Your NHS dentistry and oral health update 

24 July 2023

A special focus on Patient Safety

 An introduction from Jason Wong 

Dear colleague,

It is an honour to take up the position as Interim Chief Dental Officer (CDO) England. I want to take this opportunity to pay tribute to Sara Hurley for her hard work over the past 8 years and in particular for the “putting the mouth back in the body” agenda.

My thanks go to Sara and also Professor Rebecca Harris who is leaving her post as Deputy Chief Dental Officer this week. Rebecca has held the post of Deputy Chief Dental Officer for the last two and a half years, over which she has worked hard as the clinical lead for reform, working closely with primary care commissioning colleagues. Rebecca has been key to feeding in the voice of frontline dental teams via focus groups and in setting up clinical reference groups which have been important in shaping priorities and reforms. The first set of changes to the 2006 contract were widely welcomed last July, as was guidance supporting dental hygienists and therapists to open courses of treatment according to their scope of practice. Work on supporting dental therapists and hygienists to open, close and submit NHS courses of treatment confidently has been ongoing, with an online learning model soon to be available.

I am very aware that there is much work still to do and we must increase the pace of change of reform. I will support both NHS England and the Department of Health and Social Care (DHSC) in achieving this reform.

With Rebecca’s departure, Professor Nick Barker, current Local Dental Network Chair for Essex will be stepping in to take over this role while the process for a substantive post is undertaken.

There is also much work to do in other areas affecting dentistry and oral health. The OCDO will continue with our work on culture; making the shift to a just and learning culture and moving further away from a culture of fear. There is more on this in the content below. We all want to have proportionate and tough regulation as well as a fair clinical negligence system but it is a whole system cultural shift that is required.

Later on in this bulletin we focus in on patient safety, and look at the work of Project Sphere, a multi-organisational group working towards making the dental practice environment safe for the patient and the whole dental workforce. Support for the entire dental team providing care is  a crucial element to the change that we need to see. The role of the OCDO is to lead clinical policy for the system, with patient and profession advocacy at the core of everything we do.

It was good to see the publication of the health and social care committee report on NHS dentistry last Friday and I look forward to the Government’s response to the report. We will continue to support Ali Sparke, Director for Pharmacy, Optometry, Dentistry and the NHS Standard Contract at NHS England and his team with the reform work, as well as the minister and the DHSC team with the NHS Dentistry recovery plan.

To aid this work I am pleased to announce new members of the OCDO team, who will be joining us for at least the next three months as senior clinical policy advisors. I am delighted that former Deputy CDO Janet Clarke MBE is returning to the team fresh from her special advisor role to the health and social care committee and Charlotte Klass, Consultant in Dental Public Health is also joining the OCDO Executive team.  Shabir Shivji and Deborah Manger will both be joining the team to drive forward a wide range of programmes integrating oral health into general health including, but not exclusively, cardiovascular disease, maternity services and cancer pathways.

I will continue to focus on developing and delivering the priorities for the OCDO, our patients and our profession, and will continue to update you on progress.

Best wishes

Jason Wong

Jason Wong 

Interim Chief Dental Officer England 

Quality and safety in dental care 

The World Health Organization states that quality health services across the world should be:

• Effective: providing evidence-based healthcare services to those who need them.
• Safe: avoiding harm to people for whom the care is intended.
• People-centred: providing care that responds to individual preferences, needs and values.

What is patient safety?

Patient safety is about maximising the things that go right, and minimising the things that go wrong for people experiencing healthcare. It is integral to NHS England’s definition of quality in healthcare, alongside effectiveness and patient experience as part of the NHS Patient Safety Strategy.

Health Education England (now the Workforce, Training and Education Directorate at NHS England)  created the Patient Safety Syllabus, freely available to all. It consists of 5 levels, currently levels 1 and 2 are available on the e-Learning for Healthcare hub. Level 1 applies to all members of the dental team and level 2 applies to dentists and all dental care professionals. Levels 3, 4, and 5 are in development and will cover patient safety in more depth, including human factors.

Contributing to patient safety learning 

A valuable way people working in dental care can support patient safety improvement is through the recording of patient safety events onto NHS England’s national Learn from Patient Safety Events (LFPSE) service. The Office of the Chief Dental Officer welcomes the introduction of the service, which will support patient safety improvement across all dental care settings. 

