‘Collectively, we can overcome’
But the new chair of the BDA's principal executive committee says the pandemic has highlighted how 'the national has been lost from the NHS'
Eddie Couch describes himself as “an inherently optimistic individual”. He believes that, during the pandemic, the public has seen the value of dental care and the impact that it not being available has on their lives.
“The population needs a dental profession – and so the long-term future of practices that ride out this terrible period will be good, but I worry how many may not survive;’ he told Scottish Dental in an email Q&A conducted during November.
“We have seen the existing inequalities of oral health widen through the COVID period, we have massive problems to overcome with undiagnosed disease and waiting lists rising exponentially – and the whole dental sector faces difficulties in rebuilding. If we can utilise this pandemic to change the focus to prevention, from politicians who have paid lip service in the past, and colleagues can adapt as we already have to improve the viability then all will be well. There are huge challenges ahead for us all, but collectively we can overcome.”
That latter exhortation has, however, been challenged precisely as a result of the pandemic; since April, a number of new organisations claiming to represent the profession have emerged. They include the British Association of Private Dentistry. Crouch conceded that, despite strong campaigning – highlighted by Scottish Dental as the UK entered the first lockdown – the BDA had been “unable to secure much support for practices that relied on income outside the NHS”.
He added: “It is very understandable that this group of dentists felt they were not being represented when they saw the lack of success, and felt it was because the efforts were all put into securing NHS funding. This was not true, but it gained momentum and saw the growth of organisations who felt their voices needed to be heard. Collective action might have been a more powerful force.”
In Scotland, two other organisations have sprung up; the Scottish Dental Practice Owners group and the Scottish Dental Association. “Obviously, as someone now in a position within the BDA, I would want people to become engaged with us to fight their corner,” said Crouch, “but we will have to work hard to win back some of this lost support,” he said.
In August, the BDA wrote to Joe FitzPatrick, Scotland’s Health Minister, with what Crouch described as “evidence of the stark financial situation facing mixed practices”. The Minister responded by saying that “robust, independently verifiable evidence” was needed to take the matter further. “We will look to work with Scottish Government officials to collect evidence from dentists and practices that arc affected and use this to make the case for additional financial support for mixed practices,” said Crouch.
As Scottish Dental went to print, the BDA had called on the UK Government and devolved administrations to offer a package of capital funding, from the £2.3bn NHS COVID fund announced by the Chancellor in November – “the only hope,” it said, of restoring routine services to millions of patients. The association secured a House of Lords debate on the future of dentistry, which was followed by Crouch meeting Jo Churchill, the UK Government’s Health Secretary, to discuss funding for ventilation equipment in NHS and private practices.
Crouch disclosed that he contracted COVID-19 at the end of March; he said he was “lucky to have relatively mild symptoms” but was unwell for two weeks. Reflecting on the early days of the first lockdown, he said: “I am proud of the way the BDA rose to the challenge of the pandemic, moving staff to work from home yet delivering the go to place for information when we opened the website to all, including non-members. We secured media coverage at levels unknown previously, with dentistry front and centre in print, radio and TV.”
He said he had been supported “incredibly” by the practices where he works, as they triaged. “It left me free to attend the myriad of meetings that became necessary for supporting members, plus the multiple media engagements I had on a daily basis,” he said. “We have seen the way the profession has risen to the challenge of coping with operating procedures to ensure safe places for delivering care to patients and keeping staff safe. I have been so proud of every single member of the dental team.
“It is worrying that, as I answer these questions, we are in England in the middle of lockdown two’ and whilst we know practices will not be shut down as they were in the spring surveys carried out by the BDA indicate real concern on practice viability. NASDAL report that more than half of practices across the UK have relied on Government CBILS backed loans in an attempt to outlast the storm.
“Clearly, whilst the report from SDCEP adopted by PHE and the CDOs has given hope of reduced fallow time, the truth is that working with the current levels of PPE are exhausting for teams and may not significantly increase the throughput of patients with current social distancing measures and the reluctance of patients to attend with current high levels of infection!’
