A Covid journey

WOULD you like to do a piece on your experience of Covid lockdown and your return-to-work journey? This was the text of an email we received a few weeks ago from an editor at MDDUS.

Just now as I write, the UK remains in the rising gradient of a global Covid second wave. The false dawn of a possible return to normality in June and July seems a distant memory. Boris has had to announce another England-wide lockdown and in our corner of the Scottish central belt we are currently in Level 4.

Unsurprisingly then, my gut response was to say: "no, not really". Given all we’ve been through in the last seven months, perhaps Oasis put it most succinctly: “Don’t look back in anger”. That is easier said than done.

However, on reflection I thought, if nothing else, it might be cathartic to put our experiences down on paper. While we have no intention of being in this situation again, there were a lot of positives to come out of our near three months enforced time away.

Our practice – Paterson & Sadler – has been on the same site opposite Queen’s Park on Glasgow’s south side for more than 50 years. I joined in 2000, having just completed specialist training in restorative dentistry. Andrew Paterson retired from the practice (not dentistry) in 2017 to pursue academic and other commitments and my wife Kath and I took over, building on the specialist referral side.

We are currently three dentists, including our associate Barry Fraser, who joined us in 2014 with a masters in implant dentistry and special interest in all aspects of restorative dentistry. We are brilliantly supported by two hygienists and four nurses, including our senior nurse, Susan Clark, who has worked at the practice for over 40 years and is definitely the keeper of the ‘deep knowledge’, part of the intangibles of any small business.

We offer a comprehensive range of dental treatment from a filling to a full arch implant bridge and are what one might call a ‘mongrel’, a specialist referral practice that also provides high quality routine dental care. We have a sizeable and very loyal base of patients who attend for their routine dental care, with the majority of these in the 55-75 age range.

Whilst we currently see children of registered patients on the NHS, in terms of income we are 99.7 per cent private and do not offer payment plans. Practice revenue is essentially all from item of service, pay as you go. The majority of referrals are for implant-related treatment but we also accept referrals for endodontics, management of failing dentition and any restorative dentistry-related problem. In terms of use of clinical time, the split is about 50:50, as implant cases or more complex rehabilitations demand significantly longer appointments.

EARLY 2020

Like everyone else we watched TV and read newspaper reports about the new virus in China but, I suspect like many, we convinced (or deluded) ourselves that this was something happening ‘far, far away’. When Italy was hit hard, our sense of unease certainly increased and we knew it was only a matter of time before it impacted on the UK.

How much contingency planning did we do before lockdown in March? Probably not enough is the short answer. We have tended to lean more toward just-in-time ordering to preserve cash flow. It rarely failed. We had healthy stocks of gloves and masks so why think about stockpiling? How could we possibly run out? Supply chain was not a phrase that came up very often pre-Covid.

On the clinical side, we obviously followed the rules and ceased AGPs (aerosol generating procedures) from 18 March. The priority was to ensure we left our patients in as stable a dental condition as possible. None of us thought for a minute, however, that we were going to be still sitting at home in May and June with no real idea of when we would be able to return to work.

A letter from the chief dental officer (CDO) arrived announcing that a financial support package for NHS practices was as good as finalised. Private practices, on the other hand, were not, it seems, on anyone’s radar other than to tell us to close like everyone else. The UK government had announced an employment support package and job retention scheme (JRS) covering 80 per cent of wages backdated to 1 March, and furlough entered the lexicon. At the clinical level, the consequences for hard-hit supply chains started to manifest with limited availability of gloves and masks and prices of all PPE heading North at an alarming rate.

The day after lockdown was announced we cancelled as many patients as we could for the coming fortnight. After a short pow-wow around the staffroom table, we sent all staff home reassuring them that as far as we were concerned all jobs were safe, that they would be paid that month and that we would keep them informed of developments. There was understandable mild anxiety but no sense of panic.

We put an extended message on the answer phone, clearly informing patients of why we had to close and how to get in touch with us, advising them to use the reception email address for all but true dental emergencies and to look at our website for updates. After that, we ran a back-up to that day’s external drive, did a final sweep of the practice and, ominously, unplugged the kettle before finally locking the door. To steal an epithet from the late great Douglas Adams, the day was rapidly becoming the long, dark tea-time of the soul.

GOING INTO LOCKDOWN

None of our patients were particularly surprised by our decision to close doors, since every aspect of life was being affected in a way no-one had experienced in living memory. They were grateful to be kept informed and I don’t honestly remember any overtly negative responses aside from understandable concern from those patients in the middle of treatment as to when it could be completed.

Unsurprisingly, our immediate concerns were financial. Our income stream had already diminished in the second half of March with cessation of AGPs and then was turned off pretty much overnight on the 23rd. As a private practice we were not in receipt of the NHS funding package. We looked to freeze as many fixed costs as possible, including any practice finance agreements. We were sitting looking at a significant amount of lab work that wasn’t getting fitted any time soon and the bills that came with that work. We had some difficult conversations with our laboratories, bearing in mind that they, like us, are small businesses and were also going to be hard hit. But the response across the board was heartening, with the exception of one well-known dental wholesaler who seemed oblivious to the financial implications of the pandemic for dental practices.

