other country is there a requirement for a fallow period. We have seen no cases of coronavirus infections in clinic in any of our practices.
• The recent reduction in the fallow period was very welcome but it took too long, and the rules have not been consistent across the UK or across NHS and private, despite being evidence based. The requirements needed significant investment by providers to implement, and did not consider the realities of supply of air purifiers and extractors, the comfort and needs of patients and staff or the ability of practices in leased, protected or difficult configurations to implement changes. This de facto limited capacity for patients, as it left us with the number of surgeries that are not able to be used for AGPs.
• These limiting factors mean we cannot provide as many face-to-face appointments as we used to, and it takes longer to treat the same the number of patients. Patients are therefore finding it more difficult to access routine appointments. The NHS recognises this, and in England, set a 20% minimum activity level up to 1 October. We are still waiting for confirmation on expectations for this current period (October through March when the NHS contract ends). We have received confirmation through to December in Wales and Northern Ireland, and February in Scotland. There is however currently no additional funding provision to support extended NHS working hours.
• We are trying to manage patient expectations and have provided our patient facing staff with tools to help them communicate the reasons for the difficulties in booking appointments. We would like to work with NHS local area teams to jointly communicate the difficulties to patients, as current NHS comms are very generic and don’t truly explain how limited capacity is at present. We are also trying to work with Local Dental Committees and Local Dental Networks, but this can be challenging, as support is inconsistent across nations and even areas within one nation.
• The cost of PPE has also been challenging for the dental industry. In line with this COVID-19 infection control guidelines, we put extra patient safety measures in place including the use of additional PPE to minimise the risk of cross contamination during treatment, especially when undertaking procedures that generate aerosols. We also introduced deep cleans and fallow periods between patients. While our clinical teams have always worn PPE the increased level of PPE and global demand for this equipment, meant that supplier costs increased significantly - around 100 times higher than usual. We had to introduce a safety tariff for each private appointment in order to ensure our practices could remain viable. We are constantly looking for ways to reduce this, such as introducing reusable stealth masks.
• Another challenge with PPE is the requirement to use FFP3 masks, which are expensive and were, at first, hard to source. We were also required to fit-test them for all of our staff. Nowhere else in the world, except Republic of Ireland, has required fit-testing of these masks. This has been a long and expensive process, as masks have varying levels of fit. While most of our workforce are women, masks made for industrial purposes are difficult to fit on smaller face. These masks are also not interchangeable, so if supply is interrupted and we are not able to source the exact same mask, then any replacements need to be retested. Again, we have seen no incidences of cross infections in clinic in any country that we operate, so we believe this requirement has not only been disproportionate in terms of its efficacy but has also led to huge cost and loss of productivity.

Challenges with government communications and financial arrangements

• More broadly, we have faced several challenges throughout this process, largely driven by poor communication and coordination across government.
• This poor response has been driven by a failure to recognise that dentistry is a critical health service. Emergency face-to-face care should never have been stopped in England. While there are risks inherent to the profession, these should have been mitigated in order to service patient need. Many patients resorted to self-treatment or visiting A&E/their GP, which could have been avoided.
• While Urgent Dental Care Hubs were established, these weren’t enough to manage patient need and were slow to establish. There was also a lack of coordination from LATs and PHE in responses to issues such as indemnity of staff from other practices, a lack of clarity as to how they would be remunerated, and delays accessing PPE required to operate. This lack of clarity around remuneration led to delays in opening more UDCs and in some cases prevented them from opening entirely.
• The response for dentistry from government bodies has been slow and poorly co-ordinated across the four UK nations. This lack of clarity for providers on clinical matters and differences between regions in the application of national guidance, has led to confusion and stress for frontline staff.
• Specific advice for the dental industry felt like an afterthought, particularly around PPE.  The PPE portal for providers has only become available relatively recently.
• A lack of clarity on financial arrangements in England for months. To date, we still do not have clarity on financial arrangements for Q3 and Q4 of the NHS year, and we are well into Q3. Private practices were closed with no form of government support and no road map for a return to practice, leaving many dentists, therapists and hygienists, with absolutely no income. Most were above the threshold for the self-employed support scheme, something the industry highlighted time and time again to no avail. These practices make up 50% of the UK dental market and broaden access to NHS treatment for patients and should be given better support. There was also a lack of clarity as to what rules applied and when to private and NHS practices, and ignored the reality that most practices are mixed private/NHS.
• We believe that government could have improved this response by setting up a Dental Task Force to engage key stakeholders across all UK nations, and also taskforces within nations to address nation-specific issues such as funding. This would have facilitated agreeing a practical and coordinated way forward in a timely manner.
• In terms of broader reforms that would have improved this response, greater alignment across Local Authority Teams on matters of clinical policy and finance would go a long way to ensuring clarity for providers and more efficient ways of working. Where regional bodies, whether that is between the UK nations or local bodies in each country, take different approaches this increases confusion and hinders providers’ ability to respond quickly to changes.
• In addition, the approach taken in the UK has been far stricter than in other countries. For example, in reference to the attached document, there is no fallow period in other countries, including ROI, no need for ventilation/ air changes, no need for fit testing. There has been no contagion between patient/ dentist/ staff in surgery anywhere documented.
• Dental workers were not considered essential staff from the outset, and we have only very recently received confirmation from the CDO in England that they are considered such. This affected their morale and safety when they are providing a key service for the population. While we now have confirmation that they are, this would have been well received if it had been confirmed far earlier.

 What went well?

• Dental providers stepped up to provide triage services and there was a willingness from dental teams to volunteer to support UDCs and wider NHS redeployment. We also saw that the different NHS bodies recognised the need to support the dental business, taking efforts to adapt payment methods to reflect the new limitations being imposed on providers. In addition, we have welcomed the support and advice provided by local PHE public health teams when we have contacted them in relation to specific cases. Overall, we appreciate that the response was led by the need to protect the health and safety of both patients and clinicians.
• There was also a willingness from NHS bodies such as PHE to support the dental industry and work in collaboration with providers to ensure compliance with new requirements. Support from local PHE teams was robust and we received sensible advice that was practical and tailored to our business needs.
• We welcomed the Chief Dental Officers’ decision not to close dentistry for face-to-face care during the second national lockdown. The ability to continue seeing patients has been invaluable to those in need of our care. It should be noted however that Scotland have bucked this trend, and has now decided to close private dentistry in Tier 4 areas, again leaving those patients without access. 

Nov 2020