On 10 November 2020, Baroness Walmsley is scheduled to ask the Government what measures they are taking to ensure the continued provision of dental services during the Covid-19 pandemic. This article explores what happened to such services during the initial lockdown period, what challenges they have faced since resuming, and what plans the Government has for dentistry during England’s ‘November lockdown’.
What has happened to dental services during the pandemic?
On 23 March 2020, the Prime Minister, Boris Johnson, announced a national lockdown to combat the spread of coronavirus. As part of this, the Government suspended routine NHS dental treatment and restricted face-to-face urgent care. Instead, dentists offered urgent advice and remotely prescribed antibiotics as required. In addition, patients were able to receive care through urgent dental centres, with patients triaged into these through NHS 111 or by their own dentist.
However, this system did receive some criticism. For example, when BBC News reported in April that a man had removed his own tooth after NHS 111 refused to give him an urgent appointment, the British Dental Association said ‘DIY dentistry’ was “inevitable” given the “failure” to set up urgent care centres. Responding, NHS England said:
Having created the service from scratch in a few weeks, it might take a short time to make sure everything is running smoothly. We apologise if this means anybody is having problems getting the treatment they need in the meantime.
On 8 June 2020, all practices were able to resume routine care. NHS England and NHS Improvement released guidance that set out the personal protective equipment (PPE) and infection and prevention control (IPC) protocols practices must meet to resume care. It also provided guidance on which patients should be prioritised and said individual practices would need to risk manage progression to resumption of the full range of routine dental care. This meant aerosol-generating procedures (AGPs), such as those that include the use of a high-speed dental drill and can result in the release of airborne particles, could go ahead if practices met the necessary PPE and IPC requirements.
Commenting on the announcement that the Government would allow practices to reopen, the board chair of the British Dental Association said:
Last Thursday’s announcement came as a bolt from the blue for practices across England. In under a week practices can reopen. But from PPE to getting practices set up for social distancing, it has not given colleagues the time to plan and prepare. From lower patient volumes to higher costs we know practices will need support to survive the ‘new normal’.
On 31 October 2020, the Prime Minister, Boris Johnson, announced a second national lockdown in England starting on 5 November and lasting until 2 December. Despite initial uncertainty about whether dental services would be allowed to continue, on 2 November the Chief Dental Officer for England, Sara Hurley, confirmed that they would remain open. Reacting, the British Dental Association encouraged patients to seek treatment, but criticised the Government’s communication of the decision:
No health professional should have been left in the dark on whether they could open their doors on Thursday. That clear guidance wasn’t available at the outset, reflects the disconnect we’ve seen across government since the start of this pandemic.
What challenges have dental services faced since resuming?
Although practices were able to resume routine care in June, services are not yet operating at pre-pandemic levels. Highlighting this, the British Dental Association has said that practices “are continuing to operate at a fraction of their former capacity, owing to ongoing Covid restrictions”. It had previously warned that social distancing and cross-infection control could reduce capacity by as much as two-thirds.
Research published by the Faculty of Dental Surgery at the Royal College of Surgeons of England has supported this. A survey of 450 dentists by the faculty found that most members (93%) had been seeing ten patients or fewer per session since the resumption of services. This compared to 46% who saw more than 10 patients per session pre-pandemic. It also found that around a third (34%) of respondents did not know when they would fully resume services, with a further 36% saying they did not expect to resume full pre-pandemic services until 2021.
However, only 4% of respondents had not resumed any services since 8 June and nearly two-thirds (60%) had already begun routine procedures that involved AGPs. However, private practices were considerably more likely to have provided routine AGP procedures, with 83% having done so. In NHS hospital practice, this fell to 62%, with a further fall to 40% in NHS general practice.
In addition, the survey explored what barriers were preventing practices from resuming to pre-pandemic levels. It found that “significant numbers” of respondents had raised the issue of fallow time—the time a treatment room needs to be left empty—following AGPs as a barrier to resuming services. Respondents also raised social distancing as a barrier. It also found that although confidence in PPE supply was high, those in NHS hospital practice felt more secure compared to those in private practice or NHS general practice.
A selection of interviews with the UK’s dentists in July 2020 provided an idea of the issues faced by practices. For example, Marcus Clery, a dentist in Surrey, said that “the biggest challenge we’re facing right now is social distancing”. He also reported that “fallow time is resulting in significantly reduced throughput of patients” and that these issues were presenting significant financial pressures.
Dental practices have also raised financial concerns. Explaining this, the House of Commons Health and Social Care Committee said that practices are “unable to conduct the level of service that they had been able to provide prior to the pandemic but are still incurring substantial overhead costs and other expenses”. The British Dental Association has described the situation as “dire”, with private practices in particular “left with little or no income in this period [the lockdown], while a range of fixed business costs remain in place”.
In addition, a British Dental Association survey published in early June 2020 showed that based on expected patient numbers and estimated financial costs, only 8% of dental practices would be financially viable to open from 8 June 2020. Commenting, the chair of the association, Mick Armstrong said:
Where [dental practices] may have seen 15 patients a day, they will now see five. The only thing I can say is that they have the ability to pass on those increased costs to patients. Whether that makes dentistry unaffordable is an entirely separate matter.
What could be done to overcome these challenges?
Commenting on the situation in October 2020, the House of Commons Health and Social Care Committee said that it was concerned that “there does not appear to be a plan for the restoration of dental services in England”. It recommended that Chief Dental Officer for England Sara Hurley:
Sets out her assessment of the challenges facing dentistry services in England, and clarifies what steps will be taken to ensure dentistry services are able to continue to be restored to meet patient demand in the safest possible way whilst also remaining financially sustainable.
Following its survey, the Faculty of Dental Surgery at the Royal College of Surgeons of England also made recommendations. These included that:
- dental services are kept open throughout the remaining stages of the pandemic;
- adequate PPE is ensured across all regions and settings; and
- there is a focus on barriers to resumption, specifically fallow time.
NHS England has published a revised Standard Operating Procedure (SOP) for dentistry during the pandemic. This included guidance on fallow times and PPE in relation to AGPs.
What comments has the Government made?
In response to a written question in June 2020, the Minister for Prevention, Public Health and Primary Care, Jo Churchill, set out what the Government had done to support dental practices since they resumed routine care. She said that dentists received full NHS funding during the restart period, with no targets for numbers of treatments delivered or patients seen. She also said that as AGPs require full PPE, the Government is:
Working closely with industry, the NHS, social care providers and the army to ensure that personal protective equipment is delivered to those who need it. This includes supporting dental wholesalers to stock the equipment needed by general dental practice to safely support practices to restart face to face dental care.
Several months later in September 2020, another written question asked the Government for its assessment of the adequacy of dental practices since services resumed. Responding, Lord Bethell, the Minister for Innovation, said:
All practices were able to open for face to face care from 8 June. Dentists have been free to restart the full range of face to face dentistry as far as they believe they can safely deliver this following Public Health England guidance on infection protection control procedures and appropriate levels of personal protective equipment.
Cover image by Joseph Shohmelian on Pixabay.