Profession’s future hangs in the balance
As urgent care hubs were readied to provide emergency dentistry,
practitioners were left wondering about their future
The School of Stomatology at Wuhan University, founded in 1960, was the first dental school to be established by the Chinese Government. It is the country’s main centre for oral health research and is home to 1,098 staff and 828 students. Last year, its hospital provided dental care to around 890,000 patients.
Between recognition of an epidemic in China and the beginning of March, nine people at the school – three doctors, three nurses, two administrative staff, and one postgraduate student – had contracted COVID-19. “So far, there have been no further cases among colleagues or patients who had close contact with them,” said a paper written by staff at the school and published by the Journal of Dental Research.
“According to analyses of epidemiologic investigation and medical history, all these cases are without obvious aggregation, except two nurses from the same department, and are unlikely to result from cross infection,” they wrote.
Since 24 January, despite the increasing number of confirmed cases in Wuhan, 169 staff had provided emergency dental care at the hospital – treating more than 700 patients. “The infection was possibly limited because medical masks and gloves worn during routine clinic work of dental practitioners prevented further transmission,” said the paper. After discussing infection control in dental settings and recommended measures during the COVID-19 outbreak, the authors ask: “What should we do to improve the current infection prevention and control strategies after the epidemic? How should we respond to similar contagious diseases in the future?”
They added: “These are open questions in need of further discussion and research.”
By the end of March, Wuhan, the city where the coronavirus pandemic began, had partially re-opened after more than two months of isolation.
Crowds of passengers were pictured arriving at Wuhan train station on 28 March. People were being allowed to enter but not leave, according to reports. Wuhan, the capital of Hubei province, saw more than 50,000 coronavirus cases. At least 3,000 people in Hubei died from the disease.
While numbers had fallen dramatically, according to China’s figures, a report in The Lancet warned that relaxing physical distancing and school closures in Wuhan too soon could fuel a second wave of COVID-19 infections later this year. The study suggested that lifting restrictions in March would lead to a surge in case numbers that would peak in August. It predicted that maintaining the restrictions until April would delay a second peak until October, which would relieve pressure on health services in the intervening months.
In Scotland, businesses and the public in Scotland were required by law to follow necessary social distancing measures to slow the spread of coronavirus. The Scottish Government used powers from the UK Coronavirus Bill to make it a criminal offence to flout the strict public health guidance. To enforce social distancing, people were asked to only go outside if they have a ‘reasonable excuse’. These included shopping for necessary food and household and medical supplies, travelling to and from work where working from home was not an option, and daily exercise that adhered to social distancing guidance. Nicola Sturgeon, the First Minister, and Dr Catherine Calderwood, the chief medical officer, reinforced the message in daily briefings.
For the dental profession, restrictions on practice came swiftly. On 17 March, Tom Ferris, Scotland’s chief dental officer, said that all aerosol generating procedures in NHS dental services should stop and steps should be taken to reduce contact between staff and patients. Five days later, the services were advised to halt all routine care.
By the end of the month, they were being warned that: “In the event of a significant and rapid escalation of COVID-19 NHS Boards will move to a centralised urgent care only service for people who are asymptomatic for COVID-19. They will require assistance from dental team members in practices to contribute to the staff rota at the centre. NHS Boards must ensure that PDS/HDS dental teams at the designated urgent care centres have been trained in the use of and access to FFP3 respirators.”
At the time, Ferris said: “These are incredibly challenging times and I value your continuing support and appreciate the tremendous dental team efforts taking place across GDS practices, PDS and HDS services and NHS Boards in Scotland. Together we will get through this.”
In Glasgow, practices were being asked by the health authority to consider what PPE and other stock they had that could be “redeployed into the urgent care hubs for when the service inevitably condenses following practice closures”.
An official added: “We are currently looking to identify what we are describing as ‘hot’ and ‘cold’ spots/locations where, moving forward, we can treat emergency patients, whether they are symptomatic or non-symptomatic, COVID-19 patients. We are establishing teams who can work from these locations on a rotational basis.”
