Dentistry amid the COVID-19 crisis

27 Mar 2020

In the midst of a healthcare crisis, there has been a flurry of activity and publications aimed at the dental profession which has continued to update with the changing landscape.  Although likely to become outdated in the coming weeks possibly even days, the below provides a consolidated overview of the current guidance and advice for dental practitioners from the GDC, the four Chief Dental Officers of the devolved NHS and the BDA.

The General Dental Council

The current approach of the GDC is based on two core principles: 

  1. Minimising the burden of time and attention imposed on registrants. 
  2. Maximizing the flexibility of registrants to manage their professional activities in response to the challenges of COVID-19.

Business Continuity - The GDC recognise that whilst efforts may be focused on how best to deal with the changing requirements there is still a role for regulation. The GDC does not expect any dental professional to be providing treatment unless they consider it safe for both patients and the dental team. Treatment is now limited to  urgent treatment. This will surely pose questions for practitioners about how best to offer services to such patients.

CPD - For those concerned about the cancellations of face to face CPD courses, practitioners should consider other activities such as web based learning. To further reassure, the GDC highlight that it is perfectly acceptable for practitioners to submit a return of zero hours if 10 or more hours were recorded in the previous year. They state that they will look sympathetically at the circumstances of those who may be left with a shortfall for the declaration they are due to make this year and that nobody will be removed from the register due to a lack of access to CPD during this period.

Returning to the Register – It’s hard to ignore the calls and appeal to recently retired doctors, nurses and other healthcare professionals to return to practice over the next coming months. Many will have seen the news that the GMC have reinstated registration at a time of emergency. The NMC and HCPC are to be given the same powers in the Coronavirus Bill. The GDC does not have these powers and they are not proposed in the bill but the GDC are in discussions with the Department of Health and Social Care about emergency provision, and as the GDC explain it  ”possible that that might change for the future, but that’s in their gift, not ours”.

Although Retired Dental practitioners can still offer their services by applying for individual restoration to the register through the usual route, in light of NHS England’s direction to restrict services, below, it may be sensible to await further developments  and updated guidance as to how the government will react to the impact of the crisis on dental practices, dental staff and dental contracts in the medium to long term.

Fitness to Practise - For many who are the subject of ongoing fitness to practise investigations, concerns, or hearings, this will inevitably be an incredibly stressful period. An already difficult time will not be assisted by delays in case management and the unknowns that this situation will present in the coming months. Currently the majority of  fitness to practise hearings listed up until the end of June have been postponed, with no indication about relisting dates yet. Hearings listed from July 2020 may be reviewed in this period of uncertainty.

There are still some hearings that will be conducted, especially urgent interim order hearings that deal with matters presenting a perceived risk to patient safety. These hearings will be conducted remotely where possible, using telephone or video conferencing facilities.  Practitioners and legal teams are being notified and instructions as to participation being given on a case by case basis.

Interestingly, because the case examiners would currently be listing hearings to take place 9 months from now the GDC has encouraged the scheduling of new referrals to continue as usual to be listed for the 9 month mark and onwards. This doesn’t provide any indication as to when the hearings currently postponed will be able to take place. The GDC will be looking at how best to list the postponed hearings once they are confident that they will be able to be held in a safe manner.

The GDC is still under a legal duty to investigate concerns, and with the majority of employees now working from home, it is likely that the investigation stage of cases that do not require attendance at hearings will continue in some form. The intricacies of cases, and difficulties in meeting specific conditions that are hampered by the new situation will hopefully be considered fairly in light of social distancing and closed practices. That said, practitioners under conditional registration should adhere to all of their conditions as far as possible, and look to conducting video or telephone meetings in replacement of any face to face requirements, such a mentoring sessions or supervision meetings. Practitioners would be wise to keep a log of interactions had over these coming months to demonstrate efforts made to adhere to conditions in this difficult time.

Latest GDC news updates can be found here.

NHS England

The CDO for Wales reacted to the situation much faster than the rest of the UK. On 13 March Welsh Government stated that practices will be supported and continue to receive practice monthly income. For Welsh practitioners it was confirmed early on that monitoring of UDA targets will be relaxed or suspended.

The BDA recognises that the rest of the UK did not enjoy the same level of support quite so fast.  The NHS is taking immediate steps to revise the 2020-21 contract to reflect the disruption. Contract delivery will be considered from March 2019-February 2020, and March 2019 data will apply instead of March 2020. Contracts delivering above 96% will operate as normal. For those below 96% the normal claw position is entered up to 100% of the contract value.

