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Introduction

In some respects, thinking about 'this time last year' is a dangerous activity to be partaking in. For instance, roughly this time last year I was at an event on HMS Belfast, and let me tell you readers, it was a hoot. Yet for me, thinking about it is filled with more than a tinge of sadness. A throwback to better days, given the previous 11 months have felt like Wile E Coyote standing under a mountain of falling rocks with nothing more than an umbrella to shield him.

In these circumstances, looking back probably does our mental health and wellbeing little good, given we're in lockdown for an unspecified length of time and the cold, wintery months offer only short windows of opportunity to get out for state-authorised exercise. Yet perhaps right now it is prudent to look back to 2020 for a defining moment outside of the pandemic, and for me that day was 20 February.

Raising the bar

On that date, the British Dental Association and Public Health England held a 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. One of the biggest takeaways I can recall is that dentistry within the UK had some unique stressors, particularly relating to regulatory and contractual issues that put undue strain and pressure on the profession. Little did we all know the 12 months that followed would be the most challenging ones ever faced by the profession.

There is part of me that wonders - marvels - at how resilient the profession has been in the face of such adversity. The day highlighted too many dentists previously surveyed reached the threshold for burnout, accompanied by a feeling of occupational detachment and decreased accomplishment. Levels were highest among GDPs, those with the highest levels of NHS commitment, associates (compared with practice owners) and for those aged 35-44.1 These figures are pre-pandemic. Before NHS practices had to close their doors. Before private practices were offered no financial lifelines by the government. Before practices faced steep financial penalties if they fail to hit a quite ridiculous 45% of their pre-pandemic NHS activity targets from 1 January to 1 April 2021 when the message from the government reverted to 'stay at home'.

In these circumstances, looking back probably does our mental health and well-being little good, given we're in lockdown for an unspecified length of time

That day also highlighted how important it was to finally be discussing mental health and wellbeing out in the open. It felt like there was an opportunity for tangible progress to be made. Circumstances may have dictated the intervening months, but it just felt like the collective bar had been raised - it was now firmly out in the open and on everyone's radar. While there were elements of the profession that were deeply challenging - fear of complaints and litigation were the main stressors - much work had been done by the General Dental Council to overhaul their Fitness to Practise process, and more was yet to be done.

And then it happened. COVID-19 rampaged across the country bringing the well-documented set of unprecedented challenges with it. For the general public, more than two-thirds (69%) report feeling somewhat or very worried about the effect COVID-19 had on their life. The most common issues affecting wellbeing were worry about the future (63%), feeling stressed or anxious (56%) and feeling bored (49%).2 Further research identified that, when taking account of pre-pandemic trajectories, mental health had worsened substantially (by 8.1% on average) as a result of the pandemic.3

You would be forgiven for thinking that - with dentistry having a higher base line of stress than the general public - their situation would be significantly worse, almost critical. In a survey of their members, the DDU found 68% of respondents felt that their stress and anxiety levels had increased since the pandemic.4 Additionally, 67% said that stress and anxiety manifested on a weekly basis, 52% felt they were unable to spend adequate time with patients, 49% felt they were unable to do their jobs effectively and 47% went to work when they didn't feel well.

Yet research carried out by the BDA suggests differently.

Results showed that while most dentists had been affected by the pandemic, psychological distress was lower in UK dentists during the national lockdown period when compared to previous research using the same measures.5 How can it be that during a global pandemic, dentists reported lower levels of psychological distress?

A broken system

To me, that doesn't really make sense. Many hospital and community dentists - two groups that in the main have higher levels of job satisfaction than their GDP counterparts - were redeployed to frontline and put themselves in harm's way and still reported lower levels of psychological distress during lockdown. Their working environment works for them.

The same cannot be said for their GDP colleagues. Since the beginning of the pandemic and lockdown in England, NHS practices have had their contract funding maintained. For mixed and solely private practices, revenue has been significantly reduced and no government support forthcoming. This may explain why those with less than 50% NHS commitment (including purely private) showed similar levels of distress pre-pandemic, yet those who had 50% or more NHS commitment level had significantly lower scores of psychological distress.5

How, during a pandemic that's now claimed 100,000 lives and counting in the UK, can NHS contract holders be less distressed? After all, previous research has long drawn a conclusion that suggests dentists performing mainly NHS work report lower personal wellbeing, career satisfaction, job satisfaction, work engagement, and motivation than those working solely outside the NHS or in mixed practices.6

It all points to a system that for NHS practitioners is broken, was broken prior to the pandemic and has not been tended to in the interim. You only need to look at the previously mentioned 45% target imposed for NHS contract holders. NHS England data indicate that out of total of 6,683 contract holders, only 43% would have met this new target in November owing to current restrictions. A further 41% had fallen below the 'cliff edge', delivering less than 36% of their contract, and faced the return of the majority of their NHS funding for the current quarter, and with it risked closure.