Concerns were also growing about the viability of practices in the long-term. Alongside the initial clinical guidance issued mid-month, the chief dental officer said that financial support measures had been put into place for independent contractors. However, the announcement resulted in a flood of emails to the CDO and the GDS mailbox, as well as concern on social media. Ferris responded the following day saying that it was his priority that “practices do not financially fail”.
He said: “The financial support measures have been designed to ensure that practices have a degree of financial protection during this difficult period using the existing NHS GDS budget and payment system. We are protecting rent reimbursement, allowances, ‘cap/con’ payments and making a part payment – normally paid net by PSD – for reduced fee for item income.
“I hear your concerns around practices with a higher level of patient contributions providing income being adversely affected despite this financial support. The measures announced to date are initial measures and we are presently seeking additional funding to support the most affected NHS practices.”
Practitioners who contacted Scottish Dental warned that by not including the patient contribution in its calculation the Government was risking practices across Scotland going out of business. The CDO emphasised that, in the interim, practices should seek support from the business initiatives announced by the Scottish and UK Governments and their agencies.
“I want to reassure you that the CDO team is working tirelessly to source additional NHS funding to address these concerns. ” said Ferris.
A spokesperson for the Greater Glasgow and Clyde Local Dental Committee commented: “We would encourage practice owners to take a breath before making significant decisions about laying off or furloughing employees or making significant cuts to associates.
“The fine detail of how the Government furlough scheme might apply to NHS dentistry is far from clear, especially if the NHS are providing us with bespoke funding packages that may be contingent on having an availability of staff to be redeployed.”
In a letter to Jeane Freeman, the health minister, signed by 600 dentists across Scotland, Dr Gillian Lennox of Forth Valley’s local dental committee, wrote: “The economic impact of this crisis will continue for years. Overnight, practices have seen their incomes decimated. Every other health care sector, apart from dentistry, has received a fair funding package. Every other sector has financial stability for their staff and themselves.
“We do not. And if practitioners are left bankrupt, ultimately it will be patients who lose out. It is essential there is a fully functional dental service at the end of this crisis, or we risk the dental health of the population being pushed back a generation. We’re all in this together, but GDPs feel forgotten about in the healthcare system.”
On 30 March, Tom Ferris announced revised funding – described as a “considerable enhancement” replacing the funding unveiled on 17 March – which will cover 80 per cent of the average income from item of service and patient contributions.
Meanwhile, as part of its measures to protect the economy, the UK Government had announced support for the self-employed. But, in the wake of the Chancellor’s announcement on 26 March, James Goldman, director of advisory services at the BDA, said: “The BDA is devastated and angry that the help from announced by Rishi Sunak will not be provided to self-employed people who earn more than £50,000.”
In a letter to the Chancellor, Martin Woodrow, the BDA’s chief executive, said: “When you told the self-employed that, as a group, they ‘have not been forgotten’, I am afraid that you were overlooking the majority of associate dentists who, while being self-employed and earning over £50,000 per year, are by no means in the realm of the super-rich. The average earnings of an associate dentist today are £69,000, significantly less than an MP for example.
“We know from earlier announcements that those working in NHS dentistry across the UK can expect some income protection – which we welcome – however the reality of dentistry in the UK today is that there is a mix of NHS and private provision. Indeed, the private sector is bigger than the NHS in terms of expenditure, and the money earned from private care subsidises NHS provision in many practices. The impact on the oral health of the nation would be catastrophic if private practice were to disappear. That has to be a real possibility if no support is offered through this health and financial crisis.”
Dave Cottam, chair of the BDA’s General Dental Practice Committee, warned: “Many self-employed dentists working in largely or exclusively private practice have seen their incomes fall to zero. Failure to offer them a safety net will not only hit highly skilled individuals but will have a devastating impact on the essential services they provide. When NHS dentistry is already stretched to breaking point, letting private practices go to the wall would be criminally irresponsible.”