HAMPSHIRE and IOW LDC: Secretary’s Update Version11
28th June 2020
COVID-19 overview: All the 9 UDCs continue to function well within the H&IOW area and the 3 UDCs in GDS are finding the return to clinical practice for their own patients to be problematic. The GDS UDCs were, very recently close to being overwhelmed and now the situation has become even less sustainable as they have lost most of the supporting dental team members who volunteered to help prior to the 8th June. Some of the referrals received by the UDCs are inappropriate such as the extraction of mobile teeth. There is a great misunderstanding and fear within many practices of the expected level of triage/urgent care that they should be providing where they are in a position to see patients face to face and are also in a position to provide non-AGP care. The commissioners are aware that NHS contracted dental practitioners need guidance, especially for those practices that are fearful that they will make mistakes. The existing UDCs have reduced the number of days worked and no longer work 7 days a week. Some UDCs are experiencing referrals where a full treatment plan is necessary, for example where the source of the pain has not been identified by the referrer. It has been pointed out that triage and diagnosis are not the same thing for patients where the Hub picks up the responsibility for the next treatment steps. Some Hubs in GDS will be stepping down over the coming months.
NHSE&NHSI SE Region have requested expressions of interest to become a new UDC from all dental practices throughout the region and to date they have received 41 positive responses (those that fit in with the necessary criteria) with 9 in the H&IOW area. All these interested practices are prepared to work just part time, generally one or two days a week and some are prepared to work up to 5 days a week.
Any new UDCs will not currently enjoy the financial incentives (MOU/PPE costs) that were established for their predecessors but may have access to the free PPE Local Resilience Forum if they cannot source their own PPE from their usual suppliers. On the face of it there seems to be little incentive to become a new UDC. The commissioners are aware of the financial implications for any new Hubs and they are looking at possible incentives such as sessional payments and help with any extra PPE costs. Many opened practices are not now reporting high numbers of patient throughput although some initially experienced high numbers of patients expecting to access normal dental care provision and appointments. Activity in the Hubs increased in the first week by 17% but dropped back by the same percentage the following week. Referral rejection rates in the GDS Hubs are at 29% and in the CDS at 17%. Across the region there are in the region of 1,800 referrals per week. The Hubs were seeing up to 120 referrals per week but clearly this capacity will be reduced and even with the new part time Hubs there will be a shortfall unless opening practices see more patients requiring non AGP treatment. A second spike of the pandemic will quickly overstretch UDC provision.
The CDS is very busy mainly treating patients 70+ years, pregnant and shielded patients. The CDS (SCS) is becoming concerned that there is a significant backlog of treatment need within their normal cohort of greater risk, vulnerable and shielded patients who may be suffering in silence (lack of advocacy). The provision of care under GA is severely compromised. Hospital patients who are about to commence chemotherapy or surgery are being prioritized. However, it is difficult to contact Hospital teams to facilitate comprehensive Multi-disciplinary integrated care. The CDS recognize that the UDCs may appropriately onward refer patients with special needs such as severely autistic patients and those that have communication difficulties. The normal referral DERS pathways are still functioning with continuing provision of surgical care in IMOS/CDS.
The continuing referral of non-regular attending patients from 111 is a major concern for many practices and especially on the IOW. As a principle, if 50% of the population regularly attends for dental care and the capacity is reduced to 33% it will be impossible to satisfy demand for regular treatment. Portsmouth, as always, is likely to be a very problematic area where demand will rapidly overwhelm the service provision of NHS dental care.
The UDCs do seem to have an advantage over other practices returning to clinical practice inasmuch that they are fully PPE and urgent care SOP trained and compliant with adequate PPE.
Initially, on the 8th June around 35% of practices reopened for face to face contact with patients and a further 16% later that week. The week commencing 15th June saw another 16% start to see face to face patients and the vast majority were up and running as of week beginning the 22nd June. According to the results from the recent survey completed by 76% of contractors, 55% of contracts will be fully up and running by August, with projected activity of 77% non-AGPs and 23% AGPs. However, some practices will not be ready before the end of August with only 1% still only prepared to deliver the 3As triage. Most practices have adopted a phased approach with face to face triage and some non-AGPs. A small number are currently carrying out NHS AGP treatment (15%) and it seems that most independent/private dental service providers are operational to a greater or lesser degree. The limiting factor is Fit Testing/PPE as reported by 91% of practices although 33% reported that they had enough PPE. Many practices are confused by the tsunami of guidance, advice, numerous SOPs and the constantly ‘shifting sands’ of Covid-19 based intelligence. The NHSE and NHSI SOP for UDC Hubs is at version 7.6 (LDC website) and is an excellent more in-depth iteration of the OCDO SOP. Level 2 PPE should not seriously impact on face to face triage and the provision of non AGP care. The CDO recently announced that further development of SOPs will be at a more local/regional level and not directed from the OCDO.