Dental organisations that currently record patient safety events onto a dedicated local risk management system (LRMS) could soon see those records automatically uploaded to LFPSE; while individuals from organisations without an LRMS are encouraged to register and start recording safety events directly into the new online national LFPSE service.

Using LFPSE to record and share details of patient safety events means that you are participating in a profession-wide effort to support national safety improvement work. We recognise that most dental care is delivered in safe settings by caring practitioners, and that the profession has a safety record of which it can be proud. However, there is always more to be done to ensure that we are delivering the best possible care for patients. Whilst event reporting is a vital tool for information gathering, patient safety engagement, and shared learning, we recognise that further work is needed to facilitate a just culture for patient safety in dental settings.

Maintaining consistent, constructive, and fair review of and response to patient safety events will facilitate a supportive and safe learning environment for all colleagues. Proactive engagement with recorded events will also aid local safety improvements, while assisting continuing professional development and encouraging personal reflection.  LFPSE also enables organisations to have better oversight of incidents occurring, with concurrent analysis of these incidents and events being recorded. You can see statistics about the safety events recorded within your organisation via LFPSE’s Data Access platform which launched last year.

We strongly encourage the recording of patient safety events occurring in dental settings onto the LFPSE system. The more events that are recorded, the more information the NHS will have to identify new and under-recognised risks, which can support improvement. If your organisation doesn’t use a dedicated local risk management system, we urge that your staff register and use an LFPSE online account as soon as possible. If your organisation does use LRMS, at least one relevant individual should sign up for an Enhanced Account, to ensure you have access to any events that might have been recorded about your organisation from elsewhere, and speak to your LRMS vendor about timelines for connection to LFPSE.

The NHS England National Patient Safety Team use this information to identify patient safety risks that occur in the delivery of healthcare. LFPSE is replacing the existing National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). Through these systems, the team has access to information on over 23 million patient safety events recorded since the NRLS was launched in 2003. Over 2.5 million patient safety events are now recorded annually from across healthcare.

The team review recorded patient safety events, as well as information from other sources, to identify new or under-recognised patient safety issues. Where a risk is identified, advice and guidance, such as National Patient Safety Alerts, are developed to support providers across the NHS to keep patients safe. The data is also used to support a range of national patient safety improvement programmes.

The data can also be used locally to support a better understanding of patient safety events, safety culture, and priorities for improvement. Aggregate data can reveal high-level trends and provides the ability to triage responses based on local priorities. As the LFPSE analysis tools evolve, they can be used to identify any areas of concern, by location, specialty, physical components, and a host of other variables. The LFPSE service can reveal important information about recording patterns, staff perception of risks and concerns, and safety culture within an organisation.

Using the Learning from Patient Safety Events (LFPSE) service

Some large groups of dental practices may have a dedicated local risk management system for the recording of patient safety events. In these organisations, work is underway to upgrade your local system to be LFPSE service compliant. Once this work is completed, all new patient safety events recorded onto your local system will be automatically anonymised and uploaded to the LFPSE service. In the meantime, you should ensure at least one appropriate individual has access to an Admin Account in LFPSE, to ensure your organisation has visibility of any events that might have been recorded from elsewhere.

In organisations without a local risk management system, such as most independent dental practices, you can record patient safety events directly to the LFPSE service by setting up an online account. This will be linked to your organisation or group, so analysis can be accessed on all safety events recorded by staff to also support local improvement. The LFPSE service allows individuals to record:

• Incidents – Including those resulting in physical harm, psychological harm, or neither.
• Outcomes – A poor outcome where it is not yet known if a patient safety incident contributed.
• Risks – A risk to patient safety in the future.
• Good care – Examples of good care from which learning can be taken, promoting a positive patient safety culture.

The information inputted in to the LFPSE can then be reviewed to share learning and reinforce best practice techniques amongst clinicians. We are currently working with the LFPSE team to gain access to dental based incidents which are recorded to encourage learning from these incidents. Organisations can access events recorded under their organisation (ODS) code. 

Recording systems fulfil one or more of the following five functions:  public accountability, response to the patients and families involved, communications alert route, an indicator of risk within healthcare, and, most importantly, a foundation for learning and improvement.  According to the World Health Organization, “Globally, as many as 4 out of 10 patients are harmed in primary and outpatient health care, with up to 80% of harm being regarded as preventable.” The introduction of the new LFPSE service is part of the overarching NHS Patient Safety Strategy.

