Your NHS dentistry and oral health update 

August 2022

A special focus on Safeguarding

An update from Sara Hurley and Kenny Gibson MBE

Dear colleague,

To provide quality care, an understanding of our personal and professional responsibilities with regards to our safeguarding role remains vital. As patients return to their trusted dental practices, we are conscious that you may see signs of physical and emotional trauma. You may be privy to the disclosure of such issues during examination and treatments. Please listen to your patients, believe them, and then act. Remember no clinician has got into trouble or struck off their professional register for protecting people from neglect, abuse, exploitation or violence.

The past few months have seen notable cases regarding the safeguarding of children reach the news once more. Whilst our first thoughts of safeguarding might be about protecting children or supporting vulnerable adults who have a lack of capacity, safeguarding principles are equally applicable to evacuees, refugees and asylum seekers.  We should all be confident in using our judgement to help protect people from neglect, abuse, exploitation and violence; this special bulletin pulls together a range of resources to assist you and your staff in fulfilling your safeguarding responsibilities.

Please do keep yourself and your team updated on safeguarding responses and trauma-informed practice via our free NHS Safeguarding App (Level 1 & 2). Also available is the #NHSSafeguarding learning platform (Level 2 & 3)  for those practitioners who are more professionally curious.

Sara and Kenny

Safeguarding in the dental setting

As dental professionals, we will encounter adults at risk of abuse and neglect, and we all have a statutory duty of care to ensure that safeguarding arrangements are in place and acted upon. For safeguarding children, this is enshrined in the Children's Act 2004, whilst the Care Act 2014 covers adult safeguarding.

The General Dental Council Standards for the dental team requires registrants to raise concerns for those at risk of abuse or neglect and the Care Quality Commission Safeguarding Statement specifically seeks assurance of the dental team’s competence in safeguarding them.

The dental team is in a position where they may identify signs of abuse or neglect or hear something that causes concern. They should therefore not feel reticent to raise a concern and act to protect those who are being harmed. Safeguarding is about people and organisations working together to prevent and stop both the risks from and experience of abuse or neglect.

There is wide ranging evidence in relation to the harm, abuse and neglect that people with protected characteristics experience. This applies particularly to children and vulnerable adults, with many reports identifying widespread failures of care for those in the most vulnerable circumstances.

It should be appreciated that ‘vulnerable adults’ are not a homogenous group. Any person can be in a vulnerable situation and a person’s age or disability does not in itself make a person vulnerable. Therefore, nurturing professional curiosity is fundamental to keeping children, young people and adults safe. Safeguarding processes should also be integrated into existing dental practice systems when delivering care in order to reduce the risk for those who are vulnerable.

Working with your local teams

We encourage you to continue to refer any and all safeguarding concerns to your local multi-agency safeguarding hubs (MASH) and follow up for the outcome. If the MASH response is unacceptable or you do not receive one, you must escalate your concern.

If you do not hear from MASH within 5 days, escalation would involve resending the referral, copying in your local Designated Professional (contact details can be found via Integrated Care Boards), and contact the Named GP for Safeguarding at the patient’s GP practice.

This is especially important for: looked after children (LAC); any child who is repeatedly not brought to a planned appointment; and any adult with support and care needs who might lack contact with healthcare professionals.

Information sharing

The revised NHS Safeguarding accountability and assurance framework states that robust information-sharing is at the heart of safe and effective safeguarding practice and is covered by legislation, principally the General Data Protection Act 2018 (GDPR) and the Data Protection Act 2018.

Where there are safeguarding concerns, staff have a duty to share information. It is important to remember that in most serious case reviews, lack of information sharing can be a significant contributor. Staff should remember that the Data Protection Act is not a barrier to sharing information but provides a framework to ensure that personal information is shared appropriately. Sharing should be necessary, proportionate, relevant, accurate, timely and secure.

This is further supported by the Caldicott Principles  and specifically Principle Seven which states that the duty to share information is as important as the duty to protect patient confidentiality. It is crucial to understand that sharing information, when there is a need to share it, and a lawful basis for doing so, and maintaining its security and confidentiality, are compatible activities.

Key guidance and resources for safeguarding children

Concerns about a child or young person can crop up at any time so it is important to be prepared and to know your local safeguarding contacts so that you can get advice and make a referral. You can search for your local Safeguarding Children Partnership’s website using the NHS Safeguarding app. There you will find telephone numbers and instructions for referring a safeguarding concern to Children’s Social Care, or for referring a family for Early Help. In addition, you will find a wealth of information to support your decision making, such as threshold guidance, and signposting to local training opportunities.

You may also find it useful to consult resources which have been developed specifically for dental professionals, such as Child protection and the dental team: an introduction to safeguarding children in dental practice. This is now hosted by the British Dental Association and can be accessed at BDA: child protection.

It functions as:

• an illustrated reference manual – covering Responsibility, Recognising, Responding, Reorganising and Resources
• a fast response tool – with an interactive summary flow chart
• a training resource – with 3 hours of CPD available free-of-charge to all UK-registered dental professionals, whether BDA members or not

When your concerns relate to dental neglect and are accompanied by signs of general neglect, you must make a safeguarding referral. In cases where there is a lower level of concern and signs of apparently isolated dental neglect, it may be appropriate to consider a tiered three stage response. 

This approach is endorsed in the British Society of Paediatric Dentistry’s policy document on dental neglect in children, a fully-referenced article which explores the subject in more detail. If, at any point, the situation is found to be too complex or deteriorating and there is concern that the child is suffering significant harm, the dental team should not delay referring the child to Children’s Social Care for a full assessment according to local procedures.