The commissioners have reported that some NHS patients are being charged £20 for a video consultation and that some practices are reserving PPE for their private patients and referring 111 directed patients to the UDCs. The commissioners have reported that they are receiving whistleblowing complaints from a small number of associate dentists where practices are inappropriately charging NHS patients for treatment and those that are not prepared to pay are referred to the UDCs.
Fit testing provision within the region is now moving at a more rapid pace and HEE have teamed up with NHSE &NHSI, LDNs and PHE and are seeking expressions of interest from individuals (not necessarily dentists) to volunteer to train as Fit Testers. Fit Testing training in Thames Valley and Hampshire will take place in Oxford, Winchester or Southampton. It is likely that the initial 2 days of training will take place on the 2nd and 16th July and this will be followed up with another six training days with a potential total of 80 trained testers. There is no charge for the training with all testing kit and materials supplied but successfully trained testers will need to commit to 5 days of testing at a regional centre before the end of August. It is expected that volunteers will continue to receive payment from their practices and may claim any excess mileage expenses. It is hoped to have a good geographical spread with 80 trained Fit Testers for the H&IOW region and 560 in SE England. The SE region has sourced 200 test kits but it is unsure how many of these will be allocated to Acute Trusts as a priority. In the SE region, there will be an initial testing requirement of at least 10,000 over an 8 to 10week period (70,000 nationally) and an ongoing need for testing for dentists not wearing positive pressure hoods such as the Perso1 and 3 or Jet Stream. Some testing has already been carried out throughout H&IOW (32% Fit tested, 22%partly Fit Tested and 46% no Fit Testing) and the LDC has purchased 4 Test Kits but still awaiting delivery (end of July). Fit Testing companies charge up to £400 per day for their services and we are of the opinion that, in future state, all practices or practice organization will need to have their own trained and certificated fit testers. The indemnity issues are partly resolved by the promise of protection under the Coronavirus Act and Crown Indemnity for HEE trained testers and we are aware that some of the main indemnity providers are also promising cover eg BDA for appropriately trained and certified individuals. However, these HEE trained testers will be awarded honorary contracts attached to a Trust which will require the usual pre-employment checks which will inevitably slow down the process as this will need to go through Capita.
The chronic shortage of PPE has eased somewhat but alarmingly the prices have, for some items, increased by over 1000%. We are aware that the prices of Air Purification units such as Radic8 have increased by £500 per unit. The LDC is concerned that there is a culture of profiteering by some wholesalers. The issue of Fogging systems used in Hospitals and also the use of air purification in surgeries treating AGPs lies outside the national guidance on fallow time and currently reducing the one hour fallow time is deemed to be non-compliant with PHE guidance.
Tim Hogan Chairman of the Kent LDC in collaboration with LDC members from Hampshire (Claudia Peace) and West Sussex have produced an excellent and comprehensive 11 page ‘easy read’ paper titled ‘Seeing Patients Again in Covid-19’, covering RPE, Hoods, UDCH experiences and PPE (LDC website).
The 7 LDCs across the SE Region (KSS, BOB, Hampshire & IOW) sent a joint letter of COVID-19 focused their concerns to the commissioners and received a fairly detailed response which noted the issues raised and more fully explained the commissioner’s current position.
Very recently, a baseline survey titled ‘transition towards dental service resumption’ was reissued after a 75% return. They have since stated that as this is an essential item of data within their report to Ministers that this is now a requirement. Failure to complete this survey will be followed up by the relevant contract managers. The LDCs recognize that this is an important survey that will help to identify service coverage, UDC demand and provide capacity management. It is now clear that non returning contractors may receive a remedial breach notice under the terms of the contract.
The H&IOW LDC continually receives messages from associate dentists who appear to have been poorly treated by a small number of contractors. For example, unilateral reduction in monthly payments to allow for an unknown abatement, laboratory expenses, historical clawback where the individual performer has not underperformed but the contract has may result in zero monthly payments, dismissal and other penalties. However, some providers have contacted the LDC to give an alternative perspective to some of these issues.
The NHSE &NHSI SE Regional team is developing new work-streams to deal with the return to clinical dental practice:
- Dental Services Restoration and Recovery Task and Finish Group
- Covid-19 Dental Services Steering Group
We are unsure as to the level of LDC representation on the Task and Finish Group but we are assured that there will be representation on the emerging Steering Group.