Patient safety incidents and harm

Patient safety incidents may or may not result in harm to the patient, but they are all worth recording. Prevention is better than cure; we should seek to learn from risks as soon as they present themselves in case the learning we derive from them can prevent recurrence or escalation into future harms.

It is human to make mistakes, so we need to reduce the potential for error by continuously learning and acting when things go wrong. Healthcare staff operate in complex systems, with many factors influencing the likelihood of error. These factors include medical device design, volume of tasks, clarity of guidelines and policies, and behaviour of others. A ‘systems’ approach to error considers all relevant factors and means our pursuit of safety focuses on strategies that maximise the frequency of things going right.

LFPSE defines a patient safety incident as “an unexpected or unintended event that could have or did lead to harm for one or more patients”. This could be something that happened though it should not, or something that should have happened but did not.

There are two ways that incidents can result in no harm: one is that, although the incident ran to completion, the patient sustained no harm. For example, a patient may be dispensed out of date medication, takes it, but suffers no ill effects. The other is that harm is actively prevented from occurring. An example could be a patient being prescribed another patient’s medication; however, the error is identified, and the medicine is withdrawn, prior to any incorrect medication being taken.

Some incidents like the latter are sometimes described as “near misses” but there is no universal definition of these. In the above example, the dispensing of medication to the wrong patient was an incident, so while the potential impact was prevented, the incident itself still occurred.

The most important thing is to recognise when there have been failures in care that could have or did lead to harm, and to record them to maximise our opportunities to understand them, and work to reduce or eliminate them.

When recording incidents to LFPSE, you will be asked to make an initial assessment of the harm caused to the patient – both physical and psychological, using the scale of no harm, low, harm, moderate harm, severe harm, or (in cases including physical harm) fatal level of harm. Alongside other information about the event, you are encouraged to include details that explain how it took place, including how any harm was prevented if relevant, and any suggestions to prevent recurrence. These and all other details can be updated at any time if your understanding of the event changes.

Underreporting

Underreporting of incidents is a challenge across healthcare as it means we lose the opportunity to gain insight for improvement. One factor in underreporting is ‘blame culture’; it creates an environment of anxiety, fear and apprehension amongst staff that reduces their willingness to report patient safety incidents. Underreporting masks the true number of patient safety events and may reduce our ability to learn from and prevent repeat events.

Several main barriers to event reporting relating to blame culture have been identified: fear of litigation, loss of professional respect among colleagues, loss of respect from patients, fear of the regulatory repercussions, fear of losing one’s job, time-consuming and unnecessary paperwork, and the concern that recording or reporting will not make a difference. There is consequently a need to develop infrastructure, supported by a just culture, for the reporting of patient safety events within dentistry. 

Other barriers include lack of time to report, poor access to reporting systems and the absence of feedback after reporting. The introduction of LFPSE aims to help reduce many of these barriers.

Patient Safety Incident Response Framework (PSIRF)

The new Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. It will replace the current Serious Incident Framework (2015).

The PSRIF promotes a proportionate response in managing patient safety incidents, implementing compassionate engagement for those affected, applying system-based approaches to aid learning and ensuring supportive oversight is in place, to strengthen response system functioning and improvement. It will ensure the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals, allowing for more effective learning and improvement, and ultimately making NHS care safer for patients.

The framework represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. PSIRF removes the requirement that all/only incidents meeting the criteria of a ‘serious incident’ are investigated, allowing for other incidents to be investigated and for learning response resource to focus on areas with the greatest potential for patient safety improvement.

The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:

• Compassionate engagement and involvement of those affected by patient safety incidents.
• Application of a range of system-based approaches to learning from patient safety incidents.
• Considered and proportionate responses to patient safety incidents.
• Supportive oversight focused on strengthening response system functioning and improvement.

Secondary care providers are currently preparing for the implementation of PSIRF from Autumn 2023. Primary care providers may also wish to adopt PSIRF, but it is not a requirement at this stage. Further exploration is required to ensure successful implementation of the PSIRF in primary care settings.

Spotlight on: Project Sphere

On 17 June 2021, Deputy Chief Dental Officer at the time Jason Wong brought together key stakeholders to discuss the significant potential for patient safety improvement in dental settings. The group committed to working together in collaboration with the profession, to better embed a culture of fairness, openness and learning with regard to patient safety in dental settings.  

