A mixed practice owner from North London discusses why re-opening a dental practice after lockdown poses serious challenges.
I was shocked when I heard the news that dental practices in England could return to work on 8 June. I had been following the Scottish and Welsh Chief Dental Officers and was preparing for a similar phased approach in England. Instead we were given a week.
We have a mixed seven surgery practice comprising 33 dentists, hygienists, nurses and admin staff. Some staff are self-employed, some have been coming in during lockdown to triage over the phone, some are furloughed and some are pregnant and shielding. The logistics of getting back to work is not straight-forward.
I started by asking myself whether it was even safe to reopen. I became convinced that we could do it and create a safe environment as long as we used our professional judgement, took a flexible approach to working and pulled together as a team.
Do my staff want to return to work?
The first thing I did was speak to my staff. I phoned them individually and then held larger zoom sessions. I started with my clinicians to see who was prepared to open a clinic. Many clinicians have not been within two metres of other people for 10 weeks, and now we are asking them to come back and sit with their faces only inches away from a patient. They need to feel safe and my job as the owner of the practice is to ensure that safety.
As a mixed practice, some of my staff have been eligible for NHS payments during lockdown. But our self-employed dentists and hygienists have received very little financial support from the government. So I will look to bring them back first as I’m sure they are anxious to start.
“One concern I have is deciding which members to bring back from furlough. This comes with a massive financial risk.”
One concern I have is deciding which members to bring back from furlough. This comes with a massive financial risk of bringing them back too soon and then not being able to pay them as there is not much income coming in.
It is going to be a long time before the business is back to what it was. Furlough rules will also be changing in July. We have to accept that June is really a month to dip our toe in the water and see what happens.
How to socially distance in a dental practice
When re-opening was announced, I went into the practice with one of the dentists to review the layout and to see how well we adhere to the guidance. I needed to work out the maximum number of people we can
have in the clinic and to compare that with the minimum number of staff that we need. So if we will have two, instead of three hygienists, can we ensure that they can keep two metres between them? If it gets busy, then we will have to consider working in shifts.
On top of the usual cleaning rotas, we will have new schedules to ensure the hand-rails, chairs and door handles are regularly wiped down. I have ordered screens for the reception desk, stickers for the floors and signage for reception. We have hand sanitiser at reception and will also be asking patients to wash their hands when they enter. We will ask them to come wearing a mask, however we will have some here if they forget. We will try and avoid all use of the waiting room.
All staff will need new training sessions to familiarise themselves with the new protocols. This is especially important for the dental nurses who have to make sure that patients not only follow the guidelines but understand why they are doing it. Communication is so important and critical to staying compliant.
PPE and its limitations
"As an NHS practice, I hoped we would have access through the NHS supply chain, but I don’t think we will."
PPE continues to be a major issue for us all. Sustainability of supply is unsteady and prices will be much higher than they used to be. There is not a lot of guidance on accessing PPE. As an NHS practice, I hoped we would have access through the NHS supply chain, but I don’t think we will. So I have to keep calling suppliers and seeing what I can find.
Unfortunately we don’t have the PPE that we need to deliver aerosol-generating procedures. There is simply no reliable source of FFP2/3 masks. These need to be fit tested and there is no point getting fit testers in until we have a steady supply. So for now we will have to continue to refer some patients to the urgent dental centres.
We do have fluid resistant masks and I have spoken to staff to ensure they are satisfied with that for now. It is important to get their feedback as there is a lot of fear, including among dentists, despite the evidence from Public Health England about what is appropriate. My clinicians are knowledgeable and can make their own decisions, but employees don’t have that choice. It is my duty to ensure they feel secure that they are returning to a safe environment.
We need to work with our patients
"If we don’t open on 8 June, patients will say: Boris Johnson said you would, so why haven't you?"
If we don’t open on 8 June, patients will say ‘Boris Johnson said you would, so why haven't you?’ We have to manage that perception, even if we can’t offer everything right away. We are already telling patients via our website that we will prioritise emergencies, but some people feel a check-up is an emergency so we have to manage expectations.
It is also important that we are upfront with our patients about what they will get and that they understand it is not going to be the same as before. The fee will still cover a one hour appointment but it will likely now be divided between 40 minutes of active treatment and 20 minutes of downtime - to allow aerosols to settle (come the time that we can deliver AGP’s) and thorough cleaning.
Where appointments require education on oral hygiene and conversations to discuss treatment options, these will now take place at another time perhaps via telephone or video. Clinicians will have to get used to delivering core information over a screen, which means we will need a secure system. GPs already have these but we will have to invest in one for the practice.
Our aim is to press ahead with what we think will work and then review it after the first few weeks. We are not pretending to have definitive answers, but we will keep trying to get it right.
The future is unknown
"If footballers can be tested twice a week then why can’t we as healthcare workers?"
In a global pandemic nothing is certain. So much depends on community transmission and we are keeping a close eye on the R number. If we have another spike we might have to shut it all down again. So we will need a fluid set up for a good few months, until the Government announces it is under control. In the meantime, there is still a risk. We don’t want to open too many surgeries and then contribute to the R number.
My main priority is keeping my staff and patients safe. I do wish we could access more tests for staff. If footballers can be tested twice a week then why can’t we as healthcare workers?