Could COVID-19 kill NHS dentistry?

Julian English talks COVID-19 and the impact of new guidelines on dentistryJulian English discusses the potential impact of new COVID-19 guidelines as practices get ready to return to work.

You just know when something is rushed; and the announcement of the reopening of dental practices it seems has caught the Faculty mid-sentence. But they launched it anyway.

The publication of the FGDP(UK)’s Implications of COVID-19 for the safe management of general dental practice – a practical guide one week before the reopening of NHS England’s dental practices must on any account be considered a gamble.

Notwithstanding the mantra of always putting patients’ interests before bank overdrafts some of the guidelines may be impossible to meet. Don’t get me wrong, this document has the backing of the great and good organisations in UK dentistry – and some new ones too.

And someone needs to create guidelines that practices so desperately need to follow. But like leaving the middle seat empty on aircraft, the guidelines will have a catastrophic effect on the bottom line.

Admittedly, with the Faculty’s 29-member advisory team drawn from the dental political class (most of whom are salaried), the guidelines are not law. However, practitioners risk being asked for reasons by either the GDC, CQC or PHE if they do not follow them.

Ultimately health ministers decide priorities for the new normal and whether and in what form High Street dental practice survives. Advisers advise; governments decides.

Gaming is out

The guide will be a far greater shock to practice management than the 2006 NHS contract.

Gaming is out.

When practices open it will no longer be possible even for basic infection control – let alone for additional safeguards labelled ‘aspirational’. Because of the closed door policy, the pre-appointment preparation suggests that all patient information should be available online and contact should be made with patients prior to their appointment.

This is not just for new patients but for the beginning of each and every COT. Besides COVID screening, this would include medical history, FP17, estimates, consent and information on payment.

Video conferencing is suggested in spite of difficulties with language barriers, patients with additional needs and simply those who are without the technology. Front desk management of the appointment book will be a nightmare. Get additional reception staff now is the best advice.

Additionally the pre-treatment protocol is that the patient should be encouraged to attend alone and be taken directly into the surgery as quickly as possible following arrival without waiting in the reception area. The use of the toilet should be discouraged.

The real killer

Treatment using high-speed hand pieces as aerosol generating procedures require at least a FFP2, occasional FFP3, visor, and gown as seen on TV being used in COVID-19 hospital wards. How to reassure the under fives with staff wearing these space suits will be challenging. All fillings will be under rubber dam with high volume aspiration.

The real killer in the guidelines is a fallow time of 60 minutes for floor cleaning at the end of each session between patients and opening windows. Dental nurses may not take kindly to this additional duty. Again, it may be necessary to fully employ additional staff.

Additionally, no paper records should be left in the surgery. Clothing underneath gowns should be changed, taken home and washed daily.

There is also a recommendation of the ritual of meticulously trained in donning and doffing techniques.

This all by next week.

It is impossible to speculate how the Faculty’s 66-page document is driven by science or the need to reassure the both the Westminster village and the media. As with the opening of schools, the public will make up their own minds – thank goodness.

What is predictable is that even assuming regular patients return to dentistry like they have to parks and beaches, NHS dentistry will no longer be financially viable.

New ways of working the existing business model and the UDA system of remuneration will not sustain it. Many older practitioners even with a loyal patient base will bring forward their retirement.

Serve as a disrupter

The first to go will be the single-handed cottager. Some may be forced into a voluntary arrangement. This will fit in nicely with NHS England’s agenda of de-skilling. For associates there will be at best a cut in their percentages and under-employment.

We can expect that corporates will concentrate on the private market that allows the COVID costs to be recovered. The drift to the private sector will gather pace and support dental hygienists and de-skilled therapists.

The team concept, so beloved of academic elites, that employment of DCPs would allow performers to do more complex NHS work was always a sham. Under the UDA system extensive treatment plans for high need patients was something to be avoided.

Until the discovery of a vaccine, there cannot be any equity in the provision of dentistry. Like so much else in health and social care, the new guidelines will only serve as a disrupter.

On a positive note, Westminster and the organisations in dentistry now have a blueprint for how to conduct themselves from Monday 8 June – and we really need this.

On a realistic note, we always knew that a business using AGPs was bound to be subject to extreme conditions.

But we can open from Monday 8 June.

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