A week ago the head of the Care Quality Commission, Cynthia Bower, resigned citing that it was ‘time to move on’ after a challenging few years of leading the organisation. It is widely believed that Ms Bower resigned ahead of a report expected to be highly critical of the organisations effectiveness in regulating and inspecting health and social care services in England.
There has recently been specific criticism of the role of the CQC in regard to deaths at Stafford Hospital; a scandal surrounding clinics offering selective abortion according to sex; and the exposure of lamentably poor standards in Care Homes, with a particular case of note in Bristol.
The CQC are also responsible for another area of health care that has received little press attention but might be the next skeleton to pop out of the cupboard, the high street general dental practitioner.
Admittedly high street dentistry has never been the sexiest of subjects and it’s possible that readers interest is now rapidly waning, but stick with it for another paragraph or two and let’s see where we go!
In late 2009 The Department of Health published a document nattily entitled HTM 01-05 (no sexing up there!) providing new advice on the decontamination of dental instruments, everything from those little mirrors through to scary drills. This latest Health and Technical Memorandum was to ensure effective instrument decontamination procedures to combat the threat from a variety of health problems such as Hepatitis B and C; Syphilis; Herpes; HIV; and vCJD, the human form of BSE or ‘Mad Cow Disease’. The Care Quality Commission is responsible, among other things, for inspecting dental surgeries to ensure that they are compliant to the required standards.
In short, HTM 01-05 tells the dentists how to ensure that the instrument they are about to put into your mouth is clean and unlikely to infect you. You probably assumed that the highest standards were already in place, well think again.
More than two years after publication HTM 01-05 is the subject of acrimony and debate amongst dental professionals and the requirements are poorly understood in many surgeries. The extent and the quality of implementation of the document, whilst acceptable in some areas of England and in some dental surgeries, is inconsistent at best. The CQC, responsible for inspection and ensuring HTM 01-05 is implemented throughout the country, have blatantly failed to do so. Spread thinly across so many areas of health care, CQC inspectors often have less idea about the required standards and the background to them than the surgeries they are inspecting. Consistency is particularly poor. Whilst some CQC inspections show a good and effective grasp of the subject matter, others have hardly read the document and understand almost nothing of the subject.
You probably assumed that the highest standards were already in place, well think again.
So what’s the problem with the current standards and is there a genuine threat to public health if HTM 01-05 is not properly implemented?
The World Health Organisation say there is, or rather there could be if the current trend continues of people migration from poorer high risk countries to richer and lower risk countries.
For example, TB and Hepatitis B are rife in many poor countries, and around 10% of the population of much of the Asia Pacific region are infected with Hepatitis C. Of course, screening programs exist but with the trends in migration being what they are, the WHO suggests every dentist takes ‘universal precautions’ and assume that every patient has a transmissible condition. This is the threat that HTM 01-05 was written to combat.
Many dentists disagree the threat is real, or that HTM 01-05 offers effective advice arguing that the guidelines are not ‘evidence based’ and propagation of statistics such as those above is scare mongering. They argue that current decontamination guidelines are perfectly effective and they ask how many people have been shown to become infected following a visit to the dentist.
Not an unreasonable question, but the answer is hard to define. Many conditions, Hepatitis C and vCJD for example, have incubation periods lasting many years, even decades. By the time an individual presents symptoms it’s too late to ascertain the likely source. It’s widely felt that Hep C particularly may be far more prevalent in the general population than we realised, with an incubation period of potentially many years, a possible ticking time bomb of infection that might or might not go off in the future.
When the effects of Mad Cow disease in the human food chain were reported many years ago it was understood that the human form, vCJD, had an incubation period of perhaps 20 or 25 years and that we might therefore face an epidemic in the future from those infected but unaware. Many dentists would argue that because that time period has passed and we have seen very few cases of vCJD, the threat of infection must be lower than originally thought and the threat from infection via contaminated dental instruments must be particularly low. The response from a microbiologist I recently spoke to was that this might be the case, or alternatively the incubation period might just be longer than we thought.
The answer to all of these questions is that we don’t know. Perhaps a better question is what do we do when the consequences of a risk are severe but we don’t know the likelihood of the risk occurring? Do we do nothing until we see a problem? Do we take action ahead of the game, assuming there is a problem, but accepting there might not be and we’re wasting our time and money? A conversation is surely required here.
What of the current effectiveness of dental instrument decontamination?
The present regime for decontaminating dental instruments calls for each to be thoroughly washed and then subjected to steam sterilisation in a device called an autoclave. This is basically microwave size box that generates steam under pressure. The instruments are contacted by steam at a temperature of 134 degrees C, sufficient to kill the spores of any microorganism that might be lurking on the instrument.
However, recent research shows that the washing process is far more important than was previously thought, and that poor washing of instruments renders the steam sterilisation process ineffective. Furthermore, vCJD is caused by a damaged protein called a prion, and prions are now known not to be killed by steam at 134 degrees. The only practical method of dealing with prions in a dental surgery is effective washing of instruments to ensure their physical removal.
It’s widely felt that Hep C particularly may be far more prevalent in the general population than we realised, with an incubation period of potentially many years, a possible ticking time bomb of infection that might or might not go off in the future.
HTM 01-05 sought to address these issues by enforcing a better standard of instrument washing. Most dental nurses wash instruments by hand with a scrubbing brush. This might come as a surprise in this modern age of safer automated techniques and indeed HTM 01-05 states that surgeries should ideally install an automated instrument washer. Most surgeries have not, and there is no absolute requirement for a surgery to do so, it’s merely Best Practice, so that’s ok then!
The alternative is to follow the required manual washing guidelines, but these are highly impractical and it’s safe to say that the general standard of manual washing is often far below the standards laid out in HTM 01-05.
Even if this were not the case, there is a clear, unnecessary, and anachronistic danger of ‘sharps’ injuries to nurses engaged in scrubbing instruments by hand, an exposure to risk that would not be acceptable in any hospital or indeed most non-medical work places.
It’s clear that dentists feel that the importance of HTM 01-05 has been poorly communicated, and indeed it has, its credibility is weak. The DoH and the British Dental Association have been ineffective in addressing dentists concerns, stimulating quality debate, or gaining industry buy-in. Dentists often express the view that HTM 01-05 is plain wrong, and because no-one is addressing their concerns and the CQC are often not enforcing implementation many have simply sat on their hands for the last two years and implemented nothing.
It’s to be hoped that the dentists are correct and the new guidelines are all over-reaction, because if they’re wrong it’s your mouth that instrument is going into sometime soon.
Finally, I recently listened to the distinguished Professor Andrew Smith of Glasgow University, a respected authority on the subject, discussing the ‘potential Armageddon scenario’ for the human race posed by the widely reported increasing human resistance to antibiotics. The seriousness cannot be under estimated, antibiotics may have stopped working altogether in 50 years, meaning no major surgery and possible death from even minor infections.
Prof Smith explained that it was quite possible that antibiotic resistance could be passed from one dental patient to another via perfectly healthy oral bacteria on contaminated dental instruments.
If that is the case, one more reason why the Department of Health and the CQC need to get their act together quickly and stop leaving it to dentists to have to interpret important public health issues. They and we deserve better.
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