There’s an old anecdote about a government official and a representative of a dental organisation sharing a journey on public transport. The government official jokingly says “How bad do we have to make NHS terms before you guys will leave’.
Although said in jest, maybe the position we’re in now, is the tipping point the government official speculated about.
Years of government indifference to growing problems within the profession, a failure to modernise the service, chronic under resourcing and a complete lack of concern for the wellbeing of dental workers are long standing problems. But now beleaguered NHS practice operators face further challenges:

• The ‘lucky ones’ are running their practices on 85% pre pandemic NHS income. But many are getting significantly less than this because they’ve fallen victim to flaws in the process used to calculate financial support. Two practices, each looking after the same number of registered patients, can be receiving vastly different levels of NHS support, simply because one practice has had the misfortune to have an associate retire or relocate. That the office of the CDO has not adequately addressed this issue, some 12 months after the introduction of financial support measures, demonstrates an alarming lack of concern for practice operators. 
• NHS supplied PPE is limited
• We still don’t know how activity will be measured, even though this will affect future support payment
• We have no idea how long we’re to be stuck ‘treading water’ with the current arrangements
• We have no idea what the exit strategy is. Plans for the future of NHS dentistry are unclear, 1 year since the onset of the pandemic and 3 years since the publication of the OHIP.
• Secondary care support for NHS practitioners is falling away
• There’s a declining workforce
• Strategic planning is impossible in NHS practice with the current uncertainties
• And although the majority of NHS dental care is provided in general practice, the service is run by individuals with little or no practice or business experience. The appointment terms for CDO and deputy CDO positions make it almost impossible for GDPs to apply.  

So perhaps the hypothetical threshold for an exodus from the service has been reached. Some practice owners have already converted to the private sector. Others are contingency planning, with independent plan providers reporting a surge in enquiries. Practice owners are preparing to protect their businesses if new NHS terms are not attractive or sustainable, or if the current ‘holding strategy’ is left in place for too long.

But what of the good ship NHS Dentistry? Perhaps the response to the government official quoted above should have been “Be careful what you wish for”.

If practice owners walk away from the NHS it will create a public health crisis to which there will be no ready solution. Accessible dental care in communities will fall away. The PDS do not have the resources to pick up the slack. Over worked GPs will not appreciate having to manage significant numbers of dental emergencies on a daily basis.

Have the government and the CDO given thought to the implications across society of the collapse of NHS dentistry?

The stakes are high, and time is limited. Practice owners will not tread water indefinitely.

The conditions are ripe for an exodus from NHS practice. The CDO and Scottish ministers need to decide if that’s really what they want.

 
The author of this article has preferred to remain anonymous.

The weeks since New Year have seen huge strides being taken in the vaccination rollout, with dental personnel stepping forward in significant numbers to bolster the growing army of vaccinators.

Inductions have been held across the country making it relatively simple for people to sign up, early adopters faced a complex barrier of red tape and box ticking but these were swiftly trimmed back by a government desperate not to fall behind in the “race” to vaccinate.
So far so good.... a high proportion of the most vulnerable in society have already been immunised with a first dose and dentists along with other dental staff members have been in the thick of the action.

The silver cloud society has been waiting for seems to have arrived.

Before we get carried away though.... it’s worth remembering that even silver clouds can cast shadows and in the past fortnight these have begun darkening the dental involvement in the vaccination process.
Practice owners have been reporting increasing incidence of staff requesting time off to attend induction sessions. In some cases it seems some have even called in sick to do this.

Once accredited as ‘vaccinators’ an increasing number of staff appear to be considering a career change, some temporary but others looking like permanent move out of dentistry. More flexible working and a remuneration that many practices cannot match seem likely to be the driving force rather an altruistic desire to help out society.

Perhaps that is taking a slightly cynical view but I guess more than three decades in general practice does tend to remove ones rose coloured glasses! Disputes regarding the rates of remuneration have also unsurprisingly broken out, mainly involving general nursing staff rather than dental nursing staff at present. It does beg the valid question though, how long will GDP vaccinators be required at £230 a session when health boards are taking on dental nurses and in my case an ex-nurse at £40 a session, not long I suspect.

Few practices can afford to lose experienced staff in whom they have invested a lot of time, no little money and possibly most importantly, trust. So is this a threat we need to be taking more seriously?

It’s probably hard to say just yet but being aware of this potential black lining in the silver cloud is certainly prudent for all practice owners.

The author of this article has preferred to remain anonymous.

I was recently called to fit test for the new Alpha Solway mask at Edinburgh Dental Institute for FFP3 mask. Having fit tested for four different masks both in practice and hospital I was a bit reluctant to do this one. Thank fully I was given an appointment on a day without clinical commitments and I turned up to the appointment promptly at the given time.

