Surviving the Covid-19 Crisis
The present crisis is the worst I’ve witnessed, but dentistry will survive.
Patricia Thomson MJDF RCS (Eng), is the FGDP National Board Member for the North and West of Scotland. Here, she reflects on her experience of the COVID-19 pandemic, and how general dental practice has adapted to survive previous crises.
My diary from February to June of 2020 was busy. It encompassed formal duties in my role as an FGDP National Board Member; travelling to Switzerland mid-March to visit my son Andrew, who lives in the ski resort of Verbier; visiting Canada in May for my nephew’s wedding; and attending two weddings in Scotland in June. All of this was in addition to working as a part time associate, a role I had assumed since selling my practice two years ago.
I was aware of the spreading coronavirus in Wuhan but, like many, I thought it was a problem that would be contained, and anyway, China is a long way from Scotland. But the outbreak in Northern Italy began to make me more anxious.
I attended an FGDP Board meeting in London in late February with growing unease. I travelled by air, used the London underground, and socialised with fellow board members. Although the behaviour of people in Glasgow was tangibly changing in response to the public health threat, London appeared to be business as usual. On 4th March, I attended an NHS Education for Scotland Dental Committee meeting in Edinburgh in my FGDP capacity, and was scheduled to return to London the folloiwing week for the Faculty’s Diplomates’ Day and Annual Dinner & Awards, where I was to have the honour of delivering the citation for Prof Jeremy Bagg, the Dean of Glasgow Dental School, on receiving his Honorary Fellowship of the Faculty. My husband and I planned to travel to Switzerland immediately on my return from London.
All was going as intended until I was phoned by Public Health who informed me that I had been in contact with a COVID-positive person at work. On 9th March, in agreement with Public Health, the practice was closed, and all of us who worked there had to undergo self-isolation for two weeks. I realised that the world was about to change; this effectively vetoed my trips to London and Switzerland, but had much graver and far-reaching implications as the virus had now reached our shores.
The health board where I live, which is different from the one where the practice is situated, subsequently reviewed my case and reclassified me a ‘non-contact’, meaning I had not come into contact with the individual infected with the virus, and no longer needed to self-isolate. This new freedom arrived too late for the London trip, but I still wanted to visit Andrew in Switzerland, and we had flights booked for Saturday 14th March.
On the 10th, Andrew phoned us to say he wasn’t feeling well. He was short of breath, had a terrible headache and no energy. All his friends reckoned they had had the virus, all strangely losing their sense of taste and smell. The Swiss policy at that time was to test only symptomatic over 65s, but being asthmatic, he was tested. It transpired that Verbier was a virus hot-spot, and the hotel where he worked was an epicentre. The Alpine ski slopes were closed on the Friday, and Andrew got his positive test result early on the Saturday morning (though thankfully his health had started to improve markedly by then). Although the flight took off that day, we didn’t go. Reality was beginning to dawn.
After the two-week period of isolation was over, and the practice was preparing to reopen, we all realised that routine dentistry was about to cease. I didn’t make it back to work before the CDO for Scotland stopped all face to face patient contact. Urgent Dental Care Centres (UDCCs) were introduced, and we entered the era of telephone dentistry.
In most of the Scottish regions the individual health boards were efficient and effective in setting up UDCCs promptly. All who have been involved in manning the centres have praised the collaboration and goodwill between primary care, the Public Dental Service and secondary care to make this project operate successfully. Of course it was not a comprehensive dental service, but AGPs have been available, and any emergencies were dealt with.
The Scottish NHS system for remuneration of general dental practitioners is different from the system elsewhere. We still have a large proportion of our income based on the fee-per-item system, with additional funds made up of capitation/continuing care payments, and various other allowances and payments based on the NHS commitment of the practitioner. The practice is responsible for collecting the patient contribution, and this is deducted from the monthly payment. Most practices offer a combination of NHS and private care. The Scottish Government eventually agreed to fund practitioners based on 80% of their average NHS turnover for the past year, and to maintain the various allowances. The condition attached to the funding was that practitioners and their staff attend the UDCCs or other redeployment if requested, and carry out telephone triage for their patients. This is all great news if you have had a high NHS income over the last year, but not so good for the majority of practitioners who rely on a significant private income to fund their practices.
Dental practices in Scotland were permitted by the CDO to return to practice to offer limited non-AGP urgent dental care from 22ndJune, adhering to the detailed advice issued by SDCEP (the Scottish Dental Clinical Effectiveness Programme). I returned to work in practice on 25th June for the first time since 5th March. The only dentistry I undertook during that period was one session at the out-of-hours service at a local hospital, where I extracted three teeth and offered advice to multiple patients by phone. I was involved in some telephone triage for the practice, and although I volunteered online for redeployment, and attendance at the UDCCs, like many of my colleagues, I have not been contacted.
