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NHS England and NHS Improvement
Publications approval reference: 001559
25 March 2020
This is the third of a series of regular updates to general dental practices and community dental services regarding the emerging COVID-19 situation. An electronic copy of this letter, and all other relevant guidance from NHS England and NHS Improvement can be found here: www.england.nhs.uk/coronavirus/primary-care/.
Thank you again for your continued work to prepare for and handle the COVID-19 pandemic. We are grateful for the commitment and effort that is going into providing care for patients and for your forbearance as we seek to provide clarity in a fast-moving situation.
Since the publication of our last letter on the morning of 20 March, the Prime Minister announced later that afternoon further social distancing measures to slow down the spread of COVID-19. On 22 March a further announcement included the introduction of “shielding” our most at risk members of the population and then, on 23 March, a further set of restrictions on daily activity to contain the spread of the virus were introduced.
The emphasis has now shifted away from the delivery of routine care while minimising infection risk to a requirement to stop all non-urgent activity in line with the changes to people’s everyday lives that the Prime Minister has signalled. This is the time for a collaborative, collective and concerted effort to re-direct our talents and to help support our fellow NHS primary care colleagues when they are at their most stretched. Your skills, your time and your commitment can and will make a difference to our national
In light of these most recent public health control measures and in recognition of the difficulties that practices are facing including continuing concerns about staff safety, we are making a number of immediate changes to the delivery and operation of our dental services.
A. Changes to Primary Dental Care services
(General Dental Practices and Community Dental Services)
• Antimicrobial means where appropriate
3.If the patient’s condition cannot be managed by these means, then they will need to be referred to the appropriate part of their Local Urgent Dental Care system. These new arrangements will involve providers working with defined groups of patients to manage urgent dental care needs only, with appropriate separation arrangements in place to manage patient status and professional safety. These will be established via NHSE/I regions to manage urgent care dental needs in the specific groups of patients. The service model is described in section D, “Developing local Urgent Dental Care systems” below.
Some practices and community dental services may need to become designated providers of urgent dental care as part of these Local Urgent Dental Care systems during the COVID-19 pandemic. This will be determined and agreed with each practice as part of the regionally-organised system.
4.All community outreach activities such as oral health improvement programmes (e.g. Starting Well, routine non-urgent work in care homes) and dental surveys should be stopped until advised otherwise.
5.In order to provide accurate information to the public we are asking that all dental practices:
• Update their messaging and websites;
• Contact their regional commissioner should practice availability hours alter as a result of staffing levels; and
• Inform the commissioner of these changes and the arrangements for cover.
Your regional commissioner will then inform the Directory of Services (DOS) lead so that 111 are up to date with the correct information.
B. Contracts and funding
1.2019-20 contract reconciliation
We recognise that in most years dental activity is usually higher during the month of March and that this year the majority of contractors may have been impacted because of COVID-19. We can confirm that year end reconciliation will therefore operate in the following manner:
• For the purposes of calculating year end contract delivery, we will consider the year to be March 2019 – February 2020, and we will apply March 2019 data instead of March 2020;
• For contracts delivering above 96% over this period we will then operate normal year end reconciliation with the ability to carry forward activity to 2020; and
• For contracts delivering below 96% over this period we will enter into normal clawback position up to 100% of total contract value (TCV).
2.2020-21 contracts: cashflow and reconciliation
We will take immediate steps to revise the operation of the 2020-21 contract to reflect service disruption due to COVID19 for practices who are participating as required in the COVID response. The approach will aim to achieve the following:
• Maintaining cash flow to provide immediate stability and certainty for dental practices;
• Protecting the availability of staff to provide essential services during the response period to COVID-19;
• Actively enabling staff time that is no longer required for routine dental activity to be diverted to support service areas with additional activity pressures due to COVID-19;
• Maintaining business stability to allow a rapid return to pre-incident activity levels and service model once the temporary changes cease; and
• Fairly recompensing practices for costs incurred.
We will therefore take the following steps:
We will continue to make monthly payments in 2020-21 to all practices that are equal to 1/12th of their current annual contract value.
Contract value and reconciliation
We will progress our work with the BDA to finalise an approach to contract value and reconciliation in 2020-21 that takes account of the following principles:
• Contract delivery and year end payment for the period of the COVID-19 response should be assumed to have been maintained at a level that allows continued employment of staff (despite reduced actual activity);
• In return for this certainty, this will be conditional upon practices being required to offer all available staff capacity to other areas as outlined in section C, “Workforce” below;
• A requirement on practices to ensure that all staff including associates, nonclinical and others continue to be paid at previous levels;
• An agreed and fair reduction for any variable costs associated with service delivery (e.g. in recognition of reduced consumable costs) will be applied to all contract values;
• These arrangements will operate over a fixed number of months with an agreed end date; and
• Practices benefiting from continued NHS funding will not be eligible to seek any wider government assistance to small businesses which could be duplicative.
