In this week’s bulletin, Prav and Payman quiz Dr Christopher Orr on what practical steps dentists must take upon emerging from lockdown.
Their wide-ranging discussion covers indemnity, protective measures and adopting a triage approach to inviting patients back to clinic.
They also tackle the difference between NHS and private practices, and how regulators and dentists might improve their response, if the unthinkable were ever to happen again.
“There’s always been an element of risk in dentistry that existed long before COVID came along, and the question really is what do we do to really try and mitigate that risk?” – Dr Christopher Orr
Watch the video of the interview here:
00.17 – What do dentists need to do before returning to work?
07.47 – On indemnity
10.23 – Regulation & communication
13.07 – Assessing by need
20.35 – Looking after staff and patients
23.44 – NHS practices
26.21 – Courses and education
27.52 – Preparing for a next time
36.46 – ‘Land-grabs’
39.03 – Protocols, PPE and purifiers
About Dr Christopher Orr
Dr Christopher Orr is a cosmetic, aesthetic and restorative dentist whose past positions include president of the British Academy of Cosmetic Dentistry and the Odontological Section of the Royal Society of Medicine.
He is also a former director of the American Academy of Cosmetic Dentistry and former course director for the MSc in Aesthetic Restorative Dentistry at the University of Manchester.
Christopher was named Private Dentistry magazine’s most influential private practitioner in 2013. He is a prolific international lecturer on dentistry and often features in the press, radio TV and online media.
Connect with Prav and Payman:
Intro Voice: This is Dental Leaders, the podcast where you get to go one on one with emerging leaders in dentistry. Your hosts, Payman Langroudi and Prav Solanki.
Payman: What do dentists have to make sure they get clear before they go in and what would you do in your case in the first few weeks and months?
Christopher Orr: I think it’s probably fair to say that my overall feeling on the PPE situation is that we don’t have enough information. Unfortunately, we do have to, many times, make decisions on the basis of incomplete information. And you couple that with our national mentality of being very cautious and it’s understandable why dentists in the UK are tying themselves up in knots because many people seem to want this nirvana of 100% safety no matter what they do. And we see it at the moment with some of the teaching unions who are saying unless you can guarantee it’s 100% completely safe we’re not going back to the classroom.
Christopher Orr: And that is perhaps an unrealistic expectation. There’s always been an element of risk in dentistry that existed long before COVID came along, and the question really is what do we do to really try and mitigate that risk? First group of people we have to make feel safe is our staff. And I’m aware that in terms of what we do, and again particularly around the issue of protective equipment, we have this basically, probably three ways you can look at PPE. There’s what’s proven to be effective, there is what is recommended by guidelines, and there is what’s available. And frequently we’ve seen that what the guidance is fitted to what’s available, and that’s about as good as we can do at the minute because there’s an absence of absolutely concrete proof [inaudible] on what personal protective equipment is necessary.
Christopher Orr: The FFP2 versus FFP3 thing. The consensus opinion seems to be that FFP3 is not necessary in the dental practise unless you’re treating somebody who actually is suffering from a COVID infection at that moment. And we look around the world, most jurisdictions seem to have settled on an FFP2 mask and a gown for doing an aerosol generating procedure. That’s the basis on which the French dentists went back to work, I think it was at the start of this week, on Monday. In Germany they’ve paid long attention to transmission data coming from Wuhan province in China, which seems to indict that the dental surgery is a much lower risk in terms of transmission of the virus. So the German dentists, they have not closed. Met a man in Berlin, has been seeing patients throughout the entire lockdown period. He’s been doing that at about 60% of the normal speed. They’ve been wearing visors and some masks and that seems to be about it.
Christopher Orr: And I think we’re probably overthinking things. There are a few confounding variables that have come out from the conversations over the last couple of weeks. Some people have been suggest that FFP2 masks need to be fit tested and FFP2 masks, probably the majority would fail fit testing, if you look around the opinions of people who know what they’re talking about. the FFP2, it offers additional protection for you, but whether the additional protection of the FFP3 is necessary, that seems to be fairly negligible for dentists. That was Mark post on dental health.
Christopher Orr: So we will have to settle on something. My hope is two things, one, that whatever it is is commence work with being able to do some dentistry. Even though you can put yourself in all sorts of protective gear, but if it actually gets in the way of doing your job then what’s the point? And the second thing, which I think was either quite correctly said yesterday on webcast, was that these things, when we have these kind of standards we never seem to come back from them. Jason gave the good example of single-use endo files. We’ve not yet got to the point where we can say it’s actually we know it’s okay to re-use these things if we sterilise them. The second thing that I would hope for is something that actually, it’s a temporary situation. And whatever is in the legislation has an expiration date, a sunset clause, whatever you like on it, that can be reviewed and renewed, but otherwise, it falls away when the situation that we’re in hopefully has past. Because if it’s a permanent change to all the personal protective equipment, I think it’s a very seismic change in dentistry, which I think would grossly affect the nature of what we do.
