On 25th March, in response threat posed by COVID-19, the Chief Dental Officer for England announced that all routine, non-urgent dental care should be stopped and deferred until further notice. This caused significant concern within the profession and left many practitioners with serious financial concerns regarding their businesses.
On 28th May the CDO announced that dental practices could commence reopening from 8th June for face-to-face care. However it was made clear that in order to do so practices would need to be satisfied that they had in place the necessary personal protective equipment (PPE) and infection prevention and control measures (IPC).
NHS England subsequently released detailed guidance in the form of the ‘Dental Standard Operating Procedure - Transition to Recovery’ document. This sets out the requirements which practices will be required to adhere to as we see a resumption of routine dental services in the coming weeks and months. Practitioners need to ensure that they are familiar with the requirements outlined in this document. These requirements are rather onerous and will have costs implications for many practices. Furthermore, failing to comply with these requirements may have regulatory implications for practices and practitioners alike.
What practical steps do practices need to take in order to ensure compliance?
The Standard Operating Procedure sets out a number of key principles which are intended to govern the return to routine dental practice. It is made clear that NHSE envisage that this will be a phased return to normal operations. During the initial resumption phase, which we are in at present, the expectation is for practice-based urgent dental care. The SOP states that the subsequent pace of progression towards routine practice-based care will need to be risk-managed by individual practices.
As such, practices are directed to continue to offer remote consultations wherever this is possible. Patients who request urgent face-to-face care should be triaged remotely in order to determine the actual degree of urgency. Practices should offer any interim self-care advice if appropriate and only make appointments for face-to-face care if they are satisfied that this is clinically necessary.
Practices should also ensure that remote triaging is used to identify patients who have tested positive for COVID-19 or suspect cases, their household contacts, those who are shielding and other high-risk patients so that these risks can be appropriately managed. Patients who have tested positive or are suspected cases and their household contacts should be referred to Urgent Dental Care hubs so as to reduce the risk of transmission. Those who are shielding and/or at higher risk of complications should be treated separately from other patient groups.
Primary dental providers are permitted to carry out AGP (aerosol generating procedures) care, subject to the availability of appropriate PPE and robust IPC systems. AGP care was one of the principal risk areas within dental practice which prompted the restrictions which were imposed in March.
What are the detailed requirements set out in the Standard Operating Procedure?
The detailed requirements are set out in Appendix 1 to the SOP. This section of the document sets out the guidance issued by Public Health England for infection prevention and control and is essential reading for practitioners. Practices need to ensure strict compliance with these requirements. A number of the key requirements are summarised below for illustrative purposes:
As part of their risk assessment processes, practices are advised to carry out a walk-through of both patient and staff areas in order to identify any changes which may need to be made to practice layouts to support social distancing measures. Measures should be put in place in order to minimise the number of patients in the practice at any one time and where possible there should be single entrance and exit points for patients. Wherever possible procedures should be carried out with only the patient (and if necessary a carer/parent) those staff actually required to carry out and assist the procedure present in the room and the door shut.
Practices should implement measures to reduce interactions with reception staff. This will include the use of Perspex shields to create physical barriers for reception desks and the use of contactless payments wherever possible. Practices should also consider facilities to book appointments online or via email.
Waiting areas should be configured so as to allow for appropriate separation between patients. The SOP advises that unnecessary communal items such as newspapers, magazines and children’s toys are removed from waiting areas so as to reduce the risk of transmission. The SOP also suggests that all of the above measures are communicated to patients where it is possible to do so in order to manage their expectations.
Hand and respiratory hygiene
Practices should require patients to wash their hands or use and alcohol-based hand rub when entering and leaving the practice. Staff should be required to wash their hands immediately before treatment and immediately after any activity where there is a risk of contamination. For example putting on and removing PPE, the decontamination of equipment and the handling of waste.
Infection control precautions
All practices are required to follow standard infection control precautions. The SOP indicates that the guidance set out in HTM01-05 (Health Technical Memorandum on decontamination in primary care dental practices) and the NICE guidance on IPC should be followed by all staff when treating every patient. The SOP makes clear that it is vitally important that these principles are strictly adhered to at all times.
