key: cord-028590-rw0okd0p
authors: Westgarth, David
title: What does the future hold for the workforce of tomorrow?
date: 2020-07-06
journal: BDJ In Pract
DOI: 10.1038/s41404-020-0457-x
sha: 
doc_id: 28590
cord_uid: rw0okd0p

nan

On 20 February 2020, the British Dental Association and Public Health England chaired the first Mental Health and Wellbeing Day bringing together attendees from across the dental profession to discuss the problems with and solutions to stress, burnout and mental ill health among dentists.

Less than five weeks later, lockdown happened and the dental profession downed tools. Much of the focus then fell on securing the economic livelihoods of those affected -furlough requirements, Business Interruption insurance and business rates relief became (and still are) buzzwords. And while it became clear that economic recovery of the sector and the country were the first and foremost priorities, 'people' were left behind. Could we see loved ones, parents, grandparents? No. For many -including myself -it was 12 weeks of solitude. While I am fortunate to have survived with much of my sanity intact, for others the very problems discussed at the Mental Health and Wellbeing Day came to the fore.

According to a new poll by the mental health charity Mind, many people who were previously well will develop mental health problems as a 'direct consequence of the pandemic and all that follows' , with the worst yet to come. Two out of three adults aged 25 and over and three-quarters of young people aged 13-24 with an existing mental health problem reported worse mental health during the lockdown, its survey found.

Of adults with no previous experience of poor mental health, 22% said that their mental health is poor or very poor. Those who were furloughed, changed jobs or lost their job due to coronavirus saw their mental health and wellbeing decline more than those whose employment status did not change, the research revealed.

Of those who tried to access NHS mental health services, 25% were unable to get support, the survey found. A further 32% of adults and 28% of young people did not try to access support because they did not think that their problem was serious enough.

While the Mental Health event could not foresee what was around the corner, these issues were brought up. Where can dentists get mental health support? At what point does an individual realise they need to talk to someone? Are mental health problems on the increase? You had a perfect storm; furloughed, concerns about livelihoods and day-to-day finances, with many doing it alone and without the support they needed and of course an overarching concern about what the future actually holds.

BDA President and chair of the Mental Health and Wellbeing Day, Roz McMullan explained it is that overarching uncertainty that has the potential to have the greatest impact on the mental health of those affected.

'Life is a marathon not a sprint and is inherently uncertain with many ups and downs. You said it yourself -uncertainty. There are hills in the marathon, we see them coming and we can and should prepare; for example, buying a practice, starting a family, a parent needing support. There are potholes, when we have no chance to prepare and these can be very destabilising, for example a complaint, death of a loved one, and of course a pandemic.

'In this pandemic we need to add financial pressures, anxiety about COVID-19 itself and risks of transmission to patients, staff and family, family disruption, the need to manage schooling and caring responsibilities and possibly deal with the grief of losing a loved and cherished member of the family. This list is by no means exhaustive. No wonder research for the BDA shows signs of burnout in over 85% in GDPs.

'Our early career dentists and students have been real heroes in this pandemic, many being deployed to roles on the front line. However they are now returning to the uncertainty of missing time in training, new ways of assessing competency and even 'will there be a job?' .

'The anxiety of uncertainty is normal and to be expected. I hesitate to use the 'For those who hold leadership roles in the team and in training, show humility, humanity and sensitivity and try and model appropriate behaviours. Leaders should be prepared to delegate and ask for help. This will be a long road. Be sensitive to those in the team who are feeling vulnerable, acknowledge their feelings and ensure they are not experiencing harassment or even bullying.

'But above all maintain professional and social networks. Regular team meetings in the workplace with effective reflection and twoway communication are very effective. BDA amongst others are organising virtual Branch and Section meetings and online platforms are a good, if imperfect, way to catch up with friends and peers. Try and separate your home and work life, although that is easier said than done when you go home and the TV is full of news about COVID-19.

' Above all, be kind to yourself: eat, sleep, exercise and take some time out of dentistry to do something you enjoy and get satisfaction from. And remember, it is OK not to be OK. If you need help, then please do reach out. '

Lauren Harrhy, practice owner and founder of Mental Dental, suggested the mental health impact on the profession has been -and will continue to be -profound.