Christopher Orr: So in terms of getting back to work, I think the staff, most important, staff being reassured that the work environment is safe. Is safe for them. And most of the PPE stuff that has been recommended, a lot of it is coming from the point of view of protecting the healthcare worker. To a lesser degree, we’re protecting the patients from us because if you look at all those filtration things, they filter the air on the way in, but not on the way out. Particularly the valued ones. So therefore, there’s not a lot for the patient to stop them getting stuff from you but you’re not getting things from the patient.
Christopher Orr: So in terms of return to work, whatever date you pick, we’re going to have our staff in for probably two or three days before we start seeing any patients. Those couple of days would be used to, number one, reacquaint them with the practise, which they probably haven’t been in for a couple of months. Number two, update them on the new procedures to how we’re going to be doing things. Make sure they can put their PPE on, make sure that they’re able to do that correctly.
Payman: You envisage writing down all of these policies as in risk assessments and so forth. Would you say every practise now has to do a big-
Christopher Orr: Yes, absolutely. There’s a number of reasons for that. I know there’s been some discussion about whether the CDO has any authority over private practises. And the answer, it’s a Vicky Pollard answer. It’s yeah, but no, but yeah, but no, but kind of. In terms of statutory authority, no. In terms of indirect authority, yes. And many of the other organisations we know and like, like the CQC, like your indemnifiers, they will be looking to what the CDO is saying to give them an indication as to how things ought to be going.
Christopher Orr: So whilst there are some people who are saying if you wish to run a private, urgent dental care centre you should crack on, and you can take a view on that, my advice would be that you need to be very, very clear with your indemnifier as to whether they’re going to cover you for that, and have that response from them in writing before you start cracking on and throwing the doors open.
Payman: But what would you say… Chris, when you say that are you saying that the GDC rules are you need indemnity so that’s that, or are you actually thinking of a worst case scenario where, I don’t know, a member of the public or your team goes down with COVID-19 and blames you, the practise owner?
Christopher Orr: In theory, yes, that is the risk. Proving that the dental practise was the play, the onus of proof is on the accuser. But in theory, and of course in Britain, we like to tie ourselves up in knots on theoretical risks of this and this and this. And what you don’t want to have is being sued by somebody and your indemnity provider say, well, actually, we’re not going to cover you. And exactly what is acceptable to the different indemnifiers or insurance providers, it will vary from person to person. My advice for your listeners is they need to have that conversation.
Payman: But they might say that… Let’s say we get a disruptive indemnifier who really wants to make their name now and says, as long as you’ve got CQC and PPE and all this in place, we’re backing you. So then let’s say we start practise and your hygienist catches Coronavirus in McDonald’s and then sues you and says that there was nothing written for whatever it was, procedures. At that point, your indemnifier may not pay anyway. It’s not that you’re going to be left… It’s a discretionary thing. It depends on… For me, is it a GDC thing or is it we’re really going to have these problems? I’m not so convinced one way or the other.
Christopher Orr: We can argue this all day long. The GDC, I don’t believe it is their statutory function to determine when practises should be open and for what. Their job is to protect the public, protect patients by controlling who is allowed to do the dentistry. When those people are allowed to do the dentistry, I believe, falls outside their remit. And I know they’ve taken a bit of flack for sitting on the fence or pointing people towards the CDO, but at the end of the day, that, I believe, is the mechanism.
Christopher Orr: Now, this whole crisis in dentistry has highlighted one of the problems that we do have, that we have numerous different competent authorities who don’t seem to communicate terribly well with one another. It seems they communicate by telegram almost. This minimum amount of information goes from one to the other. They don’t seem to coordinate. Now, of course, in this country, the way we have things set up, in other jurisdictions, the dental society, the equivalent of the BDA, acts as licencing body, trade union, and in some cases offers indemnity as well, depending on how things are set up. In the UK we don’t have that. At least not for dentistry. Some other professions perhaps. And the reason, of course, things were set or split up was that at some point, somebody in the past has argued that the profession should not be allowed to regulate itself unless you’re a lawyer, because the law society do get to do that. But if you’re not a lawyer then you’re not allowed to regulate yourself because there might be a conflict of interests. Therefore, we better get some lawyers to run the GDC and regulate the dentists because they’re not capable of doing it.
