Your NHS dentistry and oral health update

An update from Sara Hurley, Chief Dental Officer England

Yesterday evening the Prime Minister and Chief Medical Officer updated the nation on the Omicron variant. Dental practices should continue to see patients in line with our infection prevention control guidelines, with the standard operating procedure helping you implement them in practice.

As we navigate the challenges of COVID-19, dental teams have shown a great ability to continue to adapt to new ways of working and challenges. The flexibility in the new SOP allows you to continue to modify your actions based on what's best for patients and your team's safety. It has been designed this way so we do not have constant changes of guidance which I know is disruptive.

Below, we have included the key points teams took away from our webinar last week and the answers to the frequently asked questions you sent in.

On the webinar right at the top of the list many of you asked about was Omicron. The situation remains that if as new evidence emerges the IPC requirements need to change, the guidance will be updated. In the meantime, you should continue to follow the guidance and SOP and screen for respiratory illness as the best way of protecting your patients, your colleagues and yourselves.

I urge all members of the dental team to get your COVID-19 vaccine, and booster if you have done so. More information is below.

The pandemic and well known structural issues underline the need for dental system reform. But the current situation has reemphasised for me the importance of clinical prioritisation to maximise the available capacity of NHS dentistry, right now. I see it as a deeply moral issue on behalf of patients who are in need of our expert care, especially for those in urgent need. 

A key component of clinical prioritisation is following NICE guidelines on check-ups. It isn't just a contractual requirement to follow them (as it has been for many years), its a professional responsibility and right now it is of critical clinical necessity. We can't accept the situation where patients who don't need a check up are being prioritised over those who need an appointment. That's not who we are. 

Finally, if you are a dentist please do fill in the England Dental Working Patterns Survey, which is a new survey NHS England has produced to help better understand your views on the challenges presented by the pandemic and the extent to which the measures put in place have helped you. 

Vaccination as a condition of deployment: guidance and resources

On the webinar many of you had questions about vaccination as a condition of deployment. The announcement was made by the Government that individuals undertaking CQC regulated activities in England must be fully vaccinated against COVID-19 no later than 1 April 2022 to protect patients, regardless of their employer, including secondary and primary care. The regulations will apply equally across the public (NHS) and independent health sector.

Since then, NHS England wrote to all dental practices on 6 December with more detail about how this requirement will work. We have also published the following to assist employers:

• Guidance for employers in healthcare in England: Phase 1: Planning and Preparation (6 December).
• Resources available for engaging and communicating with staff to increase vaccination uptake.

Please note this is iterative guidance which will be reviewed regularly to ensure any legislative changes are reflected, and feedback and queries from colleagues  across the healthcare system are considered.

Key points to take away from last week's webinar on the standard operating procedure and infection prevention control guidance

The hierarchy of controls framework

The revised UK IPC guidance adopts the hierarchy of controls framework. Many of the processes and measures described in the hierarchy of controls are well established features, described in previous SOPs and successfully adopted by dental practices. A full list of the hierarchy of controls is in the SOP (appendix A).

Put simply, limiting transmission of infection in health and care setting requires a range of IPC measures, and the ‘hierarchy of controls’ which, if applied in order, are used to identify the appropriate measures to limit transmission in general.

Safe systems of work outlined in the hierarchy of controls, including elimination, substitution, engineering, administrative controls and personal protective equipment (PPE).

Screen and assign to one of two pathways: non-respiratory and respiratory

A key part of the hierarchy of controls, is to eliminate risk, i.e. screening. To reduce the risk of transmission all practices are to screen patients prior to attending for care. Dental practices should use the UK IPC sample screening tool for COVID-19 for use in health and care settings (winter 2021 to 2022) and regularly refer back to the uk.gov site for any updates or amendments to the screening questions.

Practices should also identify, and risk assess, any necessary accompanying persons (eg parents or carers accompanying patients).

Patients should also be screen/risk assessed on arrival at the dental practice.

Based on screening the patient should be assigned to either a respiratory or non-respiratory pathway.

Patients who have screened positive should be managed in a way which minimises the risk of spread of infection.  The first step is to decide whether it is appropriate to defer the procedure or reschedule the appointment if this is not detrimental to their condition and had been assessed as clinically appropriate. This means a further clinical assessment (i.e. triage by a dental professional) is required to determine whether routine care may be deferred until any respiratory symptoms resolve and when any COVID-19 isolation/quarantine periods has been completed.

Once a patient pathway has been assigned:

• For patients on the non-respiratory pathway standard infection control precautions (SICPs) apply. Post AGP downtime does not apply. Minimum PPE requirements can be found in section 13.1 of IPC guidance.
• For patients on the respiratory pathway transmission-based precautions (TBPs) apply in addition to SICPs. PPE requirements can be found in section 15.1 of IPC guidance.
• For patients on the respiratory pathway undergoing aerosol generating procedures (AGPs), post AGP downtime applies. PPE requirements can be found in section 15.1 of IPC guidance.