According to recent YouGov polling, 46% of adults in England indicate they would be likely to cancel a routine appointment if they had one booked in during this lockdown. 45% are now less likely to seek routine care when due for a check-up, when compared to the period before the current restrictions were applied.7

It all points to a system that for NHS practitioners is broken, was broken prior to the pandemic and has not been tended to in the interim

BDA survey data indicate nearly 8 in 10 practices (79%) have seen an increase in the levels of cancelled or missed appointments since the New Year, with 43% reporting they've seen a much higher than usual rate of no-shows compared to earlier in the pandemic. More than three-quarters of practices also report issues with staff availability since the New Year, with 39% citing COVID-19 infection as having a high impact, with 53% citing staff self-isolation, and 42% problems in securing childcare owing to lack of clarity on their key worker status.

The Scottish Government, which had planned to impose similar targets on practitioners in Scotland - albeit at less than half the level expected of their English colleagues - has decided to delay their introduction until at least June in the light of surging infection rates and tighter restrictions. The Welsh Government has not introduced any activity targets at all. So why the imposition in England?

In a statement, Shawn Charlwood, newly elected Chair of the British Dental Association's General Dental Practice Committee said: 'We warned Government where their targets would lead, and now patients in pain are going to be left without options.

'This is not a model of care we could ever deem acceptable during a pandemic. However, it is the inevitable logic of a policy this Government has imposed on NHS dentists across England.

'The government's pragmatism, and willingness to change tack on policy in response to emerging evidence is something to be applauded. It's insistence on sticking to these targets in the face of the facts is not.

'It is time to abandon these discredited targets and find a way forward that reflects the reality on the front line, and places priority on the patients who need us most.'

What is normal?

Rather like my pining for 'this time last year', it's not easy to recall a daily routine that didn't involve staring at the same four walls. In June I asked Jenny Harris, Consultant in Community Paediatric Dentistry, Community & Special Care Dentistry, Sheffield Teaching Hospitals NHS Foundation Trust, what a new normal may look like once we were out of the other end regarding community dental services. One phrase she used that stuck with me was the principle of 'building back better'. As terrible as this pandemic is, isn't it also an opportunity to assess what we've taken as normal, things we may have accepted begrudgingly and areas of good practice we've always thought were ripe for change?

Besides the 'macro' issue of the NHS system, there needs to be more action and support for those suffering in silence. Concerns about mental health and wellbeing are not new - a quick search for research papers takes me as far back as 1988 showing how stressful dentistry is for those involved. So, what specific support is there for dental professionals?

You would have to say this is an area that does need to be 'built back batter'. The Practitioner Advice and Support Schemes (PASS) were operating in a number of areas and work was ongoing to develop them further and expand geographically. The Mental Dental Facebook group was a much-used resource among dentists and the Confidental helpline had now been established. There is also the Dentists' Health Support Trust providing specialised mental health and addictive disorder support. In England, dentists recently gained access to NHS Practitioner Health, an organisation of doctors working for doctors and dentists. The BDA had also recently offered access to Health Assured, an assistance programme that included counselling for those who need it. In Northern Ireland, Inspire Workplaces General Dental Services Assistance Programme is in place and is a one-stop-shop for mental health and wellbeing support. Scottish dentists and their teams have access to the NHS Occupational Health Advice and Guidance Service, and have had so since 2018.

The story is a little different in Wales. Prior to the pandemic, BDA Wales undertook research into what mental health support was available locally in Wales for dentists. The results, highlighted in Table 1, made for grim reading.

Table 1 Mental Health & Psychological support service provision for GDPs in LDCs and Health Boards in Wales
Full size table

Interestingly, the government-funded scheme for general practitioners - Health for Health Professionals Wales - not available to general dental practitioners pre-pandemic - required a shift in policy due to COVID-19 for the service to be widened to include dentists. With what I'd describe as a patchwork approach at best to safeguarding the mental health and wellbeing of the profession, it should come as a great relief that the recently-launched Wellbeing support for the Dental Team - A UK wide resource - is a significant step in the right direction of giving every dental professional access to the same help, no matter where they're from.

Student support

That also includes students which, in the current climate, is absolutely vital.

Research suggests only 56% of students reported that they had had or would have stress management as part of their degree. The leading stressors were exams, failing assessments, workload, lack of time to complete clinical requirements, and inconsistency in feedback.8 The same study also highlighted 56% of dental students reported having high stress and 57% exceeded the threshold for burnout. While there is a greater openness about mental health among this generation, these data come from pre-pandemic. Data on how COVID-19 has impacted the mental health and wellbeing of dental students in the UK is scarce, but anecdotally there is no doubt many, many students - particularly those in years four and five casting a gaze to their future post-dental school - are suffering. Data gathered from overseas show this to be the case; considerable stress reported by students regarding changes in examination processes and formats and lack of timely communication as a result of COVID-19.9,10

One has to wonder what the last year has done to the mental health and wellbeing of dental students. We've all been there - year one you're settling into new surroundings, year two it's out of halls and into housing and from year three it's into clinical and you're let loose on actual people. That's stressful enough. Throw in the generation's tendency to compare themselves against what they see on social media and strive for unrealistic standards, and you have the nucleus of a huge problem exacerbated by COVID-19.

