The negotiations between the Government and the BMA/BDA representatives on the new SAS Contracts for doctors and dentists in England, Wales and Northern Ireland have just concluded.
There are a series of ‘Roadshows’ which have been organised to explain the detail of what has been negotiated and what it might mean for you. They are being held between in February and can be accessed by BMA/BDA members or non-members using the following link:
Following this, the BMA and BDA will be holding a Referendum for their SAS members to vote on whether to accept or reject the new contract. This will be held from 7th February- 27th February 2021. You do have to be a BMA/BDA member to vote in the referendum.
The BMA/BDA will contact you to allow you to vote in the referendum. Please make sure that your registered details are correct, especially your SAS status, to ensure that you are contacted to vote.
It will come as no surprise to you that as I write this, we remain in unchartered waters with regards to Covid-19 and I hope that you and your families are well and that you are safe within your professional role. I am sure that we have all experienced, and some of us continue to, uncertainty within the workplace. Certainly, as an academic life is very different with no students on site, and a significant reduction in clinical workload in my working week. Remote teaching and learning however has exploded and am I pleased that it seems students have taken to this like ducks to water. Thankfully this continues to work well, which I am grateful for as I suspect this may well be a core component of future teaching.
Aside from the obvious, as a Council Member I have been involved in developing the BAOS website, which I must initially pay gratitude to Pete Brotherton for the spectacular revision of the site a couple of years ago. I am sure you will agree that the site is now much fresher and easier to navigate. With the essential input from Shelley, Sophie and Rita we are in the process of developing the Members’ area with additional resources and links to key areas. As part of this, I would be delighted for suggestions from Members as to how you think the Members’ area could be improved. We had a minor glitch last year relating to a complex ‘coding’ issue, causing some Members not to be able to access the journal. This, however, seems to be now repaired and should allow a direct route from the Members’ area to the journal. One aspect which I was keen to pursue, and we already have this live for the CAST group, is the use of forums to allow Members to communicate within the subgroups of BAOS. The more I consider this though, the more
I wonder if Members are less likely to use this and are more likely to use a platform which is accessible from their smartphone or tablet? More and more do we as a society crave quick and direct access to communication and having to log into a website and then a forum may be seen as laborious and time consuming! I had considered sending out a survey regarding this issue, but in the current climate I think we are all saturated with surveys, so if I could encourage you to email BAOS with website suggestions and perhaps a survey will land in your inbox later in the year!
Secondly, and finally, could I thank all Members for completing the Covid-19 survey which we have sent out each week since the lockdown. The information has been extremely useful and as I write this, myself, Paul and Divya are working hard on the data which we hope to share with you all in the near future. It has been particularly interesting discovering what our Membership have been involved in through Covid-19, and the challenges which you have faced. We appreciate the time and effort which many of you have put into recording this data.
In my Newsletter in early January 2020 I highlighted our BAOS Mission Statement, ‘Excellence in Oral Surgery through education, training and research for better patient care’ and the enthusiasm of BAOS Council to continue during 2020 to support Oral Surgeons and their teams in delivering the highest standards of care for their patients. That delivery of surgical care has been harder than we could have imagined. With the suspension of routine dental care to mitigate coronavirus transmission by close contact and aerosol, and the suspension of routine surgery to enable NHS capacity for COVID-19 patients, the face of oral surgery care has changed. My last Newsletter in March I discussed our early oral surgery response to the COVID-19 pandemic. We have experienced and learned a lot since then!
The provision of emergency and urgent care is a moral imperative. Patients with facial trauma, spreading infection and swelling that compromises the airway have typically presented directly to Accident & Emergency departments or been immediately referred by a dental practice. This service has continued and many Oral Surgeons have provided care to these patients. Urgent surgery has also been undertaken in primary and secondary care with many oral surgeons contributing. There are reports of patients not attending Accident & Emergency departments for fear of contracting COVID-19 and problems with access to urgent dental care because of PPE shortages. There have also been capacity issues around COVID-10 testing for dental professionals.
