Frequently Asked Questions
Q1. I am an NHS provider in one of the areas most severely affected by the recent swine flu outbreak. We have already seen a significant fall-off in patient attendance and we fear that worse is to come. We are still recovering from a sizeable clawback by our PCT last year when we under-delivered on our UDA target. Will any allowance be made if we under-deliver on our UDAs again this year - through no fault of our own?
Q2. I am an NHS provider, owning two large practices. I have been asked by my local PCT to supply one or more of my performer dentists to work in a Dental Access Centre and from a local CDS clinic, which is to be manned on a rota basis by several local practices. I am not terribly happy about the equipment and backup staff that will be available and I am not sure who will be responsible if anything goes wrong.
Q3. My husband and I are both dentists and we jointly own a practice. I have two young children and because of this I have been working part time. My Dental Protection membership is therefore in a part time category for up to 150 hours a year (3 hours a week on average). Our associate and VDP have both been off sick with flu and I have been working a lot of extra hours to cover for them. I have just realised that I am working a lot more than 3 hours a week on average so what do I do about my indemnity?
Q4. I am carrying out a risk assessment in my practice, as I have been advised to do by my PCT. Are there any types of dental procedure that should be avoided, or any particular precautions I should be taking with respect to my staff?
Q5. I have young children and an elderly parent with failing health living with me at home, and having heard that most of the serious cases have involved the young and other vulnerable groups. I am concerned about the possibility of my becoming infected at the practice, and then transmitting the infection to them. I also know that some of my staff also have similar vulnerable people at home ; could I become liable if they became infected at work and then transmitted this to their family?
Q6. I own a very small, single handed practice and I have read the Department of Health's advice about having separate entrances and waiting rooms for those with and without flu-like symptoms, and designating specific team members to deal with symptomatic patients. How am I meant to do this in a practice like mine? And since these measures are impractical, should I be closing my practice altogether?
Q7. Where can I obtain further advice and information?
Q8. I am a dental contractor, and my PCT has asked me to assist with the national response to H1N1 by joining the local team to inoculate the general public. As I have had no training for this I wondered what indemnity I would need?
Q1. I am an NHS provider in one of the areas most severely affected by the recent swine flu outbreak. We have already seen a significant fall-off in patient attendance and we fear that worse is to come. We are still recovering from a sizeable clawback by our PCT last year when we under-delivered on our UDA target. Will any allowance be made if we under-deliver on our UDAs again this year - through no fault of our own?
The Department of Health (England) has stated in guidance documents that ‘contractual payments should continue to be made to providers with no penalty, subject to providers having taken all actions within their power to comply with their contractual terms. The PCT and the provider would be expected to agree a reasonable and proportionate response to the disruption of normal service provision'.
One such ‘reasonable and proportionate response', if you are fit and able to practise but most of your staff are off sick and your patients are staying away, might be that your PCT could ask you and any available staff members to support the delivery of essential services in a local Dental Access Centre, or other PCT facility, or to offer your services to help and support the wider NHS in one way or another. For example, if because of illness another local practice finds itself unable to treat patients, your PCT might ask you to accept some of their patients, especially if they need urgent treatment.
In any event, most GDS and PDS contracts in England and Wales include a ‘force majeure' provision which protects a provider financially against events beyond their control, providing that the provider has done everything in their power to fulfil their contractual obligations and have kept their PCT closely informed of what was happening and why. Providers are advised to keep detailed records of:
a) levels of patient attendance (including new patients), cancellations and missed appointments
b) staff sickness and absenteeism
c) the steps they took in an attempt to maintain continuity of service provision
d) all communication with the PCT whether by letter, phone or email - especially in connection with any requests to provide additiona;/ different services on their behalf.
In the cold light of day after any pandemic has subsided, PCTs will be likely to scrutinise very closely any claim by a provider that a UDA shortfall was entirely due to the impact of pandemic influenza. All the more reason, therefore, to keep the kind of detailed records suggested at (a) - (d) above. Top
Q2. I am an NHS provider, owning two large practices. I have been asked by my local PCT to supply one or more of my performer dentists to work in a Dental Access Centre and from a local CDS clinic, which is to be manned on a rota basis by several local practices. I am not terribly happy about the equipment and backup staff that will be available and I am not sure who will be responsible if anything goes wrong.
If any dentist is not confident that their working environment allows them to treat patients safely and to an acceptable standard, then they should raise their concerns through whatever the appropriate channels are, and ideally confirm these concerns in writing, and request a written response. You should similarly obtain written confirmation from the PCT that when helping out in this way these performers are working for the PCT, not under your provider contract (under which you would be responsible to the NHS for their actions).
The Department of Health has made it clear that arrangements should be made by the PCT for these individuals to be covered by NHS Indemnity for these sessions, and you should obtain written confirmation that this is the case. NHS indemnity does not, however, cover anything other than negligence claims (it excludes a GDC complaint, for example), so these dentists do need to maintain their own Dental Protection membership to ensure that they have seamless protection. Top
Q3. My husband and I are both dentists and we jointly own a practice. I have two young children and because of this I have been working part time. My Dental Protection membership is therefore in a part time category for up to 150 hours a year (3 hours a week on average). Our associate and VDP have both been off sick with flu and I have been working a lot of extra hours to cover for them. I have just realised that I am working a lot more than 3 hours a week on average so what do I do about my indemnity?