Payman: So if you were the king of the world, Chris, what would you-
Christopher Orr: Unlikely, but yeah.
Payman: … would you stick the BDA and the GDC into one organisation? I think it would make sense because it would make the GDC more of a wet-fingered organisation.
Christopher Orr: You could do. And it’s difficult where you’ve got government stuff, private stuff all in the same pot, but it could be quite interesting to look at if you merge those bodies. But at the end of the day, again, that’s a conversation we can have over a number of glasses of wine later. I haven’t really answered the question about going back to work, which is probably what the listeners are interested in right now rather than navel gazing about whether we can merge the organisations.
Christopher Orr: So in terms of back to work, staff safety, staff training, number one. Things do have to be written down. When you are returning to work things are clearly going to be different. The CQC are probably going to want to be reassured that things are safe because that’s obviously their job to make sure that everybody’s safe, brackets apart from care homes, but that’s not our problem at the minute. So everything needs to be written down, staff need to be trained, and then within some limitations we can probably start seeing some patients again.
Christopher Orr: Prior to the lockdown, and I think there was probably a period of about two weeks where we could all see it coming if you were watching the news in any capacity, during that time, what we did at our practise was we went through all the patients who were under treatment, about to start treatment, or were due to come in for consultations. And we broke them down basically into three different groups: people to be worse off, people who will be okay if we wait, and people who we better not start things on. And the reason that was relevant at the moment is when we open up again, there are going to be that same stratification of patients. The ones who need urgent care. So the ones who have something that is broken or come off, or have a toothache they’ve been managing with AAA protocol. Those people need to be gotten in quickly. Patients who you needed to do something on and you couldn’t get them in before lockdown, again, those sort of people. So things like orthodontic adjustments, people with active caries, people who can be moved onto the next thing. So those are the people you probably need to see first.
Christopher Orr: Second group of people who will not be any worse off if there’s a delay in treatment, those are, maybe, I don’t want to say priority, but they are less urgent to get in. And people in the third group, the ones who you need to be sure you can complete the treatment on, that’s a group of patients in some practises which the dentist I think need to give a little bit of thought to. So for example, if you’re doing implants and you have a patient on whom you’re planning to do some autogenous bone grafting, you do the autogenous bone graft, there’s a clock ticking. And unless you get the implant in pretty quickly, the bone’s going to go away again. So the problem, I don’t why I’m perhaps smiling, the problem potentially is if we have a second outbreak and a second lockdown those people are not going to be able to complete treatment and you end up actually with them no better off or even worse off when they started. So a little bit of caution rather than throwing open the doors to everybody.
Christopher Orr: And again, please don’t ask me question about bone grafting. This purely comes from a conversation with George our oral surgeon. And we were having this conversation yesterday and he was saying the patients who need that type of bone grafting I’d rather not start until we’re sure that we can remain open for long enough. If we’re doing particularly the bone grafting in a patient, that is much more stable and therefore, if that was the procedure that’s planned then we can get on with doing that one. Because if we have another lockdown for several weeks the window of opportunity, if you like, is longer. So I think a little bit of caution who you get in and how. And that needs to be done on a patient by patient basis.
Payman: Prav, you were saying your practise, you’ve got loads of patients who’ve paid for their treatment already. And-
Prav: Yeah. Go on, sorry, Payman. Carry on.
Payman: Patients who’ve paid for their treatment already and are desperate to get going and desperate to finish off.
Prav: I think, pretty much we’ve certainly not been as analytical as Chris on this, but in terms of categorising I think it’s an incredibly sensible thing to have done. But I think this really hit us all pretty hard pretty quickly and so a lot of our thinking came into place on lockdown. So one of the things we realised is there were a lot of patients… So we looked at the business from several aspects, and one of them obviously, was the needs of our patients, and then the other one was from the financial aspects of the business for it to be able to survive, and how we could meet those demands. And obviously from those patients who were mid treatment, so to speak, they just needed some reassurance really. There wasn’t much we could do at this point in terms of treating them. So what we ended up doing is launching the video communication really, really early and inviting those patients to have rather than a telephone conversation, see the whites of the eyes of their practising dentist, their clinician, and just have a conversation with them. Saying, listen, we’ve put lots of things into place. We’re going nowhere. Everything’s safe but we’ve had to put a pause on your treatment.
Prav: If they were an orthodontic treatment, let’s say some kind of aligners, just keep wearing your last aligner. If that patient was due a set of aligners, let’s say that week, then what happened was almost like a doorstep appointment where they came and picked it up from outside the practise. But other than that, it was more, to be honest, these patients, they just want some reassurance that you’re still going to be there, you’re going to finish off the treatment. By the way, you’re holding onto my money there, is everything going to be okay?