The BAOS Council recommended cessation of routine care and the use of appropriate PPE with our first website advice on 16th March. We received messages of gratitude for the prompt advice from many individuals in the UK and also around the world and from several professional bodies. We recommended the use of gowns, gloves, FFP3 masks and eye protection for all oral surgical patients whether symptomatic or not to achieve maximum protection at a time when the NHS view was to use routine PPE unless a patient had symptoms or close contact history supposing that patients were not infectious if asymptomatic.
BAOS Position Statements
We went on to produce a series of COVID-19 Position Statements jointly with BAOMS about PPE and respirators, urgent care and domestic violence and abuse, that I trust were helpful. We also highlighted a limited number of articles relating to urgent care, analgesia and radiography, and the SDCEP and Cochrane Oral Health COVID-19 resources. We have all been overwhelmed with guidance from so many sources so we resisted publishing guidance from elsewhere, conscious that much has been of poor quality. Importantly we published ‘Information for Patients during the Pandemic’ on 6 April. This is a novel virus so research evidence is scanty but growing fast. Our Council’s agreed view was based on rapidly reviewing evidence as it appeared and also incorporating the learning from colleagues ahead of us in Wuhan, Hong Kong, Singapore, South Korea as well as Europe.
Many countries, including our own, moved to telephone and video consultations but we have learned, not surprisingly, that the absence of clinical examination and ability to offer an accurate diagnosis and comprehensive care has been uncomfortable. The loss of screening for caries, periodontal disease, oral cancer and others by the general dental services will doubtless have allowed disease progression, pain and suffering. There are of course, some advantages of remote consultations that we will want to keep!
BAOS has contributed to the national response to the COVID-19 pandemic with written submissions and discussion with NHS England and PHE. We were invited to review the draft changes to PPE for the CMO Clinical Advisory Group via the Academy of Medical Royal Colleges. We were invited to contribute the Restorative Dentistry COVID-19 guidance. Our views have not always been accepted but we have continued to lobby. We were anxious about the encouraged avoidance of surgical extractions, as care to avoid surgical extraction is always an aim of tooth removal, but this cannot always be reliably predicted. Avoidance of tooth removal for concern of becoming a surgical procedure would inevitably encourage inappropriate use of antibiotics and analgesics that can predictably lead to spread of infection. A surgical handpiece causes aerosol in addition to splatter and both are a health risk to the surgical team. Whilst it was acknowledged that a respirator should be part of the PPE when using a surgical handpiece the shortage of these would have inevitably driven the need to restrict surgical tooth removal.
I was invited as President of BAOS to present at a webinar about PPE by the BDA hosted by the Royal Society of Medicine. I will shortly be speaking at the European Association of Paediatric Dentistry online conference about the impact of COVID-19 on dentistry. Richard Moore, BAOS Council Member, has presented an RSCEd webinar, ‘Surgical Dental Procedures in a post-COVID-19 world – what is new?’.
Education and Clinical Research
The COVID-19 pandemic has resulted in the suspension of University face-to-face undergraduate and postgraduate teaching, with rapid transfer to on-line teaching arrangements and assessment. All simulation-laboratory instruction and clinical teaching has been suspended, as has Clinical Research. The work involved in making such sweeping changes to education has been immense for our clinical academic colleagues. The Higher Education sector is anticipating financial pressure in the autumn and some univerisities are mitigating the risk with voluntary severance schemes, my own included. The economic consequences have already impacted clinical general dental practice and has increased the financial risk for primary care oral surgeons.
It will be difficult to ascertain the full impact of the disruption to dental services, education and research but it is likely to be substantial. The immediate focus is now on return to routine care provison with likely longer-term permanent changes. The very helpful, ‘Recommendations for Oral Surgery during the recovery phase of the COVID-19 pandemic’ was published in June. The development of these guidelines was led by Judith Jones, BAOS Council Member, on behalf of the Faculty of Dental Surgery, RCS England, and Tilly Loescher on behalf of the Association of Dental Hospitals and in collaboration with the BAOS.
Richard Moore, Divya Keshani and I have overseen the BAOS Survey of its membership to understand the impact of COVID-19 on their practice and provision of care for patients. Re-deployment clearly caused initial anxiety for some and PPE shortages cause ongoing concern and stress.