How did he think that the initial return to practice had been handled by the Governments of the UK, regulators and organisations, and could things have been handled differently? “The pandemic has highlighted how the ‘national’ has been lost from the NHS, with different arrangements on funding and variance in operating procedures and the advice from CDOs and regulators.
“The manner in which the profession has heard about what is expected of them has also been incredibly poorly handled, with colleagues finding out about a reopening of practices via a prime ministerial briefing rather than ahead of a media announcement in England, and other countries hearing via politicians speaking in respective parliaments.
“Mixed messaging from regulators also caused confusion in the profession, with dentists unsure of what they were being asked to do. It is clear in hindsight that the availability of PPE – or more importantly the lack of PPE – contributed significantly to the decision to limit dentistry. I guess, in summary, if we really did plan for a pandemic, it should not have turned out like this.”
Before the pandemic, the Scottish Government was working with the profession on a ‘new model of care’ for NHS dentistry. The CDO in Wales has also spoken about using the pandemic as an opportunity to change the way that dentists are remunerated, shifting from treatment to prevention. What does Crouch believe would be the best model for NHS oral health care and the long-term sustainability of practices?
“The work undertaken in Wales to map the population of practices and their risks is one that has potential to match funding to the dental needs of the practice. In England, the retrospective reintroduction of a UDA element to the prototypes has been disappointing and obviously Scotland was only in the very early stages of developing the Oral Health Improvement Plan. My hope is that we can across all the UK move to a system that places a much bigger emphasis on prevention.
“Looking to the longer term, there is widespread acknowledgement that dental practices will not be returning to previous ways of working before the pandemic struck. A new funding model will be required, and we recently established a working group to contribute to discussions with the Scottish Government and other stakeholders. This will be a long-term initiative requiring a national consultation and possibly legislative changes.”
“I’d not planned on becoming a dental student but, as a sixth former, an open day at Birmingham Dental Hospital gave me an excuse to skip a mock exam,” recalled Eddie Crouch. Turned out, it sold him on dentistry as a career. He qualified from Kings in 1983, worked in resident oral surgery, a practice in south London, and then joined a colleague who had graduated a few years previously and bought a practice in Berkshire. After marriage and starting a family, he moved back to Birmingham, bought a practice and, despite selling it in 2003, continues to this day to provide orthodontic care there and at a specialist practice nearby, albeit now limited by his BDA commitments.
“The biggest challenge, pre-COVID, has been juggling clinical practice with my increasing involvement with dental politics,” he said. “Challenges to the provision of orthodontics have been ongoing since the flawed contracts of 2006. I had taken a Judicial Review over a termination clause in the agreement to the High Court with the partial financial support of crowd funding from many colleagues — to whom I will always be indebted.” He won the case In 2008, to the benefit of more than 3,000 dentists. “It was hard, but it showed me where commitment to a cause can lead, and how a collective act from dentists has the ability to face down unfair legislation”
For the last five years he has been the Vice Chair to Mick Armstrong, been involved in Committees across the BDA and around the UK, and in national discussions with stakeholders — together with fellow principal executive committee members, he has helped steer the BDA with Its senior management and to develop, amongst other things, its own bespoke indemnity product.
“The work of the BDA in moving contractual arrangements away from activity to prevention will, in time, hopefully deliver contracts around the UK within the NHS where prevention is regarded as clinical activity. Past efforts by the BDA in lobbying, with others, for a sugar levy and immunisation against HPV are also areas the BDA can be proud of. The association has also led on action on antimicrobial resistance and will need to exert further influence in the planned phase down in amalgam use, and how that is managed. The right combination of policy work, lobbying and media activity can achieve results.
“I am also proud of my Scottish colleagues who defeated plans to extend recall intervals beyond 12 months, given the clear risks presented by soaring oral cancer rates. And of the local dental committees (LDCs) who stepped up to the plate in March to assist in the creation of urgent dental care centres and how colleagues within LDCs distributed help and advice to dental teams.”