Prav: Then we had those group of patients who hadn’t even started any treatment and they’d handed over a substantial sum of money, especially patients who were talking about implant dentistry. We do a lot of immediate load stuff. Same day teeth treatments in our practises and they put down some hefty deposits for that and booked surgery days and clinicians. Sometimes we have clinicians travelling in to do that sort of treatment. And so there was that side of things, and we had quite a few patients getting to us asking for refunds. And what do we do to manage that process whilst we’re trying to keep the business afloat as well and you’ve got two conflicts. So the first thing we said to those patients is 100% absolutely you can have that money back, it’s yours. And no problem at all. However, on a couple of them we had offered them a heavily discounted rate at that time, so we wouldn’t be able to honour that in the future. And then the second thing was with those patients was actually their place in the diary. Now, we’re going back to dentistry on the first of June, and that’s the date we’ve set. May not be the date we go back, but that’s what’s mentally in everyone’s minds and all the patient’s minds. So we’re booking those patients in from there onwards.
Prav: And what happens as we get closer to that date, we’re having conversations with those patients. That’s happened a couple of times now. It’s incredibly time consuming but what it does is it allows us to keep in touch them along. And so those patients who’ve paid upfront, who had surgery dates booked in and whatnot, they’re going to be seen earlier. And so we have had to make some substantial refunds, understandably. Whereas some patients have said look, hold onto my money. They just wanted that reassurance that we’re still here, we’re not going to go pop. And they’re still in need of that treatment. They still want that treatment and they want us to do that treatment. It’s just they wanted that reassurance. So I think opening up that communication has been fundamental to just giving those patients peace.
Prav: Your practise, have you had any team members who have been anxious about the thought of coming back to practise or just said to you, I feel anxious, is it going to be safe, those sort of things? Because there’s so much in the press at the moment and we’ve heard quite a bit of negative press about dentistry we’ve had some of our team members express some concerns about that. Have you had anything similar at all in your practise?
Christopher Orr: Couple of things there. You were talking about patients and things. I have to be honest and say 99.9% of our patients have been extremely reasonable and understanding and I think they realise that we are all in the same boat together. So the issue with pre-payment and discount and things, that’s not how we operate, but had we been in that situation we probably would have approached it in a similar way. Staff members, I’ve not had any of our staff come to us and say we don’t feel safe. During the time when a lot of our staff have been furloughed, we’ve had small meetings, basically over a cup of tea in the mid morning with everybody just over Zoom, just talking to them and saying how are you? What have you been doing? This is where we’re at. And we’ve not had any of them coming to us saying we don’t feel safe coming back to work. But I think what comes out of what you’ve just said, and I guess the answer to both those questions, it is all about communication.
Christopher Orr: And one of the cliches that’s come out on the internet a lot in the last month or so is there’s a lack of leadership in dentistry. Higher up, certainly there’s a lack of leadership. But every person, every dentist is leading a clinical team. That is from the practise principal leading the whole practise through the associates who are leading a very small clinical team in their surgery. I think it has to come from the, not just what is in place, that will come from the practise principal, but the implementation of that. Everybody has their role to play to make sure that all of our team feel completely safe and confident that they can get back to work.
Payman: Chris, have you been in touch with your patients as well?
Christopher Orr: We’ve sent a couple of newsletter and things out. We put the video consultation thing into place very quickly. I should give credit to who’s one of my associates. just came up with that completely by himself and said, is it okay if we do this? And that’s been working extremely well. We’ve had, honestly, relatively few patients calling us. People have contacted. We have been able to give them advice and things over the phone. For the most part, they’re generally well-cared for patients, they generally look after themselves, and there have been, I think if anything, we’ve had probably fewer people ringing up with emergencies than we would have in a typical four weeks, eight week period if we were open.
Payman: So Chris, it seems like in private practise, which both of you guys seem to be talking about, there doesn’t need to be massive changes. An element of triage, risk assessment, PPE. But the timings will suit it. What’s your feeling, if you had to guess, for an NHS practise? They’ve been doing quite well right up to now being paid for sitting on the phone, but going forward, what do you think’s going to happen and what should happen?
Christopher Orr: I think a lot of that is going to depend very heavily on PPE. Availability of PPE, what standard of PPE is required or said to be required by Public Health England.
Payman: Let’s imagine there was PPE available.
