Lockdown left patients and dentists to suffer
Lockdown has had a significant effect on dentistry, not just for patients but also on dentists and their staff.
Dentistry is devolved to the four nations of the UK, so the systems are different in each country.
England and Wales use a system based on ‘units of dental activity’ (UDAs). Each course of treatment falls into one of three bands. The patient charges and payment to the dentist are in accordance with each band.
Scotland and Northern Ireland use a system based on approximately 400 different items of service, so each treatment, such as a filling or extraction, attracts a specific patient charge and payment to the dentist.
This essay will focus on England as this is the largest system, but specific differences within the devolved nations will be highlighted.
Most dental practices operate a mixed model in which they are partly NHS and partly private. It is effectively impossible to run an exclusively NHS practice, as popular treatments such as tooth whitening, cosmetic treatments and implants are not available on the NHS. Practices differ in how much private work they perform as part of their total, ranging from fully private with no NHS contract to 90 per cent NHS and 10 per cent private.
Lockdown begins
On 25 March 2020, all dental practices were told to close their doors and not treat any patients face to face. Patients who needed to see a dentist face-to-face should be referred to an Urgent Dental Centre (UDC). These were going to be set up around the country.
Problems arose in most areas as UDCs were not set up, or if they were, they did not have sufficient personal protective equipment (PPE) like gowns and masks. In fact, four weeks after practices closed down, there were still a third of UDCs not operating and over half reported shortages of PPE that affected the operational status of their practice. The result of this was that because dentists were only allowed to advise and prescribe antibiotics and painkillers if needed, patients that required urgent clinical procedures were left in limbo.
Many patients are choosing to postpone normal dental visits until the risk of infection is reduced.
This became a source of considerable distress for dental practices as their patients would call repeatedly, often in great pain, and there was no route for the staff to relieve the suffering of their patients. It caused resentment and frustration for all concerned.
Practices were allowed to reopen on 8 June 2020 as part of the dental transition to recovery. Initially this was to handle emergencies only, but with a plan to move gradually towards seeing non-urgent cases as well.
Dental practices have stayed open since then, seeing patients both for urgent and non-urgent treatments. However, severe problems for both patients and dental practices remain.
Fallow time
When a high-speed drill is used in a dental surgery, aerosols are produced and, as these aerosols might be contaminated with saliva from the patient’s mouth, there is an increased risk of infection for anybody in the room. As these droplets stay in the air for an extended period of time it means that a surgery will have to be left ‘fallow’. Nobody is allowed in the room for a period after the procedure. For most surgeries without a window it means that the room has to be left empty for up to 30 minutes after the treatment. (Initially after reopening, the fallow period was 60 minutes.)
The consequence is that the planning of appointments and staffing has become much more difficult and that clinical time and therefore overall capacity of the practice has reduced significantly. From personal experience in our NHS practice, we have had to stop taking on new patients for the first time in over 20 years.
Financial impact
NHS practices have been paid their full contract value, minus an abatement of up to 16.75 per cent, for the whole period, including when practices were closed. Dentists and staff were asked to volunteer to help in other areas of the NHS, like hospitals or Test and Trace, and many did so.
Practices who were providing mainly NHS treatment to their patients were largely able to manage their finances. However, there were serious financial consequences for fully private practices and mixed practices with a large private element, most notably from 25 March to 8 June, when they had to close their doors entirely.
Approximately three-quarters of dentists were unable to receive any support from the government. This compares to industries like hairdressing, which received support from the government, both to individuals and through the business rates holiday.
Targets
In England, NHS practices were expected to complete 100 per cent of their pre-Covid UDA target every year, but this was not applied for the two and a half months where practices were closed. After 8 June, a target of minimum 20 per cent of UDA target was applied, the reduction being due to the increased time it took to see and treat patients and the reduced number of patients visiting the dentist for regular check-ups.
After 1 January 2021, the target was raised to a minimum 45 per cent of UDA target and from 1 April 2021 the target was raised again to a minimum 60 per cent of UDA target. If practices fail to reach these targets, they will have to pay back part of their contract value, which could force them out of business.
The problem with this system is that practices vary hugely in how easy it is for them to reach these targets under the Covid regime. Many practices are converted residential buildings and have little natural ventilation. Very few practices have spare surgeries to cope with fallow time. Clearly, a purpose-built surgery with numerous dental chairs has a considerable advantage.
It also does not allow for the reality that many patients are choosing to postpone their normal dental visits until the risk of infection is abated. Sadly, many practices are likely to face large clawbacks of money at the end of the year through no fault of their own.
To be fair to NHS England, their determination to apply targets has occurred due to a small number of dentists gaming the system, meaning that these few dentists have refused patients NHS treatment and asked patients to pay privately instead, rather than exceed their minimum targets. Management and punishment of these unrepresentative members of my profession would be a preferable solution to the sweeping one imposed on the whole profession.
