Don’t mention the D word

22 December, 2011 / Infocus
 

Decontamination is never far away from the headlines and controversy. Although I’m still a practice owner with the same concerns as every GDP, my other roles mean I often need to step back from the ranting and take a balanced view of the overall picture.

Over the last 10 years I’ve seen deadlines pass and lead organisations and individuals come and go. I’ve watched new participants, with some vested interest, moving from committee to committee. Shuffling deck chairs on the Titanic frequently springs to mind.

One constant has been the mantra that there can only be one standard and that no risk can ever be acceptable. At first glance, the idea of one standard across all sectors in both acute and primary care appears plausible. With insight, however, this is more than a little naïve. In my opinion, the requirement has to be appropriate standards for each sector based on the level of risk to patient safety. The difficulty being that the specifics of these risks have never been clearly identified or defined.

Evidence

Evidence, or rather the lack of it, has been another fundamental problem. Dentists, understandably, have demanded evidence of the necessity for these major changes. Many have argued about the lack of evidence of harm caused by our infection control and decontamination processes. The counterpoint is that the lack of evidence of harm is not evidence that no harm has occurred. The experts’ argument being that no one has actually looked.

Research is being carried out in a variety of related topics. Some of these studies are likely to look further at microbiological contamination of dental instruments following our potentially inadequate processing systems. I’m not entirely convinced that this will help. This type of evidence is difficult to argue with. My confession is that I struggle to understand at which point the specific microbiology, the level of contamination and the potential to cause harm becomes significant. Zero, or a number close, appears to be the only acceptable level. The protestation as to the heavily contaminated field of operation, i.e. patient’s mouths, appears to be irrelevant.

Policy and implementation

Over the years, the organisations charged with leading on decontamination have appeared to have little understanding of independent contractor’s arrangements. They have found our anomalous contractual situation within the GDS difficult to deal with. There has been confusion around the differences between the directly managed service and a misconception that the GDS was the ‘private’ sector.

I believe this lack of understanding has improved although they are still unsure how to deal with dental practices as they have no direct connection, influence or control.

Our current strong leadership has enabled the relationship with these organisations to mature significantly over the last three years. Communications have improved with a willingness to listen and some recognition of the need for joined up working has been agreed.

I do actually have some sympathy for those tasked with advising government on decontamination policy. Their corporate concerns are mainly focused on the legal implications when anything goes wrong. This is exacerbated by the worry of the inevitable media repercussions. Hence the reason they rigidly apply guidance and regulation as a non-negotiable stance. Even if they were unconvinced as to the extent of risk in our sector, they are constrained by their circumstances and can never actually deviate from that policy position.

In reality, for those of us in a GDS setting, if something does go horribly wrong, the risk is entirely our own. There would certainly be some repercussions for our health board and external organisations but, generally, the buck stops with us.

Guidance

Adhering to all relevant guidance and regulation is the mainstay of ensuring compliance.

In managed sectors this guidance would be made available on release.

It would be read by the relevant line managers, meetings held, improvements planned, policies developed and adopted.

The information in these guidance documents filters down significantly slower in our sector. As we eventually became more aware of the guidance, the barriers to application become apparent. Guidance such as the Scottish Health Technical Memoranda (SHTMs) are extensive technical documents. These were produced many years ago by technical experts and are certainly not an easy read for dentists and their teams.

Few would disagree that these documents are now in urgent need of review and revision in line with technological changes and emerging evidence. The conundrum here is that until this guidance is reviewed nothing can actually change. The experts exhibit a limpet like adherence to the letter of guidance despite the fact it may no longer be entirely appropriate.

Another source of confusion in relation to guidance is the fact that the rest of the UK adopted HTM 01-05 in 2009. Scotland did not. The reason for this was that our experts believe our standards are higher than those in HTM 01-05 and we were leading the pack.

