Points to consider when reopening dental practices post COVID-19

Easing of restrictions

Restrictions that were imposed on businesses to reduce the spread of COVID-19 will be further eased on 1 and 15 June in England, prompting dental practitioners to question whether they can re-open and if they do, what plans need to be put in place for what may be the ‘new normal’ for a long time to come.  

Most dental practices in England have effectively been closed since 25 March, for all but the most urgent dental treatments, which have been referred via the NHS 111 service to regional Urgent Dental Centres (UDCs).

Guidance (or lack of it)

Industry bodies have provided a variety of guidance for dentists in dealing with COVID-19, prompting calls for the consolidation of the guidance into a single comprehensive document for practitioners.  In our view, there would be a real benefit to the industry in producing that guidance which should make clear what is expected of each different type of practice, whether NHS, private or mixed.

In the absence of such guidance, we note that the CQC have recently released a statement under which they “encourage dental providers to give proper consideration to the communications from the Chief Dental Officer (CDO) regardless of whether their practice is NHS, private, or mixed.”

Whilst they acknowledge that they cannot require dental providers to close unless they find clear evidence of a breach of their regulations, they have also indicated they will assess the extent to which those providers are providing an appropriate level of safety, taking into account guidance from the Public Health England, the CDO and the GDC.

It is also noted that the CDO is currently calling for an expansion to the UDC programme and emphasises the application of Infection Prevention and Control measures, but beyond that, there does not appear to be a clear roadmap for dental providers to follow when reopening their practices.

Many dentists have already implemented policies of prescribing patients over telephone and video calls and even if the practices themselves do reopen, this is expected to remain the case for non-urgent treatments for the foreseeable future.

The issue of personal protective equipment (PPE) is familiar ground for dentists, with urgent dental care services affected by difficulties and delays in obtaining adequate protection, and debate as to what PPE is necessary.  For example, the BDA has expressed “serious concerns” about government advice that fluid resistant surgical masks and other routine PPE offer adequate protection for non-aerosol generating procedures in dental care. 

Measures to consider for reopening 

In addition to taking measures required to comply with COVID-19 specific guidance, dental practitioners must also be mindful of their existing legal obligations towards patients and colleagues alike. 

Health and Safety measures

Those who are also employers should also be aware of health and safety laws which impose legal obligations to protect the health, safety and welfare of employees and others who may be affected by the operation of the business.  

The Health and Safety Executive is the primary body responsible for enforcing health and safety laws in the UK.  It has emphasised that, despite the challenges posed by the pandemic, legal obligations relating to health and safety must still be met .  In the context of the current outbreak, this means that employers such as dental practice owners are legally required to take all reasonable steps to minimise the risk of someone catching COVID-19, and failing to meet this obligation is a criminal offence.  

To fulfill their legal obligations, employers must, as a minimum, complete a risk assessment.  In doing so, dental practice owners must:

• identify activities or situations (including particular treatments and procedures) that might lead to transmission of the virus;
• consider which individuals (including patients and staff) could be at risk;
• identify how likely it is that someone could be exposed; and
• act to remove the activity or situation.  If this is not possible, all reasonable steps must be taken to control the risk identified.

If the practice employs five or more people, the risk assessment must be completed in writing. Even if there are fewer than five employees, it may be beneficial to maintain a written record. 

The issue of what measures are reasonable in these unusual circumstances is key.   It is not clear how that will impact on a practice’s ability to undertake the volume of care expected under NHS contracts, other than there is little likelihood of practices being able to deliver the requisite number of UDAs.  How that will play out for the current contract year and how that will impact on the new NHS contract that was due to be rolled out nest year, remains to be seen. 

Other measures to consider 

When considering the reasonable steps which must be taken, reference must be made both to current Government and professional guidance.  However, at the present time, the steps are likely to include obtaining necessary PPE and enforcing social distancing (both in the treatment room and reception and waiting areas).  Examples of additional measures that practice owners might consider once routine dental care resumes include:

• Taking steps to limit the number of people in the practice or in a surgery at any given time, including limiting the risk for those entering and exiting the premises (one way in and one way out, for example).
• Ensuring that people do not congregate in waiting areas, and putting procedures in place to facilitate people passing through waiting areas, rather than spending significant time there.
• Providing hand washing facilities and/or hand sanitiser for those visiting the premises.
• Completing a patient risk assessment as part of dental triage (and in advance of any on-site appointment), including confirming that patients have not suffered any COVID-19 symptoms within the past 14 days
• Allocating appointments based on need and assessing whether a telephone or video appointment may be more appropriate
• Ensuring that adequate additional steps are taken for aerosol generating procedures (such as high-power suction and rubber dams)
• Scheduling breaks between patients allow for deep-cleaning of the treatment room
• Instructing and training staff on how and when to use PPE, explaining why it must be used and any limitations
• Making sure that, if PPE is required, there are no exemptions for wearing the equipment for tasks that only take a few minutes
• Checking with insurance providers to make sure any planned reopening will be covered
• Updating or creating relevant health and safety policies both generally, and in light of government guidance on infection and control generally and the dental sector specifically 

In addition to ensuring that they meet their legal obligations, dental practice owners should keep a written record of the steps they have taken to fulfil their legal health and safety obligations.  These records could then be provided as evidence in the event of any future challenge on a dental practice’s health and safety record.

UDC practices

Practices that have been used as UDCs must also keep complete, accurate and extensive records at of emergency treatment from all stages from triage through to actual provision of the treatment. Non-UDC practices must update patient records where they have been treated at an off-site UDC.

Practices operating as UDCs will have obtained consent from their dental indemnity insurer to provide emergency treatment and the same is recommended for non-UDC practices prior to reopening. Dental practitioners should approach their dental indemnity insurer for confirmation that their liability insurance has been extended to cover COVID-19 related claims.

Good housekeeping

By way of housekeeping, those who have not already done so should also take this opportunity to revise and update practice policies and procedures in light of COVID-19, including but not limited to those on patient records, clinical compliance and, crucially, Infection Prevention and Control measures.