The health boards in Scotland have been supplying free PPE to dental practices in the form of aprons, gloves, visors and fluid-resistant surgical masks, but this is only for use on NHS patients. These supplies are intended for use in one surgery, for one dentist, one receptionist and one nurse, plus ten patients a day. We are only permitted to open one surgery per practice unless we have permission from the health board to open a second surgery. Some GDPs and nurses have been fitted with FFP3 masks by the health boards to allow them to attend the UDCCs to carry out AGPs. More recently, some practices have been sourcing their own FFP3 masks and other enhanced PPE to enable them to carry out AGPs privately.
I fear for practice owners, especially those who provide an entirely private service, and for those with mixed practices whose private income enables financial viability. It is also a concerning time for associates, who have no job security. The impact of the loss of clinical experience for students in fourth and final undergraduate years, those in Foundation/Vocational training years embarking on a career in general dental practice, and those in Core and Specialty Training, will leave a legacy for many years, and they will require much educational and pastoral support as they attempt to complete their training and undertake extensive personal development plans.
In the FGDP’s West of Scotland Division, we are about to embark on virtual tutoring for the MJDF exam, and intend to open this resource to new graduates and VDPs (FTs) who are finishing their training year unsure of future employment; we want to keep them involved in the community of dental practice. It appears the blended learning model of teaching will be the only vehicle for delivery of educational programmes for some time, and who knows, this may deliver unexpected benefits.
I first assumed practice ownership in 1985, and have since weathered many crises which we all considered existential at the time. We adapted to the danger posed by Hep B and C, HIV/AIDS, vCJD, and the introduction of LDUs. All of these were a threat to our financial viability, and all permanently altered operating procedures in dental practice, but our service is essential, and we are a very resilient professional group, so we survived.
Often a time of crisis offers the ideal opportunity to take stock and review your future plans and ambitions. Some will remember that in the early ’90s, the UK Government introduced a new NHS contract for dentistry, which they quickly realised would cost more than intended, and subsequently instigated a severe fee cut. My husband and I had just bought our practice and invested heavily in a renovation of the building and refit of the equipment. Following the fee cut, we realised that we couldn’t survive financially on the new NHS fee scale. We were forced to consider our options and made the brave move, considering our geographical situation, to attempt to convert our practice to become mainly private. We changed our business model and operated on a combination of private fees and plan patients, with a small NHS commitment, which continued until we sold in 2017. Although that crisis seemed like a disaster to us, in fact it gave us and many others like us at that time, the impetus to make the move to the private sector, and offered the autonomy to run our practice independent of NHS funding.
I know that the SARS-CoV-2 virus has led many colleagues to consider their options. Some have decided that they have had enough, and like myself, are now considering retirement. Some are realising that the private plan capitation model offers a degree of security and autonomy that is very attractive, and are considering changing their business model. Possibly some associates have reflected on the insecurity of their employment, and will be more likely to consider buying their own practice.
The present crisis is the worst that I have witnessed, and I am so grateful that I am no longer a practice owner, but I am certain that dentistry will survive; it has to. I am sure that as the dust settles, opportunities will present themselves.
We have very dedicated and effective leaders in the BDA, LDCs and FGDP/College of General Dentistry. Please take note anyone who does not see the relevance of such organisations: we need them, need to support them, and owe them a huge debt of gratitude. Much of the financial support and concessions that we have obtained from government so far are due to the lobbying of our colleagues who work voluntarily and tirelessly within our professional organisations for the benefit of us all. I have heard various cynical colleagues over the years pass judgement that these people are crazy, and tell me they don’t understand the motivation to “give back” by offering their time without remuneration. Dentistry can be a very isolating occupation, and individually we have no effective voice; to make our voices heard we need to collaborate with colleagues. Many who have refused to contribute to the greater good and support our professional bodies and organisations, either by taking out membership, paying fees, or by giving their time, are now benefitting from the selfless hard work of their colleagues who have participated in our professional organisations. The BDA’s General Dental Practice Committee and Scottish Dental Practice Committee, together with the LDCs, have been negotiating relentlessly on our behalf to secure funding, and the FGDP and College of General Dentistry have produced invaluable risk-based guidance on returning to practice. These exemplary individuals should be lauded for their magnificent and selfless work on behalf of our profession.
However our experiences over the past months have also highlighted the fact that dentistry, especially general practice dentistry, does not have a voice and representation at the level that some other medical professions enjoy. I hope colleagues will agree that now is the appropriate time to elevate our professional standing, promote our opinions and educational needs, represent our constituents at the highest level, and support the new College of General Dentistry as a professional body for all involved in general dental practice.
When we sold our practice I was less than happy, and had a discussion with a friend, a retired GMP whose opinion and sense of humour I value greatly. I complained to him that after years of being in control of my life, I now felt that I had absolutely no control of the world around me. He replied that being in control is just an illusion; no one is ever in control of their life, it’s just that for most of the time we don’t realise it. As I reflect now I accept that never a truer word was spoken; all we can do is to attempt to adapt to what the world throws at us.
We are all facing drastic changes in our lives, and a lot of it may be very difficult, but the dental profession and general dental practice will survive.
Read further reflections on recent events at www.fgdp.org.uk/deans-blog.