There were hospital visits last year in preparation for the, ‘Getting it Right First Time’ (GIRFT) report. The GIRFT visits to surgeons, clinicians, support staff and managers were invaluable in highlighting areas of persistent variation and in making recommendations that were about to be published as the COVID-19 pandemic reached the UK. BAOS had contributed to the report and we were invited to contribute again as the NHSEI wanted to incorporate specialty responses and innovative ways of working learned from the COVID-19 pandemic. We have proposed oral surgery education for general dental practitioners, more conscious sedation, greater integration with general healthcare, oral surgeons at the forefront of oral cancer identification, serving vulnerable patients and offering leadership. Delivery of this and more will require more trainees, Specialists and Consultants.
Oral Surgery Trainees
Our trainees have been involved in urgent dental care delivery and around 60% have been re-deployed to support the medical response to COVID-19. This is a new world for all of us but is particularly difficult for our colleagues at this stage in their careers. There has always been a degree of uncertainty about oral surgery career progression but this pandemic has added an additional level of anxiety. More positively most have embraced the opportunities of change.
Our September 2020 Annual Scientific Conference at the Assembly Rooms Edinburgh has been postponed until 4-5 March 2021. The majority of the members that responded to feedback requested a trial two full days, rather than the usual 2 1⁄2 days conference, with slightly shorter presentations. This will likely be more appreciated than had been anticipated as with a depressed economy and building waiting lists, study leave requests may be more difficult. Put the date in your diary!
The BAOS Councils’ mission is to serve our surgical community and will continue to lead our specialty in the UK and contribute to the support of oral surgeons worldwide. We can be proud of membership that is supportive of patients and of each other. Please also note that we now have an Instagram account in addition to our Facebook and Twitter presence. Please follow and share!
Just excuse me for a minute whilst I saddle up my hobby horse!
So where are we up to with patient safety in dentistry? Are we slavishly following checklists developed by people who do not understand the subtleties of dental care? Or are we actively involved in the concept of patient safety, realising that checklists are only part of the picture?
In my experience, the development of patient safety interventions in oral surgery has boiled down to culture change. How long does it take to change culture? It takes years. Think of the situations we work in, they are not straightforward and we are aware that errors can and do still occur. The revolving door of students and junior staff in hospitals makes this all the more difficult – the culture change is akin to painting the Forth bridge (although they found new paint for this and only have to do it every 25 years!).
I think that our profession needs to take ownership of this problem – why are we told by other healthcare professionals (who have never administered one) that a wrong side ID block is a ‘never event’? There has been some sensibility in this recently, with the wrong side ID block now clearly not designated as a ‘never event’1. At a recent high level trust meeting I attended on serious incidents, a wrong side ID block was discussed with the chair concluding ‘didn’t it just wear off?’ I believe that we are only beginning to understand the subtleties of patient safety in dentistry – why isn’t filling the wrong tooth or performing root canal treatment on the wrong tooth a ‘never event’? Or even erroneously irrigating a pocket with sodium hypochlorite in the belief that it was saline! Perhaps a dental never events framework is the way forward. I also don’t agree with the term ‘never event’ it is so negative and we know that they still do happen, so therefore it is etymologically incorrect! Perhaps they should be ‘always events’ – we always check we have the right patient, we always provide the correct treatment… Food for thought (I hope).
BAOS Council Member
While we are used to the clinical impact and disruption flu causes annually, the current Coronavirus remains a high concern and unpredictable impact with significant media attention. At the time of writing there have been 73,000 cases of Covid-19 worldwide, with a death toll of 1,868 to date. The fatality rate is thought to be about 2% affecting the vulnerable. To keep it in perspective, influenza leads to about 3-5 million cases of severe illness a year with approximately 290,009 to 650,000 respiratory deaths worldwide during an annual epidemic. This is a similar mortality rate, amongst the same at risk groups.
