Infection prevention and control is not normally a subject that causes too much excitement, but the UK’s approach to IPC has become an issue of huge significance during the pandemic. The precautionary approach adopted in relation to personal protective equipment, social distancing and fallow time has had a dramatic impact on dentistry across the past 18 months. It has also not been without controversy, with the UK being seen as something of an outlier in these areas and no evidence of super-spreading incidents linked to dentistry in countries with less stringent IPC requirements. We have for some months been calling for a roadmap away from the current restrictions.
We have for some months been calling for a roadmap away from the current restrictions.
In that context, the two quickfire consultations that closed this week have the potential to be of real importance. In case you missed it, the UK COVID-19 Infection Prevention and Control Cell has been seeking views across the four UK countries on an update to the COVID-19 specific IPC guidance for the coming winter season. As well as a consultation on general healthcare guidance, there has also been a separate piece of work on revising the appendix specific to dental settings, which will be in line with the wider approach.
Potential easing of restrictions
The consultation had some significant proposals:
- Removal of the current three distinct COVID-19 care pathways (high, medium and low risk) to be replaced by one respiratory pathway which will apply transmission-based precautions.
- An algorithm and triage process to support decisions about patients’ care pathway.
- Physical distancing to become at least one metre in all areas (although still increasing whenever feasible to two metres for the respiratory pathways).
- Triaging and testing to continue including assessment of COVID-19 and other respiratory pathogens.
- A review of the Aerosol Generating Procedures list to identify procedures that can be removed.
What this means, if enacted, is that default IPC provisions will revert to something much more like the pre-pandemic approach. But the onus will be on the practice to triage patients and defer treatment for those with respiratory infection symptoms, or if that isn’t appropriate, to treat patients in line with the current enhanced IPC approach.
If enacted, IPC provisions will revert to something much more like the pre-pandemic approach.
The potential easing of current restrictions will be greeted positively by many within the profession who have seen the current approach as unevidenced and excessive. These restrictions have had an impact across both NHS and private provision, with private practices in particular not receiving support for the associated additional costs.
The impact of working in enhanced PPE has been substantial. Indeed, in a BDA survey early in the summer, 88% of respondents said PPE requirements were having a considerable or great impact on their morale, a figure that was higher than that for the impact on morale of financial uncertainty, the need to hit NHS targets or of working longer hours. Such a change will therefore offer relief, bring the UK more in line with other nations, and give the potential for an increase in levels of patient care.
On the other hand, there are also many dentists and team members who will be apprehensive about a shift away from measures that have protected them and their patients during the pandemic, and questions raised as to whether this is the right time to deviate when COVID infection levels remain high.
Challenges we’re likely to face
There are practical questions about the implementation of the potential new guidance. The very different attitudes to risk within the profession will likely result in varying IPC approaches from practice to practice and therefore in capacity to treat patients. Many dentists and their teams would no doubt like to be able to use their professional judgement and adopt their own approach to managing the risks involved in patient care.
As we approach winter, there is likely to be difficulty under the new pathway in distinguishing between a cold and other respiratory infections during the triage process, which could lead to large numbers of appointments being deferred and dental surgery time lost. Dental practices will not have the capacity to introduce fallow time without notice when patients present with a cold or other respiratory symptoms at the time of their appointment. The change could actually end up running counter to the intention of easing restriction and increasing activity levels.
Some practices will be concerned about adopting a more routine approach given the level of asymptomatic infection in the community, with estimates of anything between 17% and 42% of cases being without symptoms. The majority of asymptomatic patients will not be identified by the triaging questions and will therefore present for treatment.
We have been responding to the consultation processes this week, reflecting the range of members’ views and questions. We will continue to be your voice in these discussions as the process continues. There will be further crucial discussions to come across all four nations around the operational implementation of any changes.
We will continue to be your voice in these discussions.
And of course, if and when any changes are implemented, we will be there with practical advice on the implications for you and your teams.