Christopher Orr: Now, the next question is how much is that PPE costing the practise? Because if you can imagine, you’re going to do a band one NHS treatment, which may include some scaling. So an aerosol generating procedure. And at the current price levels, that represents, depending on who you buy it from, 25, 35 pounds worth of PPE per band one treatment. So that therefore means that it may be financially inviable for the practise to actually do that unless the NHS assort so much PPE that they’re able to supply it to NHS dentists in high volume, which I think is unlikely given that I read on the news earlier this morning that some doctors are expressing concerns that they are being told not to speak in public about PPE shortages in hospitals.
Christopher Orr: So the PPE’s going to be a problem, and I think it may… In terms of an NHS practise, there’s one of two possibilities. It either makes it completely inviable or the government is going to apply a very big dollop off financial fudge to funding for NHS practises for probably the next 12 months. They will pay them their money, UDAs may get recorded, but whether the service levels for it are enforced, I think, is highly doubtful. And that did come across quite a bit in the CDO’s webinars. I didn’t understand a lot of what the NHS payment people were talking about, but it did seem that that might be what they’re… They’re going to be just get your money as normal. You see as many people as you can. They will keep tabs on that in some way. Because otherwise it’s not going to be feasible to open your doors because it was just about feasible to open your doors doing NHS stuff before that.
Payman: And what about for your courses, Chris? How do you see your courses being affected by all of this?
Christopher Orr: Well, a few different answers to that. If we look at the last big crisis, financial crisis that hit the world, in the time after 2008, we actually saw more patients wanting elective treatment than before. So I think the demand for treatment will be good, and therefore the demand to scale up will be good. The time after 2008 was actually one of the years where we ran more sessions rather than less. And the mindset of the dentist, we think, was that they realised there was going to be a bit of downtime and it might not be a bad time to skill up. So we would be running our programmes. and I were speaking to the people who do our website this morning, working out exactly the date we open bookings. We are planning to run the programme as normal and we will see what unfolds. Quite how you do that, it depends on how social distancing and how much social distancing is coming. But by that stage, I would imagine that restaurants would be open as normal, bars and other places would be open as normal so it should be, I hope okay, for all of us.
Payman: I think the evidence-
Payman: … I think the evidence from abroad is that the patients are prioritising healthcare. Have we lost Chris? Patients are prioritising healthcare in the return. I don’t know if you guys yourselves have thought about this, but you think about when we go back, it’s realigned your priorities and what’s important and what’s not. And healthcare seems to be, it’s in my mind as hey, look after yourself a bit more. So I think we’re good in the medium term as far as that goes. Chris, we were talking on the phone and I was saying to you it’s a funny situation because if we were a dentist a 100 years ago in the last pandemic you could have more influence, sort out more problems than as a dentist now. And I looked it up. Two AM last night, I looked it up.
Payman: In 1921 there were 5,000 registered dentists and right now we’ve got how many UDC? They claim 400 UDCs doing the same treatment really. It seems to be extraction treatment. Hopefully we’ve got better PPE now. But how do we next time, I don’t want to go finger point this time, next time there’s a crisis, and there will be one, whether it’s a financial crisis or something like that, how do we next time not end up in the mess that we’re in this time as a profession? Because you can see other countries reacting much better much quicker, and much, much more scientific way. And we’ve got to rely on one dentist sitting in Leeds who’s doing a lot of reading to come and tell the government what the latest science is, while the government’s telling the whole nation that they’re letting the science decide what they’re doing.
Christopher Orr: Well, it’s interesting actually. This is a point that I’ve heard Dominic O’Hooley raise a couple of times. That there is not a huge amount of transparency in where the information the CDO was basing their decisions on. I think at the end of the day, there’s a universal problem that politicians are reelected every roughly five years and they tend to want to have things that they can show to the electorate within that time period. So they can say hey, look what we’ve done for you, let’s get reelected. The difficulty we have here is that by many accounts, the government will present with a lot of information on how they shouldn’t prepare for this and they didn’t really pay attention to it. So they were a bit hamstrung and they missed the boat on a couple of occasions. So I think in terms of preparedness, there’s an awful lot that we will learn from this pandemic. If there is another one in our lifetime then hopefully we will be in a better place to respond quickly, and that probably means having stocks of PPE and things ready so that there isn’t this sudden shortage of it.