We anticipate that this approach gives certainty over both the immediate cashflow for practices and the longer-term ability to maintain income and contribute to the COVID-19 response across the NHS.
We recognise the impact that self-isolation and social distancing is having on the dental workforce. We also realise that the changes to primary dental care outlined above will mean that there is freed capacity within a highly skilled workforce, and we appreciate the offers that have come in from the profession to contribute to the wider COVID-19 response. This will now be a condition of the approach set out in this letter.
As well as providing remote support to patients who contact your own practice / service with dental problems, we would like to direct the freed-up workforce capacity to support:
• Urgent dental care services being set up in the NHS regions (see below).
• NHS colleagues working in wider primary care
• NHS colleagues working in the acute COVID-19 response
• Local authority and voluntary services COVID-19 response.
As part of the funding support, the NHS expects that dental practices will fully support the redeployment of professionals and staff working in general dental services to support the wider NHS response, as is happening across the rest of the NHS. In particular, we ask staff contact details are made available immediately and for practices actively to support any national or local calls for help. This will include helping to staff the new Nightingale Hospital that is being established in London and other similar facilities that may be established over the coming weeks. You will receive a further communication on this on Wednesday 25 March.
D. Developing local Urgent Dental Care systems
Across every NHS region we require rapid coordination of the development of robust and safe services through the creation of local Urgent Dental Care systems across a range of sites to provide care for urgent and emergency dental problems.
These systems should be established to meet the distinct needs of the following groups within the population with urgent dental care needs:
1.Patients who are possible or confirmed COVID-19 patients – including patients with symptoms, or those living in their household
2.Patients who are shielded – those who are at most significant risk from COVID-19
3.Patients who are vulnerable / at increased risk from COVID-19
4.Patients who do not fit one of the above categories
Each local Urgent Dental Care system will involve provision at a number of sites in a way that allows appropriate separation and treatment of patients in the categories above.
The range of conditions provided for by local UDC systems are likely to include, but are not limited to:
• Life threatening emergencies, e.g. airway restriction or breathing/swallowing difficulties due to facial swelling
• Trauma including facial/oral laceration and/or dentoalveolar injuries, for example avulsion of a permanent tooth
• Oro-facial swelling that is significant and worsening
• Post-extraction bleeding that the patient is not able to control with local measures
• Dental conditions that have resulted in acute and severe systemic illness
• Severe dental and facial pain: that is, pain that cannot be controlled by the patient following self-help advice
• Fractured teeth or tooth with pulpal exposure
• Dental and soft tissue infections without a systemic effect
• Oro-dental conditions that are likely to exacerbate systemic medical conditions
Each patient should be assessed and managed on their own merit, taking into account the patient’s best interests, professional judgement, local UDC arrangements and the prioritisation of the most urgent care needs.
Local Dental Networks, Commissioners and Local Dental Committees should work together with local Dental Public Health colleagues to define and implement a system that meets the principles set out above to meet the dental needs of their local populations and to appropriately support staff to provide services safely.
The exact mechanisms, facilities and approaches will need to reflect existing local arrangements in way that that can be flexed. It will also require the development of some specific and bespoke arrangements, especially for the suspected and confirmed COVID19 patients, and for those who are being shielded.
The flexibility around operation of the contract outlined above enables staffing for each local Urgent Dental Care system to draw flexibly on a wide range of professional groups including general dental practice staff, community dentists, hospital dentists and academic dentists in a way that best fits local circumstances.
E. Personal Protective Equipment (PPE)
We recognise that the issue of staff safety and confidence in PPE guidance is very important for staff engaged in direct patient care. A number of professional bodies have issued their own guidance over the weekend.
We will continue to be led by the emerging evidence and are currently seeking urgent updated advice through our NHS Infection Prevention Control (IPC) colleagues and Public Health England. We will implement their guidance throughout our urgent dental care services.
Dental public health colleagues are being trained to fit test FFP3 masks and they will be available in regions to carry out this function.
We appreciate that these are significant changes that will have major implications on your personal and professional lives and will bring about new ways of working locally and nationally. We know that the profession are calling for further guidance and we are fully committed to working openly and constructively to rapidly update and clarify guidance as the position evolves.
We are grateful for your patience and understanding as we work with dental teams across the country as quickly as possible to keep you and your patients safe and supported, to produce information and guidance, and to listen to your concerns and suggestions as the situation progresses.
Thank you again for your commitment and engagement as part of this unprecedented national effort.
With very best wishes
Sara Hurley, Chief Dental Officer England
Matt Neligan, Director of Primary Care and System Transformation
GDC Latest Update
Advice from Wales Updated 23-3-2020
2020-03-23 – Red Alert letter to all dentists from CDO – PDF (E).pdf
United Kingdom Government & Public Health England
Centre for Disease Control and Prevention https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html
General Dental Council
British Dental Association
Financial Assistance and Advice