I carried the on-call mobile phone throughout lockdown and our patients were very understanding, but obviously concerned that they were going to be left in a limbo state for a very long time. Mercifully few contacted us in pain and we followed the ‘advice, analgesia, antimicrobials’ directive and liaised with their GP practice and subsequently directly with pharmacies by phone, sending prescriptions through the NHS email system. That said, after 30 years of telling patients that antibiotics were of absolutely no use for acute pulpitis, it felt just plain wrong to be doling them out when we knew we could do much better.

Where necessary we filled in the triage form and remotely referred patients to the appropriate UDCC (urgent dental care centre). For non-emergencies, basically broken teeth, we certainly did feel at times like the proverbial chocolate fireguard. You are trained to deal with a patient’s dental problems as timeously as possible, so to be simply reassuring them that their broken and ‘just a wee bit’ sensitive tooth would be fine until…well until the powers that be let us back to deal with it... was pretty depressing.

I recall a conversation with one lady who had got a bit carried away with a DIY repair kit on her chipped lower incisors. We discussed the merits of using an emery board to file down what looked, from the images she sent me, like a scale model of the leaning tower of Pisa. I don’t think I have felt more useless. Simply talking to patients (as we all know) helped allay their worries, and the fact they knew they could contact us by phone was often all that they required.

NO END IN SIGHT

I think the worst part of the whole period was the anxiety of not knowing when it would end and when we would be able to get back in to treat our patients and earn a living. Barry had a couple of days based in Glasgow Dental Hospital where he was triaging patients but, like many self-employed, did not qualify for the self-employed income support scheme.

We had a very successful viable business before 23 March. The thought of that going down the drain was galling to say the least. I think we lurched from, “Ach we’ll be fine” to fleeting thoughts of having to apply for insolvency to ever more frequent fits of incandescent rage at finding ourselves in this position. Sharing our anxieties, thoughts and ideas around remaining viable with colleagues was incredibly helpful. In particular, Bruce Hogan, a friend and colleague in the same boat as us in Glasgow, deserves special mention for his insight, empathy, camaraderie and clear thinking.

Here we were, the same as private practices across the country, playing by the rules and being told by those in well-paid, protected public sector employ, with no real understanding of the realities of what we were going through, that “computer says no” when it came to financial assistance.

We were eligible for the JRS as well as the small business rates relief payment of £10K. Furlough continues to be a very welcome cushion while we work under the current restrictions.

Along with a group of like-minded colleagues, we wrote to the Scottish Government pointing out the potential looming disaster for many practices with a mixed private and NHS income stream, who would be hard pushed to remain viable. This request for support was at a fraction of the level provided to committed NHS practices but enough to keep us viable. Predictably, we received a fairly standard letter back pointing us to all the avenues for financial support that the Scottish Government had made available to business. In other words, they regarded us as no different from any other private business; they had bigger fish to fry and were really only (barely) interested in NHS dentistry.

Maybe I would have had a much more restful time not sitting in my kitchen writing letters or on Zoom calls but you can’t always just pull the duvet over your head. Dentists across the UK mobilised support for action very quickly. In Scotland we have the 'Saving Scottish Dental Practices' network on the Mighty Networks platform. This has been driven primarily by David Offord at Vermilion in Edinburgh and has attracted almost 900 members to date from across the practice profile spectrum. At the UK level, the BAPD (British Association of Private Dentistry) now has 10,000 members and is an ever-louder voice on the UK dental politics stage. At a practical level, sourcing and importing PPE via the Saving Scottish Dental Practices Network, independent of dental wholesalers, was a prime example of lateral thinking in action.

BACK TO WORK

In order to be viable as restrictions eased during the summer we needed to be able to carry out surgery and AGPs. By mid-May we had confirmation that the CDO Scotland had no jurisdiction over private practice. Whatever the perceived rights and wrongs of that, it meant that whilst being extremely mindful of the safety of our patients and our staff, we could plan how we would re-open. We had frequent discussions with like-minded colleagues. Following the initial SDCEP document, we produced our SOP (standard operating procedure) and through Mighty Networks we were able to source an initial supply of disposable gowns, visors, aprons, IIR and KN95 masks. A friend of ours with contacts in the construction industry helped source a dependable supply of 3M FFP3 and FFP2 masks at a competitive price. As we see children on the NHS, we have also been in receipt of IIR masks, aprons, visors and gloves, which is welcome.

We were certainly not the first practice to reopen but were in the vanguard. It was a pretty stressful time but we knew we had to see our patients again. The final straw was when a regular patient with a perfectly saveable premolar who had been referred to a UDCC for management of pulpitis, contacted me to say he had been offered antibiotics or extraction. My patient was hearing this from a senior clinician in a dental hospital. Needless to say the tooth was successfully root treated, uneventfully, over two visits.