'I know from experience colleagues have felt quite downtrodden and powerless, scared and frustrated over this period' , she said. 'There has been uncertainty over possible job losses and disputes over pay. Many have found sourcing PPE a huge challenge and getting used to wearing it yet another massive hurdle.

'I know that young dentists in particular have found the mental adjustment to implementing AAA quite difficult. We are so used to hearing that antibiotics don't cure toothache; it has felt strange and unnatural to prescribe antibiotics over this time. Many are suffering great moral injury because they have not been able to care for their patients in the way they would like to. '

Dental Core Trainee Alice Duke also found 'the new norm' difficult.

'It has been challenging, especially as a dental core trainee where much of the focus is on learning new clinical techniques and gaining clinical experience in new disciplines' , Alice said. 'I felt very anxious during the first few weeks and found it difficult to sleep, as did many of my colleagues. I had just moved departments from restorative to paediatrics/ orthodontics and found it difficult to adapt to the constantly changing protocols, as well as working alongside new staff.

'I spent a few weeks working from home which involved helping to develop new standard operating procedures to be used in the department. I also had the opportunity to be involved with research and quality improvement. I did feel disconnected from the profession during this period and missed the clinical environment.

'Dentistry is a profession founded on principles of communication with colleagues/ patients and teamwork, so adapting to working alone in an office environment took some adjustment. I found planning my day and participating in many virtual meetings/ discussions/webinars helped me to remain engaged and motivated. ' Special Care Dentistry Registrar Natalie Bradley discussed her sudden shift in focus and the stress that carried her and many others who found themselves in urgent dental care hubs. 'Many hospitals have had to adapt to become urgent dental care hubs during the peak of the pandemic, with both the hospitals I work in beginning to start to resume some ' According to a new poll by the mental health charity Mind, many people who were previously well will develop mental health problems as a 'direct consequence of the pandemic and all that follows', with the worst yet to come.' routine services. But the number of patients we have capacity to safely see is dramatically fewer than usual and there is going to be a large backlog of patients to see. Waiting lists will be affected and in some cases, patient criteria have become much stricter in order to reduce waiting times for priority patients. Patients who were on waiting lists before the pandemic may now receive letters saying they no longer fit the criteria to be seen in hospital and need to seek care elsewhere.

'In this time their oral health may have deteriorated and their needs increased, which is a problem on the horizon the profession will need to tackle. '

Thankfully, this isn't to do with letters, the Office of the Chief Dental Officer or returning to work, but rather the future workforce. With disruption to their clinical time with patients, will dental students be ready to hit the ground running? For 5th year dental students making the transition to foundation training, for 3rd and 4th year students downing tools and not engaging with outreach programmes and honing clinical skills, the concerns are real. I spoke to dental students Mairi Cameron, Neha Mehta and Rachel Jackson who couldn't help but cast their gaze towards what the profession might look like when they qualify.

'For me there is a bit of uncertainty when thinking about our place in the profession after I graduate' , Mairi said. 'It was worrying reading about the number of dental practices that said they may be forced to close and thinking about the knock-on effects this could have on our cohort in the longer term.

' Any significant time away from clinic will reduce our confidence in our clinical skills and treatment planning abilities and will require a considerable amount of remediation. We're very lucky at Aberdeen in that we start seeing patients in our first year of study, so we have spent a fair amount of time in clinic already. I know that our clinicians and those all over the country are putting a lot of work into reorganising the next academic year. I have faith that dental schools will find a way to get their final year students to the level of a safe beginner over the next 12 months or so. ' Neha added: 'I completely agree. I am definitely concerned about my graduation and career as a dentist. These past few months have completely disrupted my time at university and this has meant that vital time on clinic has been lost. The university are looking at evening and weekend clinics to make up for lost time and bring our skills back up. However this might not be feasible as we have missed a whole term of teaching and so they are looking at lowering requirements to take finals. This concerns me because upon graduation I might have less clinical exposure and lower skills compared to other students who graduated not being affected by COVID-19. Although this pandemic might not have affected my chances of graduation I might be at a disadvantage and find it harder to cope during my future career. '