Christopher Orr: The other thing that I think is quite interesting if you look around the rest of the world, again, one of the issues in, or the lack of issues in Germany, stems from the fact that they make, in Germany, the vast majority of their hospital equipment, whereas we outsource it all. And in Germany they had a period of time where for a couple of weeks supply levels were low and they did not like that. It was unacceptable that there wasn’t enough stuff. But things got back to normal quite quickly, whereas here we were ordering stuff from China. A lot of the places in the early days of the Chinese lockdown, the regions where the factories were were all locked down as well and the supply chain, it’s still not back to normal. There’s lots of stuff that you can order on Amazon, for example, where if I order it today I’m going to get it in July. So I think better prepared, and it’s better management of stocks and trying to order things in advance so that we have them, knowing that some stuff might not necessarily get used. And again, there’s a balance that we have to accept there where if you plan for overcapacity there is going to be some wastage there.
Christopher Orr: And I think really I was very disappointed couple of weeks ago. I can’t remember which government minister it was. The talk about the Nightingale hospital in London had only seen handful of patients and [inaudible 00:32:46]. And yes, of course it was [inaudible] you don’t want to have bodies piling up in the streets and in A and E. So the fact that the government spent that money, there is going to be some spare capacity, which unfortunately is lacking in the NHS because everything is pared back to the bone. So better budget for the NHS. And sorry to say it, that actually might mean higher taxes for us to pay so that we have that in the system when we need it.
Payman: Do you not think it’s more of a systemic issue though? There are dentists now who have PPE who can’t work. PPE isn’t what’s stopping them. For me, it seems to be the speed of decision making in our profession is slow. And in the end, we’re looking to one human. All right, she’s got an office, but again, she’s the head of the NHS. So shouldn’t the profession now set itself up in a way that there’s a scientific community, a scientific board that can look into things if there’s a scientific issue quickly? Because look, that’s all I see. I see the politicians saying it’s the scientists. And then we look where we know what’s going on in our area and there’s no science. We’re relying on one Dominic O’Hooley to teach us to read the work. What have you thought, Chris, when you’ve read all of this work from the different SOPs you’ve seen? Do you feel like that’s what’s happened? Is that there’s such a vacuum of information from the top that the grassroots is pushing information up? That’s my sense of it.
Christopher Orr: Yes and no. People are responding because they feel they need to try and make sense of the world around them. That’s a normal human response. I do not envy anybody in the Department of Health, their job, just at the moment. The problem that you’ve got is that if you issue advice it needs to be well-written and fairly robust so that the number of exceptions and queries on the advice is absolutely minimum. I can imagine there is somebody in the CDO’s office right now, a team of people, probably rewriting standard operational procedures for when NHS practises are going to reopen. And when they’ve finished that task it needs to be checked, et cetera so that it’s valid, and then it can be passed down. So people who like firing stuff off without any kind of validation, I think it’s counterproductive because, again, that national mindset of caution. People like to be told very clearly in black and white this is what you do, and then you go on and do it.
Christopher Orr: So could we respond better for that, possibly. A committee of dentists who make recommendations. And again, the question is who do you put on to such a committee, and how do you actually feed them into the whole process? How do you get everybody to say yes, we agree with that, because we have a large number of clinical standards and standard setting organisations. So the FGDP and NICE and many other organisations, and there are so many guidelines that come out that it’s almost impossible for anybody to keep track of what you’re supposed to do under normal circumstances, never mind right now. So yeah, less bureaucracy and speedy decision making, I’d love to see that. How you would actually go about achieving it, I really don’t know. Head scratcher.
Payman: Prav, going forward, your [inaudible] your marketing now. Are you thinking you’re going to be coming out of this in a better way somehow? Do you think there’s an opportunity in it? I do. I think there’s a land grab. If we’re talking in those terms, I think that the practises who focus on [inaudible] people working from home is what I was going to say. People working from home who are relatively getting richer right now.
Prav: And do you know what, even if I’m looking at my team, and I’m talking about the team in my digital agency rather than my practise, speaking to them, they’re getting richer because they’re being paid, they’re spending less money, they’re not going out. But do I see it as an opportunity? Well, I think initially we’re going to go back phased approach, less volume. So what you’ve really got to think about is how you’re going to phase that comeback. And if you go out and launch some marketing campaigns and get a truckload of leads coming in, and then start processing them and having conversations with patients, where are you going to fit them in? And so from our perspective, what we’re doing, initially, for at least a short to medium term, we’re extending our hours.
Prav: So we’re going to do six days [as standard 00:38:13]. We’re going to do more evenings. And [inaudible] patients [ought] to take care and look after our existing patients who’ve been waiting patiently for so long. So to get that out of the way, so to speak. Are we running marketing campaigns now, yes, absolutely. And we’re having video consultations with patients and they’re all subject to an in-person clinical checkup. So we have a conversation, we build some rapport with those patients. We talk to them about the way we do dentistry. We give them some approximate price guides, saying it’s from this to this. But for you to get a treatment plan, you need to come in and have a comprehensive assessment and this is what the investment in that assessment is, and we’d be looking at getting you in around this period of time.