Both viruses have a similar transmission through droplet spread or direct hand to mouth contract. It is therefore reassuring to know that basic hand hygiene remains paramount in the effective reduction of transmission of both viruses. The Covid-19 virus also has a lipid envelope and therefore a wide range of disinfectants are effective at cleaning and decontaminating clinical environments. Standard PPE including surgical masks help to reduce the risk of healthcare workers contracting influenza. However since the Covid-19 outbreak has been classified as a Public Heath Emergency, the UK legislation requires employers to provide fitted FFP3 masks to protect against contamination with Covid-19. FFP3 masks are only effective on clean shaven faces as facial hair prevents the creation of an effective mask seal. The current concern with the spread of Covid-19 has lead to a high global demand for face masks and face shields and a reduced availability. Dental suppliers are now limiting the purchase volume of all face masks to general practice, which could potentially compromise the provision of dental services. The true impact of Covid-19 and our ability to reduce transmission, may only be apparent at the time of reading this article.
BAOS Council Member
In 2008 the World Health Organisation’s (WHO) devised a Surgical Safety Checklist. Following a year-long worldwide study of nearly 8,000 patients. There was clear, compelling and compounding evidence that, when this checklist was used, there was a one-third reduction in surgical deaths and complications. This checklist was introduced into every hospital in England and Wales.
There had already been reported errors of amputations of wrong limbs or the removal of a healthy kidney.
In 2009 the National Patient Safety Agency started, for the first time, to collect data on ‘never events’.
The concept of ‘never events’ was introduced in the NHS in England in April 2009, following a proposal by Lord Darzi in his report High Quality Care for All. This initiated the NHS Improvement Group to be formed.
NHS Improvement defined the term ‘never event’ as “serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers”.
The term ‘dental never event’ was introduced in 2015 by NHS Improvement and following this, later that year, NHS England introduced its own National Safety Standards for Invasive Procedures (NatSSIPs) which build on the existing WHO surgical checklist. NatSSIPs offered healthcare professionals general advice on how they can enhance best practice through a series of standardised safety checks and education and training. The standards also support NHS providers to work with staff to develop and maintain their own, more detailed Local Safety Standards for Invasive Procedures or LocSSIPs.
In 2018 the National Patient Safety Agency revised it list of ‘never events’ and categorised incidents in relation to ‘surgical’, ‘medication’, ‘mental health’ and ‘general’ domains.
Today all commissioners and providers of NHS care are required to report ‘never events’ for a list maintained by NHS Improvement. Statistics are collated and published regularly.
In the year to March 2019, a total of 496 ‘never events’ were reported to NHS Improvement– and of these 42% were classified as Surgical – wrong- site. Of these, wrong tooth extraction was 20% of cases.
In 2016 a working group including the Joint Colleges of England and BAOS produced a toolkit for developing ‘LocSSIPs to avoid wrong-site extraction’. It was noted that although dental may not be on a par with the loss of a limb or major organ but it could still be devastating for both patient and clinician.
BAOS provides guidance on our website with regard to the LocSIPPs process for wrong-site extraction. We advise that in mitigating such risks it is critical that dental teams develop checklists appropriate to their specific clinical environment and provide adequate training for staff in implementation and use. There should also be active Quality Improvement of the processes involved to ensure that checklists are being used correctly and that teams can learn from mistakes – including investigation and root-cause analysis. Any “punitive” action should be avoided when incidents do occur to encourage openness.
The reporting of ‘never events’ is key to learning lessons from clinical errors although some ‘never events’ have always been contentious. As recently as 2019, wrong site local anaesthetic was downgraded. This change put an end to the unnecessary and highly stressful investigations associated with ‘never-events’.
The Home Countries have their own way of reporting these clinical errors;
- In England never events must be reported via the Serious Incident Framework. In 2021, this will be replaced with the Patient Safety Response Framework (PSIRF).
- In Wales, never events must be reported to the National Reporting and Learning System (NRLS).
- The Scottish Government implemented Healthcare Improvement Scotland and Northern Ireland also has its own reporting requirements through the Regulation and Quality Improvement Authority (RQIA)
Deliberate failure to report a never event is likely to constitute a serious failing and breach of Care Quality Commission, Health Inspectorate Wales, Care Inspectorate in Scotland or RQIA requirements.