I was called into the testing facility by a courteous staff member and I was surprised to see the Quantitative testing initiative by NHS Lothian. All my previous tests were qualitative where I had to decide whether the mask is a good fit based on my feedback of tasting the aerosol. I am not sure how the qualitative test and quantitative tests compare with each other but obviously quantitative test results are more valid and objective.

The picture below shows the connections to test subject and readings taken as the test progresses.

I cannot thank NHS Lothian enough for this great testing facility. It is state of the art and gives the user the reassurance that the fit test is reliable. Another advantage is the fact that you do not have to deal with the bitter tasting spray. It gives the user much needed reassurance.

I hope all health boards roll out this testing facility, which should have been made available months ago but can fully understand the challenges in procurement and set up. Let us not forget staff training is also challenging in these difficult times.

Please check with your health boards whether they are offering quantitative testing.

Now I may be a bit thick, or at least slow on the uptake. However a thought struck me last week.

If you’re anything like me, you will have

• Extractor fans, giving at least 10 air changes per hour (mine is about 19 ACH)
• Gowns (washable, single-use, or both)
• Visors
• Gloves
• FFP3 masks, respirators, hoods, etc
• Hand-washing/ sanitising etc
• Enhanced environmental cleaning

All this to deal with the threat of the Corona virus which you may have heard of at some point in the last 7 months or so.

But I had a patient for routine examination and hygiene at the end of the day last week who had a cold sore.

This got me thinking.

Ordinarily, we are encouraged to reappoint such patients a week or 2 into the future to avoid the risk of spreading HSV-1 (or indeed HSV-2 and no sniggering at the back). But with all the gear to mitigate the risk of Covid-19, surely there is no need to delay treatment for someone with a cold sore? After all, the majority of people with HSV 1 or 2 in their saliva do not have symptoms, just like about 40% of Covid positive people.

Just a thought.

NHS contractors have been waiting with bated breath for further details, following the Health Minister’s recent media announcement about a return to normal NHS dentistry from the 1st November. Most of us were taken aback by such little notice, compounded by comments from the Chief Dental officer. The R number is going up all over the UK like it has never done before and we don’t know what the future holds for us from the pandemic perspective. Many major cities in the UK are in Tier 3 and Central belt of Scotland is in severe restriction as we read the PCA.

Where should I start? As a group of committed and caring practice owners we have stood for a strong preventative approach in achieving excellent oral health for the Scottish population. But yet again the approach taken is disease centred…..more treatments rather than prevention.

They have set the period from November 20- February 21 as a monitoring period for the future level of support funding, to be applied going forward from April 2021. This will be measured against the backdrop of the NHS gross from April 19-March 20. Can they have chosen a worse period? With the R number rising in many areas, we enter the normal winter period, topped up by the Christmas holidays and the New year lull, the timing is concerning as it puts many practices in a disadvantageous position.

The average item of service and registration calculations period for historic calculations from April 2019- March 2020 is not clarified as the previous FSM (Financial Support measures) calculations were Feb 2019-March 2020. This needs clarity and the rationale for change.

The model based on a 3 tier system of support is potentially unfair as the level of activity is unpredictable at the best of times, and more so now with patients being extra cautious about making those extra journeys to health care environments unless they have a problem, and add on top the patient number restrictions (10 per day), fallow period , working in bubbles, the list goes on. This will have a direct impact on registrations and item of service activity. We do not know how the registration is measured for every practice during this period. The modelling is intended to provide good financial support to those who have good averages already, and practitioners need to show 20% of pre pandemic output to maintain the 85% of support funding in the longer term. Others will potentially struggle.

What happens to Associates, who are moving or starting new positions, in this period? They need a few months before they find their feet in a new workplace. It would be too much to expect them to walk into the ultra-threatening environment of a new surgery with Covid restrictions, PPE etc, and to have a moderate to high output of work straight away.

We do not know yet anything about GP234 and the impact of the skewed NHS/private mix of these unpredictable times. Will this have an impact on what payment models will be implemented come April 2021.Many practices were providing significant levels of private treatment during Phase 3.

Overall, this appears nice in the short term with practices receiving secure increased payments, approximately 7.8% on top of what they are being paid at present, and thank you SG for sending Santa early. SG must ensure practitioners don’t lose 85% funding through circumstances out with their control and will have to demonstrate continued goodwill to NHS dentists for the service to survive. in a country with one of poorest Oral health outcomes in Western Europe and amongst OECD nations, I hope the future model will be based on prevention and not numbers, am I dreaming?