A new perspective

Missed dental appointments often give particular cause for concern. Considering the child as ‘was not brought’ instead of ‘did not attend’ encourages us to look at the situation from the child’s perspective. Sheffield Community & Special Care Dentistry service has developed, evaluated and shared a pathway to help manage missed appointments in a standardised manner, ensuring that the dental team assesses risk to the child and shares information appropriately with other professionals.

A 9-page quick start guide Implementing ‘Was Not Brought’ in your practice provides top tips, flowcharts, and templates. Supporting documentation can be downloaded from the BDA Safeguarding page.

It is important to remember that when you have concerns about a child’s safety and welfare, you do not need to manage this alone: help and advice is available. You do not need to be certain of the diagnosis: that responsibility does not rest solely on your shoulders. The decision whether a child is being maltreated and what needs to happen will be made by an experienced group of child protection professionals working together. But you must refer if you have concerns. Any member of the dental team can make a safeguarding referral. If unsure it is better to intervene early rather than waiting for a crisis to develop. Safeguarding children is everyone’s business.

Key guidance and resources for safeguarding adults

For many at-risk individuals, the Covid-19 pandemic has led to increased vulnerability to abuse and neglect. The Office of Health Improvement and Disparities identified that self-isolating, shielding and social distancing disproportionately impacted on vulnerable populations, including: older people; people with learning disabilities or autism; those with underlying health conditions; and minority communities.

Individuals from the at-risk group are also more likely to have poorer oral health and may present to dental practices, often for urgent dental care. Since the pandemic began, we have seen a significant increase in domestic abuse and mental health illness. Decreased social contact has contributed to an increase in neglect and self-neglect that can lead to serious risk of illness and wellbeing of an individual. Therefore, it is important that, as health care professionals, we are vigilant about the signs of abuse and neglect and are aware of how to raise and report concerns.

Dental teams often see patients over a long period and may be the first to notice changes in behaviours and self-care that may indicate self-neglect and a need for support. Facial and dental injuries with sometimes inconsistent histories can be a sign of physical abuse of which dental teams should be mindful. Concerns should be raised for adults who are dependent on carers/family for support and are not brought to dental appointments. The concern should be discussed with the person who should have been brought to their appointment, and contact made with their care/support system. The BDA expect to publish this additional pathway for vulnerable adults in Implementing ‘Was Not Brought’ in your practice in late 2022.

Safeguarding in general practice: A toolkit for dental teams

People with protected characteristics and who have a range of multiple and complex service requirements may be in positions that increase their dependency on others and make them less able to protect themselves from harm or abuse.

Safeguarding in general dental practice: A toolkit for dental teams highlights how dental services can intervene by connecting safeguarding with good practice in meeting the needs of those at risk and therefore work to reduce health inequalities.

Compliance with the Human Rights Act 1998, the Equality Act 2010 and the Mental Capacity (Amendment) Act 2019 are all fundamental to these aims. Dental teams do not need to know about the execution of safeguarding referrals in detail, but they must know what to do when abuse is suspected, how to act to prevent abuse and when to make a safeguarding referral.

Recommendations

The Public Health England Toolkit recommends that every dental practice should:

• have a named Safeguarding Practice Lead
• ensure all members of staff know how to access the NHS Safeguarding app for local safeguarding contact details
• ensure all members of staff (clinical and non-clinical) undertake the appropriate level of safeguarding training
• have a robust safeguarding reporting system in place, and ensure staff are familiar with this system.

Trauma-informed practice

Trauma-informed practice is a strengths-based approach, which seeks to understand and respond to the impact of trauma on people’s lives. The approach emphasises physical, psychological, and emotional safety for everyone and aims to empower individuals to re-establish control of their lives.

Trauma-informed practice recognises the prevalence of trauma and its impact on the emotional, psychological and social wellbeing of people. Awareness of trauma has progressed over the last 20 years, incorporating knowledge from attachment, child development and cognitive memory. Frameworks of practice have changed from purely bio-medical (medicine and psychiatry) and/or purely psychoanalytical (psychology) models to include the psycho-social (trauma-informed) and a recovery focus (recovery-oriented).

In a social work context, children, young people and their family members may be living with the legacy effects of overwhelming stress (trauma). Despite the large numbers of people affected, many of us don’t automatically think of the possibility that someone we meet, speak with or support may have experienced trauma. This makes us less likely to recognise it. Keeping the possibility of trauma and the sensitivities and vulnerabilities of people who may be trauma survivors in our assessment focus is therefore the first step towards trauma-informed practice.

Having a basic understanding of how stress can affect an individual is important. Knowing this will make us less likely to fuel other people’s stress levels. This means paying attention to ‘how’ we engage with other people, as well as to ‘what’ we do. It also means thinking about what may have happened to someone, rather than judging what is ‘wrong’ with them.

Assisting victims

If you are assisting a victim where trauma relates to domestic abuse or violence, please treat the situation with respect and confidentiality. You could support the victim to consider seeking an appointment with the Independent Independent Domestic Abuse Advisor (IDVA). Some regional areas across the UK have specific care pathways, others may require victims to visit their local A&E department to request contact.

If you are assisting a victim where the trauma relates to sexual abuse or violence then, please treat the situation with respect and confidentiality. You could support the victim to make an appointment with their local Sexual Assault Referral Centre (SARC).

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