Steps are also being taken to minimise disruption with cashflow and business stability and payment will continue to be made monthly equal to 1/12th of their current contract value.

 The most recent NHS England guidance, dated 25 March,  follows the latest government announcement on stricter social distancing requirements. As of 25 March 2020, the NHS impose immediate changes to the delivery of dental care, key features of which are outlined below.

  1. All routine, non-urgent dental care including orthodontics should be stopped and deferred until advised otherwise.
  2. All practices should establish a remote urgent care service, providing telephone triage for their patients with urgent needs during usual working hours, and whenever possible treating with:
    1. advice
    2. analgesia
    3. antimicrobial means where appropriate

If the patient’s condition cannot be managed by these means, then they will need to be referred to the appropriate part of their Local Urgent Dental Care system.

  1. All community outreach activities such as oral health improvement programmes and dental surveys should be stopped until advised otherwise.
  2. Dental practices should provide accurate information to the public, updating messaging and websites in line with practice changes.

The NHS are also encouraging dental professionals that are healthy and isolation-free to assist with the following:

  • urgent dental care services being set up in the NHS regions
  • NHS colleagues working in wider primary care
  • NHS colleagues working in the acute COVID-19 response
  • Local authority and voluntary services COVID-19 response.

The NHS also calls for  the rapid coordination of urgent dental care systems to care for emergency cases, including patients with possible or confirmed COVID-19 symptoms, and their families, vulnerable and at risk patients. The sites should allow for separation of treatment for those differing categories and will be arranged on a local basis depending on facilities available.

The full publication can be found here.

The British Dental Association

As of 24 March advice to dental practices was that, subject to risk assessments being undertaken and clinical judgement applied, regular care could continue, despite stringent restrictions on the movements of the public  having come into force on Monday 23 March. BDA Chair, Mick Armstrong, has recognised that “we are now at a point where it is nigh on impossible to provide routine treatment in dental practices.” There has a been some disquiet about the support offered to the dental community, and he continued that "dentists are being treated with indifference by NHS England and in the absence of official guidance many surgeries across England have followed their colleagues in other parts of the UK in shutting down or moving to deal with emergencies only”. The most recent publication by NHS on 25 March addresses some of these concerns and appears to provide some clarity.

The BDA are looking to press the Government to allow dentistry to be included in the emergency legislation. In response to the crisis the BDA has urged dentists to be prepared to work in other ways to support local efforts. Understandably, emergency and urgent dental care centres will still need to be staffed, and dentists are urged to consider what transferrable skills they could use to support the ongoing NHS effort in the upcoming weeks and months. In particular, whilst clinical skills may be wholly different, dental practitioners should be well-versed in the use of sterilisation, and cleaning required. Dentists could also utilise their skills in taking medical histories. The extent of how and what duties may be called upon by dentists is not clear at this stage, and practitioners are being urged to use their knowledge and their professional judgement going forwards.

BDA has today recognised the confusion as to advice on PPE, and when higher end PPE should be used. Clarification is being sought on this and live updates as to the BDA’s commentary on the crisis can be found here.

The BDA have also clarified that there is no need for dentists to notify the CQC of the changes in practice arrangements due to the pandemic.

Conclusion

In unprecedented times the need for healthcare professionals to apply clinical judgement is key. For some, this judgement may incur a risk if choosing to assist in providing urgent treatment. For others this judgement may require them to isolate.

Dentists should still be mindful, that in weeks and months to come, actions now may impact future practice. Practitioners will benefit from taking action in whatever manner possible, whether this be volunteering, undertaking electronic learning, or adhering to conditions electronically.

If practicing over the next few weeks or months then ensuring you apply clinical judgement to each request for treatment and document the same and having the most appropriate PPE for you, and your staff will provide the best personal protections over the coming weeks Ensure efforts and actions are documented to evidence activity and adaptability in the crisis.

Changes to Guidance and recommendations will inevitably be made as the crisis continues and we will endeavour to provide updates as that happens.

Helpful information for dental practitioners is now also available here.

Authored by Holly Paterson, Solicitor, BLM
holly.paterson@blmlaw.com 

 

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Disclaimer: This document does not present a complete or comprehensive statement of the law, nor does it constitute legal advice. It is intended only to highlight issues that may be of interest to customers of BLM. Specialist legal advice should always be sought in any particular case.

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