Clinical prioritisation remains in place and practices should follow NICE guidelines 

In addition to prioritising the urgent dental care needs of their existing patients, practices are expected to accept referrals/new patients seeking urgent dental care.

A key component of urgent care is the provision of follow on care to further stabilise disease, treat and prevent. This should be delivered in line with the principles outlined in the document Avoidance of Doubt: Provision of Phased Treatments and in line with Delivering Better Oral Health updated Nov 21.

Re-call of patients with incomplete care plans, oral health needs that may have increased, developed, or gone unmet during the pandemic eg children, patients with high oral disease risk, patients whose oral health impacts on systemic health, and those who have been through stabilisation and need review.

Contractors are reminded that they should should implement NICE guidance on risk-based recall intervals, to support optimisation of their service capacity. This is a contractual and professional requirement. 

Frequently asked questions about IPC and the SOP

What are the contractual implications of these changes?

Contractual requirements for the next financial quarter (January - March 2022) are being put together and NHSE/I will inform you of them as soon as possible. Contractual arrangements between October and December 2021 remain as communicated in September.

What is the impact of the Omicron variant?

The current IPC guidance is about reducing the risk of transmission of COVID and respiratory infections. If, as new evidence emerges the IPC requirements need to change the guidance will be updated.

Where and when should we screen patients? How do we minimise empty slots?

Screen prior to appointment day either by telephone call, email or SMS. Rescreening is recommended on arrival at reception, and if positive the patient can either leave the practice or be moved to a dedicated room if available.

Can we use LFTs to enhance for COVID-19/respiratory illness risk assessments?

There is no testing requirement in England. Practices should note that LFT's should not be used to defer care. Further, a lack of a negative test must not be used to refuse patient care. If LFT is used it must be on a voluntary basis.

What do I do if a patient attends and a medical emergency ensues before screening and assessment occur?

Assume the patient is on the respiratory pathway and use TBPs. Follow the medical emergency protocols in line with the relevant clinical guidelines and the practice medical emergency equipment as required by CQC and the GDC. 

If CPR is required, practices should have already rehearsed and prepared for CPR in a COVID environment based on the guidance provided by UK Resuscitation Council:

• Quality standards in primary dental care
• Quality Standards: Primary dental care equipment list

Practices should be acquainted with the use a face masks/pocket mask with oxygen port.  If a decision is made to perform mouth-to-mouth ventilation a resuscitation face shield should be used. 

Can we ask for patients for their vaccination status?

There is no rule on this, however you need consider why you are asking the question. Vaccination status cannot be used as a means for discrimination or refusal of care for a patient. If a patient is defined as clinically extremely vulnerable, it may be advisable to ask them for their vaccination status as part of a risk assessment.

Can you carry out an AGP in a non-ventilated room with a patient on the non-respiratory pathway?

SDCEP recommends that AGP’s must not be performed in rooms with no mechanical
or natural ventilation. SDCEP states that "if there is no mechanical or natural (open window of suitable size) ventilation AGPs must not be undertaken in that room, as this will be in breach of both Health and Safety at Work etc Act 1974 and maintain high concentrations of aerosolised upper respiratory tract secretions generated during the AGP".

Practices should note that Workplace (Health, Safety and Welfare) Regulations 1992 (section 6 Ventilation) state that all enclosed workplaces must be ventilated by natural or artificial means.

All dental care providers are strongly encouraged to investigate dental surgery ventilation and the modifications that may be necessary to meet the requirements of current UK healthcare guidance and legislation.

Practices in this position are strongly encouraged to seek specialist advice, such as your local public health team.

The post AGP downtime algorithm, taken from the dental IPC annex, is below.

What should we do if a patient has returned from a holiday abroad and has yet to receive their test results?

Patients should be following the latest government guidance on testing and isolation. You should ask the patient (and any accompanying individual) that they have had their test and a negative result. If they have not been tested, then you should conduct a clinical assessment and if treatment cannot be deferred you should treat as per the respiratory pathway. 

Patient facing assets

Resources supporting latest IPC guidance including social media assets and posters for health care settings to use at entrances to notify visitors that they need to wear a face covering (updated to remove reference to 19 July).  The resources also now include  'Keep a safe distance' poster.

You can download them online here.

Request for responses on the pandemic and your working life as a dentist

NHS England is asking for your insights to better understand how the pandemic has impacted your working life, including working patterns and morale.

The England Dental Working Patterns Survey provides an opportunity for primary care dentists to share views on the challenges presented by the pandemic, and the extent to which the measures put in place by NHSEI, and the Department of Health and Social Care, have helped you.

We would like to hear from dentists working in primary care, either solely for the NHS, in mixed practice, or in wholly private practice. The survey is anonymous, and NHSE will not be able to attribute any submission to a specific individual. The deadline for survey responses is midnight, Sunday 9 January, and the results are due out in spring 2022.