'Right now I am more short sighted as my concerns are focused on a lack of clinical exposure and simply becoming a safe beginner' , Rachel explained. A full remote replacement for the clinical application of theoretical knowledge and skill has yet to be created. Not having patient contact to build relationships and the ability to transfer theory and practical skill is fundamental in the transition from non-clinical to clinical practice. For all the blended learning and online resources etc regardless of stage we now find ourselves back in the lecture room. The quality of online remote learning will now dictate the learners' development until face-to-face practical teaching resumes. It can be achieved though. Unique problems such as this require unique solutions and despite the initial stress for staff and students, it is an amazing opportunity to really study and modernise the delivery of a dental curriculum moving forward. '

Lauren believes the lack of clinical development could be a real issue in the years to come. She said: ' Although webinars and online development has played a key role since the beginning of lockdown, I have been concerned about the restrictions leading to a lack in clinical experience. I know that dental schools and postgraduate schemes are working extra hard and coming up with innovative ways in which clinical experience can be gained. The need for preparation has increased. '

Alice echoed Lauren's concerns about clinical competencies and pointed to some resources that may help to fill the void.

'Meeting the total requirements for procedures such as molar endodontics and extractions to ensure successful progression to finals is challenging enough as it is' , she told BDJ In Practice. 'That's why I feel now is the time to capitalise on the advancements made in digital education i.e. e-learning, haptic simulation and distance learning.

Technology has advanced rapidly over the last decade and many clinical techniques can now be taught, practiced and assessed virtually or remotely via dental simulators i.e. Moog Simodont Dental Trainer, HapTEL Training System. This technology utilises haptic virtual reality simulation for sensorimotor skill acquisition. As many of these systems do not require an assessor or patient to be present, social distancing guidelines can be followed and clinical skills improved, without risk of transmission.

I feel there is scope to modify the current techniques used in dental education to make up the shortfall in clinical experience that students have lost as a result of COVID-19. As many of these technologies are already utilised within the dental curriculum, emphasis on further resources for remote learning should be and are being facilitated for dental students. ' Natalie added while clinical development was clearly an issue, deeper concerns lie ahead.

'Besides being an able clinician ready to treat patients, I also worry about their wellbeing. Concerns about their future careers, with the dental landscape looking completely different to what they expected when they began dental school, will surely put a lot of pressure on them and with much of their training now being delivered virtually, there is a risk of students becoming isolated.

'Support must be in place to address not only students' learning, but addressing their health and wellbeing needs. '

In April research by the BDA suggested 70% of practices reported that at the time they could only maintain financial viability for a maximum of three months, with those providing predominantly private care worst affected.

While the NHS side of practices have been offered some support by government, the BDA has warned that if those practices with a greater reliance on private work go under whatever service remains will be unable to meet patient demand.

In Scotland following confirmation from First Minister Nicola Sturgeon that services would recommence from 22 June, the BDA issued a warning that a combination of higher costs and lower patient numbers could prove fatal for services in Scotland. Shortages of PPE are expected to place limits on patient numbers. While the authorities recently distributed more than three million individual items of PPE to dental practices, volumes are only sufficient to enable practices to see around 10 patients a day. The Assembly Committee for Health in Northern Ireland were warned to expect similar outcomes if government inaction persisted.

Prior to the pandemic recruitment was already facing a crisis, and there are no doubts this will only serve to elevate concerns for job seekers and recruiters. Natalie suggested that while many of the young dentists she mentors and coaches are worried about their career options, the situation will be dictated by those practices who survive the pandemic.

'It is difficult to say, with the risk of some practices not surviving through the pandemic, this could mean associates and other members of the dental team not having steady work. On the other hand, I suspect that with reduced capacity to see patients at the same rate as before COVID-19, there will be a call to work longer hours or on a shift pattern which could increase demand for associates and worsen the recruitment crisis.

'I think that we need to remain vigilant to the possible risks to our professional careers during this time and in the future; the 'new normal' isn't just going to be isolated to our supermarket trips, but to our working lives and career paths looking into the future. ' Alice suggested that while the recruitment sector will be hugely affected, it remains to be seen whether that will be for good or for bad. 'COVID-19 will obviously change the profession -perhaps indefinitely -but we are arguably fortunate that there will always be a need for dentists, even more so now as a result of the backlog of patients not seen due to lockdown. Whether this will be in in a positive or negative way is dependent on how the remuneration system is restructured, the cost/availability of PPE, the capacity for practices to accommodate new patient workflow and the government social distancing guidelines. All of these factors are liable to change and by no means an extensive or exhaustive list.