Aubrey Craig at MDDUS was an excellent sounding board at that time, providing wise counsel and reassurances with regard to our legal standing and indemnity at a time when the profession was being as good as threatened with police intervention for opening in one health board while practitioners in another adjacent board were being given a green light.

An independent health and safety adviser arranged for our staff to be face-fit tested for FFP3 and FFP2 masks and we purchased four different types of mask to increase the chances of all staff passing on at least one. Thankfully everyone passed on two masks. We had ordered an initial supply of disposable fluid-repellant gowns and also re-usable ‘Yorkshire’ gowns. We find the latter significantly cooler to wear than the disposable gowns, though the constant laundering of these is yet another chore after a tiring day.

Like everyone else, we gladly handed over our gowns, masks and gloves for the greater NHS need at the start of lockdown. Getting re-equipped was again not without its challenges. The cost of consumables was eye-watering compared to pre-Covid prices. Availability has certainly increased significantly and prices have come down but VAT has, quite incredibly, been added back on from the start of this month. As dentists, we are not VAT-registered, so this is yet another cost to be factored in.

RESTORING ROUTINE CARE

Pain takes priority and our first forays into treatment were for patients in acute pain and those ‘walking wounded’ with broken and intermittently symptomatic teeth who had been on the triple A mousewheel for many weeks. We also had a significant backlog of patients with large, complex treatment plans that had been put on hold. These cases are time-hungry, requiring long appointments, but to be blunt are also the most remunerative and vital to our survival from a practice viability perspective. Trying to balance the urgent and essential with an understandable demand for routine dental check-ups and hygienist visits has been a challenge.

We are now performing AGPs and have provided a full range of treatment for our patients since July. Initially our fallow time was 60 minutes, but with mitigating factors such as high-volume suction and rubber dam and the most recent information from SDCEP/ FGDP, we have reduced this to a minimum of 20 minutes. Realistically it is never less than 30 minutes.

The fallow time has to be factored in to making appointments. We have three surgeries but the smallest is used almost exclusively by our hygienists. This has meant that we can realistically only have one dentist in at a time, working between two surgeries. This demands that the pre-appointment phone triage process (where we also update medical history and do a Covid questionnaire) has to provide as much information as possible. We all know from (bitter) experience that, for example, crowns rarely just fall out but upper incisors do shear off at gingival level not infrequently. Add in the need for fallow time and your non-AGP re-cement crown appointment then turns into a far more time-consuming problem that can throw the diary right out the window.

Fallow time also hurts at the fiscal level. Surgeries lying empty for chunks of the day has a significant impact on the bottom line. Fixed costs don’t change, wages must be paid and materials costs never go down. This is obviously a major issue for NHS practices whose model is predicated on high-volume throughput. It is currently the cause of much debate on future funding models. but no less affects private practice. We have had to reassess our charging structure as the practice is operating at no more than 50 per cent capacity.

WADING IN WET CLAY

Managing AGPs is probably the most frustrating and demanding aspect of getting back to providing care. Wearing FFP2/3 masks with a full-face visor and fluid resistant gowns on a hot (or even a vaguely mild) day can be extremely uncomfortable and very tiring as you rebreathe your expired air. At times, the simplest procedure starts to feel like wading through wet clay. Communicating through masks and visors is difficult and exhausting. That said, you get used to anything and given there is no immediate likelihood of life returning to normal; it’s just what we have to do.

Our staff have been brilliant. Everyone has stepped up despite the worries of lockdown, the near paranoiac levels of additional cleaning, the additional time and patience required at reception when taking calls and making appointments, as well as the demands of wearing PPE. We could not be prouder.

Personally it has been very stressful not knowing how or if we were ever going to recover our business. Our children were also very much aware of this and had their own challenges, with two missing their Nat 5/ Higher/ Advanced Higher exams and our eldest uncertain of receiving his place at university. Our youngest was being home schooled with daily online classes and homework to complete, so every day was, quite literally, a school day.

FUTURE HOPES

Doing good dentistry is difficult at the best of times. Patients may be forgiven for not appreciating this. Striving for excellence during Covid can at times seem an almost laughable aspiration rather than a realistic expectation.

We don’t underestimate the threat from Covid. This is a virus that kills and can leave previously fit and healthy individuals with life-changing, multisystem effects. That said, we also need to be careful not to sleep walk as a profession into adopting work practices and levels of PPE that all but guarantee mediocre clinical outcomes becoming the norm, not to mention the attendant economic and environmental costs. Good science needs to prevail. We could spend a fortune on additional equipment that when properly scrutinised makes little or no appreciable impact on reducing infection risk. These decisions need to be made with input from wet-fingered dentists with skin in the game.

For us, though, it’s pretty simple. We will continue to support our colleagues who entrust us with their referred patients, and to look after our own loyal patient base who have kept the faith with us throughout this difficult time and appreciate the care they receive under challenging conditions.

Doing the best job we can for those two groups – I think we would be happy with that, although a mask with a built-in coffee dispenser wouldn’t go amiss.

John Sadler is a specialist in restorative dentistry and prosthodontics, and Katharine Sadler is a general dental practitioner