Payman: Prav, as a marketing guy, are you saying that you’re going to be marketing safety as well? I think it’s an error, personally, but have you bought fogging machines and air purifiers and all of that?
Prav: So what we’ve done is we have bought PPE. The various masks, visors and gowns. We haven’t bought air purifiers, and that may change. And the reason being… Actually, do you know what, if I segment my two groups of practises. In one we have, in one we haven’t. And in actually the one we haven’t, we’ve bought three that go into rooms that have no windows. So that’s the three [inaudible] that we’ve bought. But to be honest, a big part of the purification [line 00:39:56], it’s not my area to go [inaudible] the patients, and we’ve had certain team members who’ve expressed some concerns. But we haven’t gone all out and bought 11 purifiers for 11 rooms, for example. And so from a marketing perspective, back to your question, are we going to be marketing safety? Yes, but not as a USP. I think more in terms of reassurance. That saying, as dental professionals, it’s always been an incredibly safe environment to come into.
Prav: We’ve put some additional protocols in place to step up that level of safety, which will include a oral mouth rinse, less people in the waiting room. No escorts allowed into the practise anymore, et cetera, et cetera. It’s according to the SOPs. Am I going to be using that? If a patient is choosing their dentist over an SOP, over an air purifier, we’ve got something seriously wrong.
Payman: I think it’s a mistake.
Christopher Orr: No, I agree. The issue of air purifiers, there is no proof at all that they reduce the risk of transmission. And such evidence is unlikely to be forthcoming. So from my point of view, the air purifiers are there if you wish to make your team feel you’re doing everything possible. Fantastic. But the 2,000 pound a surgery ones, absolutely not. Again, I agree completely with you, these are not devices that we should use to market our services and try to claim that we’re better than some other practise, because in the absence of proof that they actually do what we’re implying they are with such marketing, we’re misleading patients. So yes, perhaps to make your team feel better. Perhaps if it makes you feel that you can turn around rooms more quickly, particularly those without windows, fantastic. But otherwise, no, it’s not a marketing ploy.
Payman: What I would think about air purifiers is they’re a good idea in general pre COVID. So if you’re that cat, if you’re the person who wants this thing that cleans your air in general, fine, absolutely fine. But I’ve been thinking about this a lot and what we’ve done with our team is we’ve focused our team on finding mom influences around each of our regional centres. And mom influencers have much more engagement than pretty girl influencers with their audience. And so in each town there’s two or three moms who’ve got massive Instagram presences and we’re going to be reaching out to them and saying come and have a free teeth whitening, as soon as that’s an appropriate thing to say. Because let’s say in a town like Leicester perhaps, where you’ve got those two practises, or you’ve partnered in those two practises, there’s literally three or four of these types who set the agenda for the moms. And the reason I’m pointing out moms is because mom is the safety representative in the house. So what I’m saying is marketing safety comes in many ways, many forms. We mustn’t just think I look like a spaceman, here’s my fogging machine. That might make us feel safer but I don’t think patients want to see that in marketing.
Christopher Orr: It implies there was a problem that we weren’t dealing with before. At the end of the day, we’ve had aerosol and the knowledge of aerosol for a long time. We had it when HIV came along, and we have not had anybody catch HIV through aerosol transmission in the dental surgery in how many years of being aware of it.
Prav: I do feel if, and to be honest, I’ve actually seen some campaigns already go out, with people who’ve made videos about their whole protocol. And it’s almost sending a message out to those patients along the lines of this is a very dangerous place to come to, guys. But because we’ve got all this stuff on, you’re going to be safe.
Payman: It’s just very one-dimensional thinking, isn’t it?
Prav: Yeah. And I think the other thing is that everyone’s pushing this message out as though every person walking through your practise is COVID positive. And they’re not even taking into account that hold on, we’re doing these pre-screens. There’s a level of risk mitigation that’s going on prior to a patient even being allowed to step through your door. But the measures that some people are taking, it’s almost as though you’re having to treat these people in a space because you’re assuming every single person [has got it 00:44:46].
Payman: But then [crosstalk] a thing that I accept that. It’s the marketing of it that I find strange. There are smarter ways to market safety than saying I’m wearing a spacesuit. Chris, going forward, what’s your message to principals and associates? [Because we’re going 00:45:06] to have to work together now.