'It must be acknowledged that the delivery of services, both in the NHS and Private sectors, will need considerable modification. Patient workflow capacity, the UDA remuneration system and provision of elective aerosol generating procedures are particular areas where changes must be made in order to comply with COVID-19 guidelines. I feel adaptability and resilience are key areas of professional development to focus on during these uncertain times. Although the future remains uncertain, I like to think the pandemic has given us the chance to start afresh and the opportunity to address the shortfalls in the previous system. ' The risk of infection to professionals in vulnerable groups i.e. pregnant, underlying health conditions, may deter return to work completely. The capacity for practices to accommodate both patients and dentists in a socially distanced environment may force clinicians to seek employment elsewhere, work part-time or between a number of establishments. The pressures of providing private dentistry may increase treatment prices for patients and/or the variety/modality of elective options available. We may see shifts in recruitment in both primary and secondary dental care, with some individuals opting for the stability of a set salary. I find it almost impossible to predict in the current circumstances, and while that may not sound optimistic, I would encourage young dentists not to be disheartened or concerned, but to embrace the opportunity for change, leadership and integration of new digital technologies into all aspect of the profession as we forge what 'new' will look like. '

The watermark of concern runs through Neha and Mairi too.

Mairi said: 'I imagine if dental practices with VT trainers are forced to close then it's possible that there will be fewer jobs for new graduates. I'm also aware of the financial blow that COVID-19 has inflicted. I worry that dentists may be forced to reduce their NHS work and increase private work to keep their businesses viable, leaving some of the most vulnerable patients without dental care, and possibly some newly graduated dental students without VT posts. Again, it's the uncertainty. '

Neha added: 'When I graduate I feel like there will be fewer jobs available. Many surgeries may have fewer dentists as they cannot afford it and therefore this increases the competition for jobs. My main concern is that after my vocational training year, practices will be less inclined to hire a newly qualified dentist compared to one with lots of experience due to the need for time efficiency in this current climate. '

While she understands the concerns of Neha and Mairi, according to Lauren, the enforced break may have provided the opportunity for many to reassess career paths and choices.

'Yes, in the short term it may seem that there are fewer opportunities for young associates' , she said. 'Yet I know that most are using this period to step back think hard about how they want their career to progress. It's an opportunity for some to be able to make brave decisions that may take them in a direction they may not have previously considered. Salaried positions may become more attractive going forward as they could offer more stability and peace of mind. If you have ever felt like diversifying your skills or your portfolio then the time is now for finding support and making enquiries. '

The mental health event identified that a range of patient-related factors were the main stressors for dentists, but the BDA's research found that, while dissatisfied patients remained the second greatest stressor, fear of complaints and litigation was now the main factor. The risk of making mistakes, red tape and bureaucracy, and concern about the GDC were also leading causes.

It is without a doubt the situation the world finds itself in, but red tape and bureaucracy are only likely to increase. Patients will be fearful of catching COVID-19 from their dentist. What happens if a patient complains to the GDC that their dentist was responsible for them developing COVID-19? Where does the burden of proof lie for starters. Which makes you think that during the period of inactivity, the GDC may do something to ease the burden on their financially stretched, hugely stressed registrants.

That did not happen.

In an update to registrants on 20 May, GDC Chair Bill Moyes wrote:

'The impact of the COVID-19 pandemic continues to have a significant effect on our lives. I am very aware that the effect of the suspension of routine dental care and services is severe and that it has prevented you providing the patient treatment and care you want to -and in some cases has caused financial difficulties. We have been ' It is without a doubt the situation the world finds itself in, but red tape and bureaucracy are only likely to increase. Patients will be fearful of catching COVID-19 from their dentist.' asked whether the GDC could respond by making changes to the Annual Retention Fee (ARF) paid by all dental professionals or by introducing an emergency payment by instalments scheme.

The Council has thought carefully about the options available to us, but we have decided not to make changes to the ARF levels or to introduce a payment scheme. These are not decisions we have taken lightly, and I know they won't be welcomed by some of those we regulate, so I want to be clear about the reasons why we have made them.