This combined with a huge reduction in capacity in all practices has meant that seven out of 10 patients have major problems finding access to dental care.
These targets apply to England; in the other nations, there are no, or much lower targets for dentists to achieve.
Mental health
Dentistry is well known to be a very stressful profession but during the period that all practices were closed, it was found that dentists were less stressed than before the pandemic. The study suggests that this is due to less fear of litigation and complaints, more time to spend with family and a general feeling of being off the ‘treadmill’.
The data shows that practice owners were the most stressed, presumably due to worries about the financial viability of their business. Even though we have no data from after practices reopened, I would anticipate that after targets were reintroduced and then increased, and the threat of clawback of money for NHS work became more likely, then stress levels in the profession would probably be increased to more than pre-pandemic levels.
Positive effects
The fact that NHS practitioners and their staff have been able to see fewer patients due to lower targets and the need for fallow time between patients has meant that the working day has become less stressful.
Dentistry has also become more visible in the public eye, media interest has gone up and the need for a new NHS dental contract has moved up the agenda for both politicians and civil servants.
Negative effects
Since March 2020, there has been a substantial reduction in recall appointments for patients, which means that severe conditions like mouth cancer will have gone undiagnosed or will be diagnosed later.
Practices have suffered financially due to a non-existent or reduced income from private treatments. I have friends who were forced to sell their practice at a considerably reduced price, due to limited financial support and an absence of clear communication from government. They retired earlier than they would otherwise have done, and anecdotally this has happened all over the country.
Severe conditions like mouth cancer will have gone undiagnosed.
Communication from NHS England and the Department of Health and Social Care has often been late, lacking or incorrect. When practices reopened in June 2020, the information to patients indicated that the service was back to normal, which frustrated patients as this was far from the truth. Additionally, in March this year, practices were given only three days’ notice before their targets for the year were changed by NHS England. Practices around the country had to change their working patterns, staff contracts and plans for the year ahead within three days. And any failure in these areas would fall squarely at the feet of the practice owners and their professional staff.
During the time practices were closed, Local Dental Committees (LDCs) assisted the NHS by organising dentists, in rented vans, to collect PPE from practices which had no need of it during the closure. LDCs then redistributed the PPE to where it was needed, such as prisons and pharmacies. When practices reopened and needed supplies of PPE again, this was not forthcoming. This left many practices feeling abandoned by the NHS.
The future
Unless requirements for fallow time and PPE are abandoned, the future dental service will be considerably more expensive, and this will apply to both NHS and private treatments. If dentists are only able to achieve targets of two thirds (66 per cent) of previous output, then one additional dentist will be needed to help cover the work of every two dentists, meaning the whole service will be 50 per cent more expensive, a cost that will fall partly on the government and partly on patients due to NHS patient charges and private treatment fees.
The tradition of seeing patients every 15 minutes on the NHS has been under pressure for a while, especially from younger practitioners who prefer less stress and a different work/life balance. The slower pace due to fallow time will probably have encouraged this desire for change. Anecdotally, we hear that older practitioners are considering retiring earlier than planned due to the increased PPE and restrictions on their working methods.
This will all mean that many more dentists will be needed to meet demand in the near future. Since it takes at least six years to train a dentist, it is probable that we will have a severe shortage of practitioners in the near future.
We have also seen a general disillusionment with the NHS amongst dentists. Anecdotally this has become more prevalent during lockdown, which would mean that in a time of workforce shortage, the NHS dental service will come under even more pressure.
What is needed for the NHS is a completely new dental contract. This is accepted by all the stakeholders: civil servants, politicians and dentists. In fact, a new contract has been piloted for over 10 years, but so far the political will has not been there to change it.
There are now signs that the political will might be there, but for us to get an NHS dental service fit for the twenty-first century takes political courage and funding.
It is badly needed for both patients and the dental workforce and I hope that this might be the one positive aspect that comes out of this pandemic.
Henrik Overgaard-Nielsen
NHS dentist
Henrik Overgaard-Nielsen is an NHS dentist in London and was Chairman of the General Dentist Practice Committee of the British Dental Association representing over 30,000 dentists in the UK as a senior trade union official. He held this post for four-and-a-half years until he was elected to the European Parliament in 2019. He is Danish, has worked against the European Union for over 40 years and was heavily involved in the 2 Danish referendums on the Maastricht Treaty in 1992 and 1993. Henrik has co-chaired a Eurosceptic political party in Denmark and his political home is left of centre.
Henrik was also the Chairman of the Federation of London Local Dental Committees for 10 years, a statutory body representing the majority of NHS dentists working in London. Henrik sat on the National Steering Committee at the Department of Health for many years.
Henrik lives in London with his family and various rescued pets.
Follow Henrik on Twitter: @brexithenrik
