The opening of all the Urgent Dental Care Hubs (UDCHs) across the SE Region is now complete. The management of these UDCHs has progressed to the point of having the NHS England South Region Standard Operating Procedure (SOP) signed off and published (website). The SOP Version 7.1 is a living document which will be reviewed bi-monthly until July 2020.The associated sub groups have merged and continue to feed into the main urgent care working group. The three GDS and six CDS sites in our area are all working well in H&IOW. However, the future sustainability of some PPE is still concerning and especially gowns. A Webinar on PPE is being considered by the Urgent Dental Care Working Group.
There is a total of thirty-nine sites (one extra Hub in Buckinghamshire) across the SE region with 9 sites in H&IOW:
Gosport, War Memorial/CDS LIVE
RSH, Southampton/CDS LIVE
Somerstown/CDS Portsmouth – LIVE
Basingstoke/CDS Brambly’s Grange – LIVE (Hot)
Winchester/ GDS LIVE
Fareham/ GDS LIVE
The CDS is prioritizing the shielded and the vulnerable (increased risk) cohort of patients (Population Groups levels 2 and 3)
Group 2 Shielded
Group 3 Vulnerable/Increased risk
GDS is treating population groups 1 and 4.
Group 1- Patients who are possible or confirmed COVID-19 patients – including patients with symptoms or those living in their household. However, identified COVID19 positive patients will be referred to a ‘hot’ site.
Group 4- Patients that do not fit any of the other categories
The main problem has been access to FFP3 Respirators’ Fit Test Kits and the fact that the masks (there are several variations of the FFP3s) will only fit, at best, around 80% of clinical staff some of whom will have potential co-morbities and/or will have vulnerable family members which will eliminate them from front line services. We are also aware that some FFP3 masks are not water repellant and these must be used with a full protective face shield and/or goggles. Likewise, any non-liquid repellant gowns should be supported with an appropriate protective apron. The LDC has access to four dental professionals qualified to perform the Fit Test and three test kits. Currently the fitting cost is £40 per person and this includes any re-fitting procedures. We are very grateful for their offers to help all dentists in the SE and we are also very grateful to the many others from outside of general dental practice that have worked so hard to help fit test our identified dental workforce in the Hubs.
The LDC has been assured that the necessary PPE is in place for the UDCH in GDS practices. PHE made the initial drop to the Hubs. All sites processes may be regarded as ‘hot’ inasmuch that the same PPE regimen will be at the required operative sensitive, standard, to take account of asymptomatic COVID patients. However, the most recent national guidance states that non-AGPs do not require full PPE including FFP3 respirators and that a FRSM is satisfactory. Practices are urged to consider the GDC’s and any other national guidelines (FGDP, BAOMS) that may influence a mandatory risk assessment carried out before treating any patient. A cough is potentially an aerosol generating event and the latest national resuscitation council guidelines state that chest compressions may only be carried out with an FFP3 mask as an operative mandatory PPE requirement. PHE guidance for doctors and dentists is a minimum not a maximum. In addition, social isolation, ventilation and cleaning are all important components. It is important to recognize that FFP2 masks should also be fitted correctly and further PPE consideration given to the fluid resistant surgical mask element where FFP2 masks are not fluid repellant.
Universal testing is going to be very helpful and especially for front line dental teams. In the UDCHs, aerosol generating procedures (AGPs) should be avoided where possible and appointments will need to run hourly to give down time for appropriate 30-minute air clearance and 30-minute surgery wipe down procedures. A four-surgery practice might be able to see up to 18 patients per day. The LDC has been looking at the Radic8 air purification system and the iQair air evacuation system. However, the BDA’s GDPC does not look favourably on these systems as being effective and remain unconvinced as to their value – Caveat emptor was quoted. The LDC Secretary feels that this may well be the future and that negative pressure ventilation systems may become essential so that surgery turn-round time can be reduced.
Several weeks ago,a Standard Operating Procedures (SOP) meeting of the regional steering group agreed that Oral Surgeons would be best placed to undergo surgical procedures efficiently including extractions and there was a general consensus that our oral surgery colleagues should be attached to each of the UDCHs. However, there were some practical obstacles to this preferred option which included the requirement for inclusion on the National Performers List and the transfer of necessary equipment – it is recommended that contaminated PPE is placed in a pillow case that is then inserted into a plastic bag. Oral surgeons would be better placed to work in a more familiar Hospital setting. We are aware of some dentists that are on both the performers list and the GDC’s Oral Surgery Specialist List and we welcome their offers of support.
The LDC understands that as a matter of course all the MCN Chairs will be consulted by commissioners/LDNs on whatever arrangements are proposed in the future when the fine detail is finally agreed.
A raft of Dear Colleague letters are being circulated to all NHS dental practices within the NHSE&I SE region to identify the available workforce and to address other matters including a mandatory requirement to evidence the triage activity in all practices where there is an NHS contract. The LDC launched a PPE survey on the 29th March and it has received a very good response. We are very grateful to those practices that have offered up their surplus PPE.
There will be other UDCHs identified in general dental practices over the coming weeks/months but these are likely to be in small numbers and they will need to conform to the NHSE&I SE Region’s published SOP document.