The group is encouraging the entire dental team to get involved: the safety of patients requires a team approach and is the responsibility of every individual. The Office of the Chief Dental Officer England, NHS England, General Dental Council, Care Quality Commission, Health Education England, College of General Dentistry, subject-matter experts, Human Factors board, and the British Association of Private Dentistry have been working together to make these changes. Furthermore, the Project Sphere group has worked with indemnity providers to create an indemnity consensus statement, to reassure and guide clinicians regarding the best place to obtain advice.

Ongoing from Sept 2021, Project Sphere has looked at: 

• Raising awareness of the recording mechanism LFPSE
• The introduction of wellbeing support for staff reporting incidents  
• Learning and development for the practice team 
• Templates to aid team discussions about learning from safety events

For more information on Project Sphere, please join the FutureNHS Dentistry workspace.

Publication of patient safety huddle sheets 

As part of its work to improve patient safety across dentistry, Project Sphere has produced huddle sheets and the supporting guidance document.

The huddle sheets have been designed to embed the practice of undertaking safety huddles (which are regularly performed across secondary and tertiary care), amongst primary care oral health and dental care teams. The huddle sheets intend to help primary care professionals deliver the best possible safe care for patients by implementing an established consistent, constructive and fair evaluation of patient safety events. The huddle sheets intend to address the potential barriers to reporting listed above, whilst complementing existing dental patient safety standards and toolkits, as well as the NHS Patient Safety Strategy.

By encouraging non-judgemental, open reflection when anticipating and reviewing patient safety events, a culture of openness and learning can be instilled across primary dental care settings. Consistent evaluations through the huddle sheets, in conjunction with local reporting mechanisms, will aid local safety improvements whilst enhancing the patient experience and promote team working, continued professional development and personal reflection.  

The huddle sheets aim to facilitate systematic evaluation of the impact of patient safety events on clinical sessions/days and team members, identifying any potential additional support and training required. Maintaining patient safety continues to be a responsibility equally shared amongst the entire dental team and all team members are encouraged to engage with and lead the huddle sessions. 

The documents provided: 

1. Daily safety huddle sheet: a framework for discussion, enabling issues to be raised at the start/end of a session. Can be performed verbally, as well as written down.   
2. Post-patient safety event huddle sheet: to be used shortly after a patient safety event, in conjunction with local incident reporting mechanisms. 
3. Reflection huddle sheet: to be used a significant amount of time after a safety incident, near-miss, or major event. The amount of time can be at the discretion of individual teams e.g., 1, 3, 6 or 12 months following the initial incident or event.
4. Huddle supporting guidance document: assists in the completion of the huddle sheets and encourages systematic evaluation of elements comprising the working system and environment. It prompts teams to identify human factors which can be modified to maximise performance and processes in primary care dental settings. It serves as a guide, created with the knowledge that each event and team are unique, possessing their own considerations. 

We encourage teams to download and edit the huddle sheets, so that they may be adapted to meet individual practice needs. Maintaining copies of both the post-patient safety event and reflection huddle sheets is advised, to support and evidence learning. 

Regulatory support

Project Sphere is grateful for support from dental regulators. The General Dental Council (GDC) highlighted the LFPSE service in their August 2021 newsletter. Stefan Czerniawski, Executive Director of Strategy at the GDC, said that "patient safety is, and remains, fundamental to our purpose, so I hope we will be able to take the discussion we all started in June 2021 further forward and very much look forward to contributing to that."

John Milne, formerly the Senior National Dental Advisor for the Care Quality Commission, says that the "CQC are supportive of this process and recognise it is important to learn from untoward incidents and near misses."

Additionally, many interested organisations wish to create and embed a patient safety culture within dentistry. Fleur Kellet, Associate Dental Dean for Foundation, Core and Fellows, NHS England – Midlands (Workforce, Training & Education) says:

“It is important that we develop a culture of compassion, and fair accountability with regards to patient safety incidents. Considerate communication, improved reporting processes and post-incident welfare assistance play a vital part in improving patient safety culture. All team members have their part to play in creating a culture of constructive support.

As a profession we need to empower teams to review organisational, environmental, and human factor elements that may have contributed to a patient safety incident without fear. Creating an environment where individuals are supported to raise and resolve concerns, address incidents of unsafe care with empathy, respect, and rigour is essential. With increased compassion, improved processes and support structures, the dental profession can be the vanguard of positive change.”