Because our membership categories are based on the number of hours worked in a whole membership / subscription year, you have complete freedom as to how these hours are distributed over the year. Some members work more hours during term time and fewer hours in school holidays, for example. Estimate how many hours you think you will work over the whole of your current membership year (taking into account your renewal date) and if you will exceed 150 hours in the current year, contact our Membership Services department to adjust your category to one of the three other levels that might apply:
Working up to 500 hours a year in total
Working up to 1,000 hours a year in total
Working more than 1,000 hours a year in total. Top
Q4. I am carrying out a risk assessment in my practice, as I have been advised to do by my PCT. Are there any types of dental procedure that should be avoided, or any particular precautions I should be taking with respect to my staff?
The most obvious precaution is to avoid, wherever possible, treating patients who are the height of their infectivity (this will usually be in the period immediately following the first onset of symptoms); this can be achieved by screening patients (ideally before they attend for treatment, or failing that when they arrive at the surgery). Some practices are writing to patients in advance of their appointments and advising them to contact the surgery and/or reschedule their appointments, should they have any flu-like symptoms. It should be made clear in any such communication that this is designed to minimise the spread of infection across the community as a whole, not simply to protect the dental team.
Any dental procedure that produces aerosols (such as the use of ultrasonic equipment, air turbines and 3-in-1 syringes, has the potential to disseminate droplet infection and should be avoided if this is possible.
If you have any staff members who are pregnant, or who may be pregnant, or who may be immuno-compromised for any reason, you should take steps to exclude them from the treatment of any infected patients. Top
Q5. I have young children and an elderly parent with failing health living with me at home, and having heard that most of the serious cases have involved the young and other vulnerable groups. I am concerned about the possibility of my becoming infected at the practice, and then transmitting the infection to them. I also know that some of my staff also have similar vulnerable people at home ; could I become liable if they became infected at work and then transmitted this to their family?
Such concerns are understandable, but clinical dentistry is by no means the only potential source by which you might become infected, and one cannot realistically exclude all of these possible contacts while still having a reasonably normal life. The starting point from an ethical perspective is that healthcare professionals should not refuse treatment to a patient simply because they do not want to place themselves at risk - but in dentistry the situation is rather different from that of a medical practitioner who is called upon to examine and treat the influenza itself in an infected patient. Elective or non-urgent dentistry can often be re-scheduled without detriment to the patient and you should assess each case on its merits, checking the patient's medical history in the usual way. The Department of Health (England) recommends postponing non-urgent care and treatment for infected patients until they are no longer symptomatic (in most cases they will continue to be infectious for seven days after first onset of symptoms, but are most infectious when symptoms first arise). Patients who know that they are suffering from influenza may be less likely to attend for dental treatment (other than in an emergency) anyway, so the potential problem is self-limiting.
In England and Wales, NHS providers will have a clause in their contract to the effect that they must not decline to treat a patient on the grounds of their oral or medical condition (and other situations). But deferring treatment (when appropriate) is not ‘refusing to treat a patient'. A patient requiring urgent / emergency treatment is a slightly different situation, and you should consider the available options and discuss them with the patient.
The ethical position becomes more complicated for most practice owners because they have a separate legal responsibility to provide (see above) a workplace which protects every employee's statutory right to health, safety and welfare. Situations may therefore arise where one's responsibility to patients and one's responsibility to employees might come into conflict. Each situation should be assessed on its individual merits at the time, and advice is available from Dental Protection's advisory team.
As for your potential liability if staff members become infected, if you take reasonable precautions, communicate the steps you are taking to all team members and provide your staff with appropriate personal protective equipment (PPE), then you will have discharged your duty of care to your employees and it is highly unlikely that you could be held liable in the unfortunate event that their family members do become infected. Here again, there may be a variety of ways in which they might have become infected, of which having a family member who works in a dental practice is but one of many. Top
Q6. I own a very small, single handed practice and I have read the Department of Health's advice about having separate entrances and waiting rooms for those with and without flu-like symptoms, and designating specific team members to deal with symptomatic patients. How am I meant to do this in a practice like mine? And since these measures are impractical, should I be closing my practice altogether?
The DoH advice is intended to reduce the risk to non-symptomatic patients and healthcare teams, and it provides a range of recommendations for those situations where it is feasible to implement them, Where it is not, you should take whatever steps you can within the practical constraints you face and continue to offer services to your patients while it remains possible to do so. In some areas the PCT will be able to provide more practical assistance than in others and it may be possible for small practices like yours to work collaboratively in order to overcome some of the practical problems faced by smaller practices. This would normally be co-ordinated locally by the PCT / Health Board. Top
Q8. I am a dental contractor, and my PCT has asked me to assist with the national response to H1N1 by joining the local team to innoculate the general public. As I have had no training for this, I wondered what indemnity I would need?
As mentioned in the position statement the existence of a pandemic does not alter the GDC's standard guidance that all registered dental health professionals should only provide treatment within the limits of their training, competence and physical ability. Once you have been trained for the procedure you will be able to assist the PCT. You should also check with the PCT that you will be indemnified by the NHS Litigation Authority (NHSLA) when doing this work. There appears to be some variation in the arrangements across different PCTs and so if you find that indemnity is not being provided by NHSLA please contact Dental Protection. Similarly if you are approached to provide a similar service on a private basis you should clarify the situation regarding indemnity by contacting Dental Protection before signing any contract.
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