The remote triage will continue in general dental practices under their NHS contracts using the 3As and onward referrals are now actioned through a DERS urgent care pathway, therefore, triage will be a three-stage affair.
NHSE&I South East Region, recently (21.04.20) generated a Dear Colleague letter to update all dental practices on the new referral pathway that is DERS based. In addition to the referral pathway it is now possible to email a prescription to the patient’s choice of pharmacy. The letter contains detailed instructions.
The appropriate PCR will be collected at the UDCHs. The signing of PR forms and Medical Histories has been waived and tablets will not be used. The LDC has tried to contact the LPC but without success.
The LDC recognises that GDS practices and the CDS clinics are running the UDCHs for the first few weeks so many of the SOP details will have less impact on service delivery such as induction, familiarization with the practice software systems etc.
We have an escalating urgent and non-urgent care access problem with some patients needing care that can no longer wait and the LDC is continuing to field many calls from NHS and private providers for advice in this regard. Additionally, patients are contacting the LDC through Facebook and via the website. Many practitioners are keen to start seeing non-AGP patients but CQC and the indemnity organisations continue to have a cautionary view on this and the CDO has stated that urgent care sites must be approved in line with the national SOP or its regional/local SOP that are based on the CDO’s national SOP.
In this regard, the LDC is gravely concerned for the wellbeing of practitioners, staff and patients and the risk of inadvertently spreading COVID-19. BDA members can access the BDA’s excellent risk assessment advice to help with their compliance with the GDC’s guidance.
The CDO stated in her most recent Webinar that AGPs should only be performed in the designated locations with appropriate PPE and the LDC’s interpretation of her advice is that no practice should be providing face to face treatment unless they are an authorized UDCH.
AQP IMOS contractors are now funded based on their past 3 years activity and they will be most welcome to provide additional help to support the UDCHs.
Dental business continuity is of paramount importance so that we can pick up the pieces in an unknown future state. Clearly, private practices must be protected due to the lack of capacity within the current NHS Dental services. This was not fully addressed in the CDO’s most recent Webinar as being outside the remit of NHSE&I. BDA is making strenuous efforts to support private dentists through its private dentistry sub group Chaired by Shawn Charlwood and we are aware of the new British Association of Private Dentists BAPD who now have 7,500 members and who are looking at Articles of Association. Currently membership is free and open to all private practitioners irrespective of whether or not they are 100% private or in a mixed practice. The LDC has been in receipt of numerous challenging messages from private practitioners and we have offered our empathetic support.
The LDC has been in contact with SCAS/111 and it seems that some practices are inappropriately sending patients directly to A&E or through 111 during contracted hours and the LDC does not support their actions unless there is a true emergency situation which should be around 1% of their patients seeking urgent care. This is an ongoing problem exacerbated by poor signposting for patients and poor lines of communication from some NHS practices.
We are also aware that some practices are not offering advice and support during their contracted hours. A NHS survey has already taken place and it is likely that in some circumstances NHSE&I will consider options such as remedial breach notices and abated funding measures.
The NHS has produced the redeployment guidance/arrangements for dental professionals and their staff that includes the urgent dental care provision sites and within the wider NHS. This guidance has been circulated. This continues to be pitched at a voluntary engagement level. However, discussions are now being held to evaluate the possible future impact on contractual payments where staff refuse to engage in the process.
The 2019/20 year-end will be set at the 29th February. Therefore, this will represent an 11 month year plus either March 19 or March 20 and where practices activity was greater in March 2020 compared to March 2019 the former will be favourably considered by NHSE&I to avoid unnecessary contractual performance hardship. This was picked up in the most recent CDO’s webinar 24.04.20 by Matt Neligan.
However, we are very concerned that NHSE &I have yet to announce how activity under the 20/21 contract year will be assessed and GDPC/BDA are pressing for an answer from Carol Reece and Matt Neligan and we are aware that this decision will be taken at the highest level (Health Minister Jo Churchill). It had been suggested until recently, that a likely formula would be 100% contract value for 75% (depending on the period of ‘lockdown’) of the activity but this is by no means sure. It will be impossible to even achieve 75% of the activity if the SOP is introduced to all dental surgeries and where there will be a paradigm shift in the way that all dental practices operate.
There has been refreshed and more equitable guidance on the interpretation of the Treasury rules on Furlough Payments that take into account the proportion of private/NHS service commitment and this has already been circulated.
The Office of the CDO released its 4th version of their Letter of Preparedness which did not reassure dentists in the current COVID-19 crisis and there is now further confusion surrounding the PPE policies that affect general dental practice. The LDC’s main concern is that the PPE guidance has been tailored to the shortage of PPE. The LDC does not consider that an FFP2 mask gives sufficient protection when carrying out face to face dental treatment but clearly, we are managed by national guidance. Dentistry is the second highest medical treatment risk with aerosols generated by coughs and sneezes irrespective of any other AGPs via dental AGP generating equipment.
The LDC will endeavor to keep GDPs and their teams up to date as a matter of course.
Keith Percival BDS MGDS RCS FFGDP(UK)