Although HTM 01-05 has not exactly been welcomed with open arms by our colleagues in the south, it is at least a single readable document. The general principles are virtually the same as our requirements. There are differences in the details, some of which are even more challenging than ours.

Some details in HTM 01-05 have already been challenged in relation to emerging evidence in areas such as storage times, which were originally based on expert’s best guesstimates. I believe there is a plan to revise the whole structure of HTM 01-05 and potentially change it significantly in the coming year.

Manufacturers and suppliers

Manufacturers and suppliers are inevitably involved with the provision of decontamination equipment. This presents dentists with another dilemma; on one hand these companies are trying to convince us that they can solve all our problems simply and cost effectively if we purchase their product. On the other hand, the experts tell us some of these items don’t fulfil all the technical requirements. Who are we supposed to believe? This has left dentists, as usual, between a rock and a hard place.

One example of this problem has to be washer disinfectors and the difficulties with cleaning handpieces. These companies must shoulder some of the blame here.

All manufacturers and suppliers have had 10 years since the first Glennie technical guidance demanded a move to automated cleaning processes. Some forward thinking and joined up working might have served to obviate some of the problems we have to work through now.

There appears to have been a serious lack of communication on all sides which has resulted in a classic case of the cart before horse.

Recent progress

Despite this seemingly despondent diatribe, there have been some glimmers of light at the end of a very dark tunnel.

In these times of recession I do sense a hint of a more pragmatic approach from some quarters. I sometimes even convince myself that the precautionary principle might have slithered off into the long grass.

The tangible effects have resulted in some significant concessions; one being an acknowledgment that manufacturers’ instructions are the legal position in relation to testing requirements. The other was the statement from Scottish Healthcare Technologies Group that there is no evidence for improved patient safety or cost benefit in having vacuum autoclaves in the GDS. Commonsense had prevailed for a short time at least. Predictably, these positive changes are being challenged by academics and the technical experts. We will need to watch this space.

The future – compliance

Compliance with guidance means more than having a separate room for decontamination. It
involves having validated equipment tested and maintained, robust processes, documented training, management systems in place and lots more besides.

As we hurtle headlong towards the December 2012 deadline and this mysterious concept, the answer to the million dollar question of who will come and get us if we don’t, can’t or won’t fully comply, is still not certain.

The potential for Health Improvement Scotland to assume the role of inspection and inspection regulation of dental services in Scotland is still alive and well.

The fact that the CQC has assumed this role in England has heightened my concerns.

The preferred option, in my opinion, would be for a new robust and efficient practice inspection system to be introduced. This would cover infection control and the general requirements for decontamination compliance. I would welcome a move away from a tick box exercise proven to have little value in reality.

This could still be undertaken through health boards and retain peer input. If this could be accepted by all parties we might manage to keep the burden of further external scrutiny and regulation at bay.

The last word

It’s hard to argue that our practices did not need to improve in response to public and Government demands around the highly charged issue of healthcare associated infection. The status quo was not an option.

Over the years I’ve seen the general mood of the profession move gradually from incredulous disbelief to a disgruntled acceptance that decontamination requirements are here to stay. This transition was eased, to some extent, by funding during the good old days of practice improvement grants.

My concern has always been the provision of support, both financial and practical as the missing components. That has been resolved to an extent through concerted efforts from dental practice advisers, NHS Education, some health boards and the Scottish Dental Clinical Effectiveness Programme.

There are certainly still barriers in relation to fully embracing and implementing the changes but most are moving in the right general direction.

I firmly believe the days of ranting about the general principles of these changes are done. However, there is still plenty of scope for vociferous haggling over the detail.

Decontamination has certainly been a catalyst for change. Despite our intrinsic resistance, in many situations there have been positive outcomes.

Those who have seen this as an opportunity and not a threat have grasped the potential to improve their practices. Delivering patient care in pleasant surroundings with better working conditions for our hard-pressed teams can only be a positive experience for both patients and professionals.

Change is never comfortable. It is usually an inevitability and can occasionally have a happy ending.

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