Aerosol-Generating Procedures (AGPs)
Given the risks associated with AGPs, the requirements are stringent. The SOP indicates that where possible AGPs should be avoided and should only be carried out where there is a clear clinical necessity. Where an AGP is required, the procedure should be completed in a single visit where possible.
There are strict PPE protocols for AGPs. These include disposable fluid repellent gowns, disposable gloves, eye/face protection and FFP3 respirator masks (FFP2 or N95 respirators are permitted where FFP3 are not available). Respirators should be worn by those undertaking the procedure and those assisting. Where a member of staff cannot wear a respirator mask, for example due to facial hair or religious headdress, they should use suitable alternative such as a surgical hood with face shield.
In addition to the strict PPE protocols, where an AGP has been carried out it is recommended that the room is left vacant before cleaning. For a neutral pressure room the recommendation is that the room is left vacant for one hour before cleaning.
Practices will need to be mindful of the risk to the physical and mental health of staff during the resumption of operations. The SOP makes clear that staff who are extremely vulnerable should not be returning to work during the initial resumption phase. Staff who cannot be described as extremely vulnerable but are vulnerable nevertheless may need to be redeployed to non-clinical activities. Clearly staff who have either tested positive for or have symptoms of COVID-19, or who are in a household with someone who is positive or symptomatic, should not be permitted to work and should self-isolate as appropriate.
Practices will need to ensure that they have sufficient supplies of PPE to ensure that staff are protected during treatment of patients and during decontamination procedures. The SOP states that for non-AGP care those carrying out and assisting with procedures will require eye protection, disposable fluid-resistant surgical masks, disposable aprons and gloves.
The SOP also stresses that this period will be one of heightened stress and anxiety for many healthcare professionals and the steps which will need to be taken within dental practices may well heighten this stress and anxiety. Practitioners are advised to have regard to the guidance on staff mental health and wellbeing issued by NHS Employers, NHS Practitioner Health and the British Dental Association.
What are the regulatory implications for practices and practitioners?
Practitioners need to ensure that they are aware of the guidance which has been issued by the CDO and NHSE and that this is implemented in their practices. This is a developing situation and as such practitioners will clearly need to regularly check for updated guidance and if necessary adapt their practices accordingly. Both the Care Quality Commission and the General Dental Council have made clear that they will have regard to relevant guidance when exercising their regulatory functions.
In their update to the Dental Sector, dated 19th May 2020, the CQC indicated as follows:
“As part of our regulatory function we will assess the extent to which providers are providing an appropriate level of safety within the context of our regulations. In doing so we will refer to prevailing guidance, not limited to but including guidance from PHE, the CDO and GDC to help us reach a judgement on the extent to which the service currently being provided complies with our Regulations.”
The General Dental Council adopted the joint statement from the chief executives of statutory regulators of health and care professionals which indicated as follows:
“We recognise that the individuals on our registers may feel anxious about how context is taken into account when concerns are raised about their decisions and actions in very challenging circumstances. Where a concern is raised about a registered professional, it will always be considered on the specific facts of the case, taking into account the factors relevant to the environment in which the professional is working. We would also take account of any relevant information about resource, guidelines or protocols in place at the time.”
The combined effect of the above is that a failure to regard to the relevant guidance may have implications for the registration of both dental practices and dental professionals alike. It is therefore important that practitioners ensure that they have regard to the requirements set out in the Standard Operating Procedure.
While the dental sector will clearly welcome the opportunity to begin the process of resuming normal operations, it is important to note that during the initial resumption phase the sector will be a long way from ‘business as usual’. The requirements placed on practices during this initial resumption phase are onerous and will have significant costs implications. For some smaller practices it may not be feasible to resume operations at this time. For those practices that are able to resume operations, it is important that the obvious urgency to reopen is tempered and that practices have full regard to the requirements which have been set out by the CDO. Failing to do so could have regulatory consequences for practices and individual practitioners as regulators also begin to resume their normal operations.