Clinical leadership in patient safety

Interim Chief Dental Officer Jason Wong discusses contemporary concepts relating to patient safety for the College of General Dentistry in this seminar. Recent studies of organisational culture and patient safety emphasise the role of senior leadership. Senior leaders can support learning and communicate the importance of safety over other organisational goals. Effective leaders show active engagement with patients and staff, which has a bearing on safer patient care.

Dentists, dental nurses, and dental care professionals can all play an important part as clinical leaders. Clinical leaders make sense of patient safety problems, mobilise resources and implement solutions. They also create a just culture: one of fairness, openness and learning in the NHS. This is to make colleagues feel confident to speak up when things go wrong, rather than fearing blame.

How should dental leaders encourage a just culture?

• Encourage non-hierarchical team structures and welcome challenge.
• Lead teams effectively by using local practice-based learning and recording of both near miss and significant events.
• Encourage professionalism to flourish.
• Encourage the use of  standard operating procedures such as ‘Local Safety Standards for Invasive Procedures’.
• Digital interoperability.
• Take a system-level approach by working with regulators to encourage leadership, professionalism, learning culture and upstream support.

Recognition of dental leadership

The 25^th Annual Dental Awards presented by The Probe, in association with the British Association of Dental Therapists (BADT), have announced Jyoti Sumel as Dental Therapist of the Year for 2023.

Further resources

• Civility Saves Lives: with increased compassion and a mindful approach to civility in the workplace, dentistry can lead the way in the approach to the management of untoward events.
• LFPSE primary care webpage: information for primary care organisations and staff about the introduction of LFPSE.
• NHS England » A just culture guide.
• Further LFPSE resources, including recorded presentations, on-screen walk-throughs, communications materials, podcasts, discussions boards and more are available in the Patient Safety workspace on the FutureNHS platform.
• LFPSE user guides are available from the lower ribbon on-screen in the online service
• LFPSE FAQs

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Recent dentistry and oral health bulletins 

Previous bulletins can be accessed by clicking on the links below:

Special focus bulletins 

The Office of the Chief Dental Officer and the NHS England team regularly produce 'special focus bulletins' on clinical priorities and key aspects of patient care. These bulletins summarise the key information dental teams need to know and act as a refresher, combining best practice, expert opinion and useful resources. If you would like to suggest a topic for a future special focus bulletin please email the CDO's team at England.CDOExecutive@nhs.net 

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The NHS primary care bulletin provides resources on health policy and practice and we encourage you to sign up for this, too. It is aimed at teams across general practice, dentistry, community pharmacy and optometry. 

Key advice, guidance and resources for NHS dental teams

NHS updates to the profession 

Key letters from the Chief Dental Officer and the NHS dentistry and oral health team are online here. 

Infection prevention control (IPC) 

NHS practices should refer to the NHS England Infection Prevention and Control Manual which details the principles NHS dental practices should now follow to deliver care. The accompanying dental framework identifies hazards and risks with guidance on measures that should be maintained as we move to new, improved and safer ways of working. 

Dental recall priorities for children: implementation tool

Children are a clinical priority group for all NHS dental teams. Practices are encouraged to use the NHS implementation tool which assists dental professionals in the recall of children for a dental appointment, in line with NICE guidelines. You can view the tool online.

Avoidance of doubt note: provision of phased treatments

This document is to support dental professionals, and to clarify where it might be appropriate to provide phased treatment spanning over several courses of treatment (CoT). You can read it online here.

Health and wellbeing support

The new Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. It will replace the current Serious Incident Framework (2015).

The PSRIF promotes a proportionate response in managing patient safety incidents, implementing compassionate engagement for those affected, applying system-based approaches to aid learning and ensuring supportive oversight is in place, to strengthen response system functioning and improvement. It will ensure the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals, allowing for more effective learning and improvement, and ultimately making NHS care safer for patients.

The framework represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. PSIRF removes the requirement that all/only incidents meeting the criteria of a ‘serious incident’ are investigated, allowing for other incidents to be investigated and for learning response resource to focus on areas with the greatest potential for patient safety improvement.

The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:

·       Compassionate engagement and involvement of those affected by patient safety incidents.

·       Application of a range of system-based approaches to learning from patient safety incidents.

·       Considered and proportionate responses to patient safety incidents.

·       Supportive oversight focused on strengthening response system functioning and improvement.

Secondary care providers are currently preparing for the implementation of PSIRF from Autumn 2023. Primary care providers may also wish to adopt PSIRF, but it is not a requirement at this stage. Further exploration is required to ensure successful implementation of the PSIRF in primary care settings.