The work we have to do, which is laid down in law, has not fundamentally changed. We are required to remain financially stable and to meet our statutory obligations to ensure the public are protected and confidence in the professions is maintained.

Nearly all our income comes from the ARF collection. By revising our regulatory approach and increasing our efficiency, we have been able to secure greater value for money and reduce the ARF -and we hope to continue along this path. But we don't want to make changes now that we can't sustain, and which might lead to inefficiency and increased costs in the future.' 1 As you can imagine, at a time when income had been reduced to zero, this decision was met with universal dismay. What kind of shambles are they running not to even consider payments in installations? Did they make use of government money to furlough staff? Yes they did, and yet in a clarification on this, the announcement read: 'That is why Council decided that at present the level of the ARF should not change. ' 2 No mention of the possibility of instalments, which is why in a letter to Moyes, BDA Chair Mick Armstrong stated:

'It is a great shame that our regulator, who prides itself on making significant improvements to its way of working, wants to work collaboratively with the profession, and whose finances include a significant budget operating surplus and significant reserves, cannot see how positive such a move would have been, and how negative its absence is.

' As always, the impact will be greatest on the most vulnerable of the profession: new graduates, many of whom have lost their part-time jobs; young dentists leaving dental foundation training and potentially struggling to find their first associateship; and dental care professional colleagues who are significantly affected by the closure of practices and the expected lengthy return to the provision of dentistry over the coming months.

'It remains a matter of fact that a relatively easy change that is within the GDC's power and would have had a profound positive reaction amongst the professions it regulates -unlike so many other possible positive changes where 'inflexible legislation' is cited as the reason for its lack of agility -is not forthcoming.' 3 It is moves like this that do nothing to improve the patchy relationship the profession has with them. Yes, they have made great strides throughout recent years, but more can be done. As Alice suggests, the profession already has enough on their plates.

' As a profession, we have been put under a huge amount of emotional, financial and clinical stress. This is on top of the normal anxieties that exist whilst living through a global pandemic. The GDC must recognise and appreciate that this will inevitably have some influence on our performance as professionals.

'There have been periods where guidance has not been available, unclear or contradictory, putting clinicians in the impossible situation of trying to work within the best interests of their patients, whilst ensuring the safety of their staff and themselves. I hope the GDC takes this into account when investigating potential complaints about dental professionals during this period.

'They must also realise that as the quality of dental education has been impacted, I feel they should offer extended support to newly qualified dentists, who are now entering an uncertain professional environment with less clinical experience that would have been ordinarily obtained. After all, we are all human and we do make mistakes. ' I asked Roz how COVID-19 stresseson top of pre-pandemic stress -would be supported by the BDA and where people can go for support.

'The Mental Health and Wellbeing report and action plan 4 has just been published and shared with all the attendees. While the focus has changed to how we support our colleagues at this difficult time, we will return after the acute phase of this pandemic to some of the important long-term objectives in that report.

'In the meantime, the BDA are doing all we can to support the wellbeing of dentists and their teams by sharing resources, signposting, webinars and of course the offering with the award winning Health-Assured, which is available to all levels of membership, including students. The BDA Benevolent Fund does amazing work every day, supporting those who are in financial difficulty and is open to all dentists and their dependants.

'For me, the revolution of online platforms to meet professionally, personally and clinically will be a lasting change, and one which will also benefit the planet. I would also like to think, as a society and profession, we have learnt how much we rely on each other, and how showing support and encouragement within dentistry and to all of society, is key to us all living and working well. ' We have talked about hills and potholes in this marathon of life. This pandemic is our Everest. I remember exactly where I was when, I heard President Kennedy had been shot, even though I was only seven years of age. For seven-year-olds now and everyone else, this will be a key milestone in our lives. Personally, I don't think life will ever be quite the same again. ' ◆

News release: BDA blasts GDC as ARF remains unchanged during COVID crisis

Campaigns: Tackling stress in dentistry

You can get mental health and wellbeing support information and advice from: AE The BDA Benevolent Fund: www.bdabenevolentfund.org.uk/ AE Dentists' Health Support Programme: http:// dentistshealthsupporttrust.org/ AE Health Assured: https://bda.org/ health-assured https://doi.org/10.1038/s41404-020-0457-x