In fact, maladaptive perfectionism, associated with higher levels of psychological distress, depression and anxiety, is particularly prevalent in dental students. Why is this a problem? We live in a world where fully established, practising dentists do not feel able to admit to making mistakes for fear of litigation, let alone those with stabilisers on trying to navigate their way through the final years of dental school and/or foundation training in a COVID-19 impacted world. And this doesn't even take into account the impact COVID-19 has had on dental academics.11 Kathryn Fox said it best in her paper:

'University educators need to aid the transition of emerging adults into full adulthood and support them in areas such as dealing with uncertainty, learning to cope with failure, assessment of risk, self-reflection and goal setting. Educators in dental schools and foundation training also have a role in delivering constructive feedback by tailoring it to the specific task that is being undertaken, in order to encourage the trainee to reflect and identify areas for their development. A coaching approach rather than a judgemental one is required. The judgemental approach tends to encourage the defensive, grade-orientated response in the trainee who may respond personally, whereas a coaching approach allows the trainee to reflect on their experience and identify their areas for development and take feedback as to how these can be addressed. In addition, the importance of self regulation (controlling one's behaviours, emotions and thoughts in pursuit of long-term goals), has been highlighted to dental students as mechanisms (to help deal with such emotions) have been introduced in some schools. In addition, sessions regarding personal values, accepting feedback, the effect of mindset and the benefits of personal goal setting have been found to be of benefit to students. The aim of these interventions is to facilitate students who have grown up in a culture of 'safetyism' to deal with uncertainty, develop their risk-taking abilities, improve resilience and to cope with failure or adverse outcomes. This needs to be consolidated in foundation training in order to develop the trainees' confidence in their own ability to take on challenging situations.

'Although society has become far more litigious over the past ten years, dental indemnity organisations (DIOs) have a role to play in educating dental students and young dentists on the technical rather than perceived risks of patient litigation and referral to the regulator, and how these can best be dealt with throughout a dentist's career, without causing undue stress and anxiety. In addition, DIOs could play an important role in continuing professional development on subjects such as dealing with difficult interactions, conflict resolution and managing patient complaints, to prevent these from escalating. The profession should also campaign against the ubiquitous advertising of ambulance-chasing law firms and 'no-win, no-fee' contracts, which ultimately lead to defensive practice and poorer patient outcomes'. 12

Moving the needle

Without wishing to become embroiled in a discussion of a political nature, I think (hope?) you would be hard-pressed to find someone (outside of the Cabinet) impressed with the UK's handling of the pandemic to date. The perpetual cycle of restrictions cities like Manchester have faced - it has essentially been in some form of lockdown since last March - has eroded mental health at a worrying rate. Yet there appears to be one area the UK is excelling at: the roll-out of the COVID-19 vaccinations.

Last month NHS England confirmed that all dentists, teams and support staff - in both NHS and private settings - will receive priority access to the vaccine.

In a message sent to all NHS Trusts and Foundation Trusts,13 chief executives have been instructed to 'work with CCGs and local systems to offer COVID-19 vaccination to all healthcare workers working in primary care as well as independent practitioners and independent providers including general practice (including locum staff), community pharmacy, dentistry, optometry and hospices.' Northern Ireland also moved to confirm their vaccination schedule.

One question that sticks its head above the parapet is whether dentistry can rely upon the roll-out of the vaccination to return to something resembling normal patient-flow and service. It's one thing for dental professionals to be given priority access to the vaccination - the very nature of their work places them at great risk - but what about the rest of the population? High priority groups, mostly cascading in age, in all honesty are not the profile of patients seen on an everyday basis. And besides, until the population is vaccinated, dental professionals face continued restrictions. Reduced practice capacity, longer hours to get patients seen while being burdened by enhanced PPE as we approach warmer months - the second cycle for many - most likely does not fill anyone with joy. One social media poll by an American dental hygienist drew some terrifying results - dry eyes, sore throat, rash, runny nose, pressure blister on nose bridge, coughing at night, TMJ discomfort, eyestrain, tight chest, chapped lips, ear pressure, occlusion changes, clogged ears, bloating, itchy tingling skin, bloody nose, intermittent PVCs, facial muscle twitches, and sleep apnoea - all as a result of their enhanced PPE.14

If that is to be the case, the uncertainty remains and with it the stressors of merely treading water, sometimes taking on too much water. If we're being honest, no-one expects the current lockdown to end any time soon - First Minister of Wales Mark Drakeford has already announced an extension to theirs. For the profession this means restrictions on movement, fallow time and the stress of being in limbo. Social distancing and all the disruption it brings to daily life is probably here to stay for longer than anyone wants to think, even if the harshest elements of lockdown can be lifted by spring, potentially offering the profession some respite.

Until then I'll sit back on my sofa and think about that evening on HMS Belfast while trying not to become a real-life incarnation of Mr W E Coyote.