Christopher Orr: I think there’s a lot of stuff that we’ve already talked about. It’s really number one, make your team feel safe. Number two, make sure that everybody is trained and comfortable before you start seeing patients. A phased approach, you’re not going to go back to a full book of patients. You need to think about who needs care the most. And I would encourage all dentists to go through their patient books, the patients whose appointments were cancelled or deferred before the lockdown, those people need to be the priority. We mentioned also, and Prav, you talked a lot about patients who’d prepaid for treatment, there are the patients who are on maintenance plans. So the Denplan, Privilege Plan, those sorts of things. Those people, again, the ones who did not cancel [inaudible 00:45:54], their loyalty to the practise needs to be recognised. So in terms of getting people in at the appropriate moment, those people need to be prioritised. Because again, that’s where the business aspect of things comes in. You need to thank customers for their loyalty. So principals point of view-
Payman: If one of your delegates said, listen, I’m going to open, I’m going for it, would you advise them to go for it?
Christopher Orr: … I would advise them that they have got indemnity cover in place and that has to be in writing from their indemnifier. They need to have carried out their risk assessments and probably have some up to date standard operating procedures. It’s interesting to see that a lot of the new dental societies and associations and groups are staying away from writing standard operating procedures. That they seem to be waiting for the CDO to come out with some things. But I think the major thing, really, is making sure that everybody’s safe and making sure that you are indemnified. And like I said early with your indemnifier, you need to be crystal clear with the indemnifier about exactly what services that you’re planning to offer.
Payman: Let’s say you have. Let’s say you’ve got all of that down and some new indemnifier, TVS, one of those PDI whatever, says you’re covered. Can they go?
Christopher Orr: Yeah.
Payman: Advise them to [inaudible 00:47:23]?
Christopher Orr: Go for it. As long as everybody’s happy, everybody’s safe and you’re indemnified, I don’t see why not.
Payman: I’d agree with that. I’d agree with that. Especially as we’ve seen it. We’ve got the advantage of being three weeks behind so many other virus regions and we can see what’s happened over there. Prav, you going to open up soon?
Prav: Like I said, we’ve set a provisional date and I think I am not the person to make that decision. I’m just the guy that brings the patients in and helps with the patient journey and the communication sides of the practise. So for me being a non-clinical member of the team, I’m certainly not the right person to be making those decisions.
Payman: What’s your date? 15th of June?
Prav: No, first of June we had provisionally, but we’re moving patients along 15 days at a time. So I’m definitely not that person to make that decision. Having heard everything that I’ve heard, and listened to the science from Dominic, I’d open tomorrow if I could. 100%. And I don’t think with the way dentists and how our practises have been operating pre COVID, I just think we just need to respect a little bit more distancing, a little bit more space. And I think a lot of these are SOPs that have probably taken things to a level slightly above to be additionally cautious, so to speak. And Chris, as you said earlier, going over the top with these masks and some of them the inspire there is protected but the expire there isn’t, and stuff like that. So there may be an argument for sticking a normal mask on on top of that.
Christopher Orr: I’ve heard that said. To be perfectly honest, the whole thing with the masks, I think we are overthinking it. Very, very classic dentist way of looking at things. We try to over-engineer and we get to a point where you actually can’t do anything because you can’t make a decision. So from that perspective, it’s really just about recognising that we can’t do everything to be 100%, but 95% may be the level that we have to accept.
Payman: Well, thanks a lot, Chris. And hopefully we’ll get back to some form of normality. Thanks for injecting some common sense into it.
Christopher Orr: Thank you.
Payman: There’s information overload.
Christopher Orr: I think it’s been information overload for the last about three months. And that’s the problem. That this continual need to make decisions and change things as we’re going along and evolving situations. It’s very stressful. Very stressful indeed.
Payman: All right, Chris.
Christopher Orr: But hopefully back to normal soon. [crosstalk 00:50:18].
Prav: Have you got an opening date, Chris?
Christopher Orr: Beg your pardon?
Prav: Have you got an opening date?
Christopher Orr: I am going to have the staff coming back, I’m thinking either first of June or eighth of June. And we start booking patients in towards the end of that week and gradually ramping it up over the next couple of weeks. So early to mid June. Exact date to be determined.
Payman: We’re waiting for the chief dental officer now, with the legal situations kind of clarified yesterday as well. I guess we’re just waiting for that. Brilliant. Thank you, Chris.
Prav: Thank you. Thank you so much.
Christopher Orr: Thank you very much, both of you. Thank you. Take care. Bye-bye.
Outro Voice: This is Dental Leaders, the podcast where you get to go one on one with emerging leaders in dentistry. Your hosts Payman Langroudi and Prav Solanki.