It must be remembered though, that it is the GDC who sets standards for professionalism within the dental profession, which include a duty of candour for all dental professionals and how we should all respond when there has been an unexpected or unintended incident resulting in death or harm. This includes notifying the person affected and providing an apology and account of what happened.
Saying sorry is not the same as admitting liability.
BAOS Council Member
Being asked to write this newsletter for the January edition of our journal, I find myself spending time (like many of us at this time of year) reflecting on the past year and planning for the time ahead. However, this introspection is not aimed at my work or family life but actually at the BAOS annual conference!
We are in the process of hashing out the figures from the 2019 conference, looking at not only the financial outcome of the conference but also the delegate feedback of the event. Being part of the planning committee along with Anna Dargue, Pippa Blacklock, Rebecca Hierons and our administrative team, I have discovered there are a huge number of decisions to be made. All of the Council members are volunteers and although passionate about provision of education and teaching for our members, none of us are professional conference organisers! There is also a financial pressure to ensure the event does not jeopardise the overall financial health of the organisation especially as recent conferences have all made a slight loss. BAOS council are adamant that we don’t run the annual conference as an exercise to make money and our aim is primarily to organise an excellent educational event which “breaks even” or ideally makes a modest profit. I am pleased to say that early indications are that the 2019 conference has fulfilled this aim. Financially we are likely to make a profit from this year’s conference and the feedback is generally very encouraging. However, there has been some constructive criticism of aspects of the conference. We will be providing feedback to the conference venue to highlight areas which they could improve on and all of the speakers will be given their individual feedback. Like all things in life, the adage “You can’t please all of the people all of the time” does seem to be particularly true when reading the feedback comments. Most of the delegates this year were very pleased that the conference was held in Bristol, but we did have a few comments that Bristol was “inconvenient” and “difficult to get to”. The catering at these events is always divisive, we spend a great deal of time discussing menus, trying to account for all different dietary requirements and hoping that at the event, the food produced will live up to the caterers promises. This doesn’t seem to have been the case for all delegates and again we will be feeding back to the relevant parties.
All of your comments are a big help in planning future events and in 2020 we are changing the structure of our conference as a result of overwhelming feedback from a recent survey. The conference will be held over 2 days instead of 3 with only 1 formal dinner and no “informal” social night. The aim of this is to reduce the amount of study leave required and reduce accommodation costs for delegates. We are also considering moving away from holding the conference in Edinburgh bi-annually. There are many reasons for this, but a significant factor is the cost of running the conference in Edinburgh is considerably higher than some other cities, with venue, catering and AV costs being up to 50% higher than Bristol for example. These increased costs lead to an increased ticket price despite all of our efforts to keep delegate fees as low as possible. For comparison, the 2018 conference in Edinburgh had a full ticket price of £550 compared to the Bristol ticket price of £500.
The 2019 conference in Bristol seems to have been “The Perfect Storm” as far as conferences go – very reasonably priced venues for the conference and social events which allowed us to reduce the ticket price compared to previous years and an excellent educational programme with interesting speakers which attracted record-breaking attendance levels. Normally we hope for 300 delegates to attend the conference, but Bristol far exceeded this. I am hopeful we will use this great success to plan an equally successful conference in 2020 and the first job on the to-do list is to shortlist the caterers!
Oral Surgery journal now available via App for Apple as well as Android!
You will be aware that we went paperless with our Oral Surgery journal so the first issue of 2019 was online. An Oral Surgery journal App was immediately available for Android devices but unfortunately not for Apple devices users! The approval by Apple has taken some time and this was not foreseen so many apologies for that. The journal has always been available to everyone via the BAOS website and Google of course but it has been frustrating for Apple devise users not to be able to use the App and its functions.
I am pleased to announce that our journal Executive Publishing Manager with John Wiley & Sons, Martin Tilly, and the Wiley App Development team recently re-submitted the Oral Surgery App application to Apple and it has been approved, so it is now available. Great news!
Professor Paul Coulthard
On behalf of Dr Helen Petersen, Editor-in-Chief, who is currently on maternity leave.
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