There has been widespread recognition that pandemic disruption to healthcare will be long-lasting and that services will need to plan their way through an extended recovery period that makes the most of the NHS resources available. This is the first report that captures and quantifies the impact of ongoing disruption to pre-pandemic referral patterns for oral surgery care across England through the analyses of 1.75M referrals.
During 2020, Oral Surgery (along with Orthopaedics & Trauma and Ear, Nose and Throat) was one of three specialties in England with the largest reduction in completed pathways compared to 2019(6). Reduced referral numbers and suspension of treatment pathways can be expected to be major factors on this adverse disruption to pre-pandemic services.
The literature suggests that patients were able to access emergency care, and explanations for the dramatic increase in referrals post-pandemic could be due to GDPs having limited clinical time to provide care and therefore are referring more or patients’ oral health has deteriorated during the pandemic due to no ongoing oral healthcare.
Since the restrictions were imposed on dental care in March 2020 due to the pandemic, there has been a reduction in access to routine dental care for all which includes those patients’ seeking treatment for odontogenic infections. There was a delay in the publication of guidance for UDCs following the pandemic with the key message of advice, analgesia, and antibiotics (AAA). Despite this however, perhaps due to the effectiveness of Urgent Dental Care Centres (UDC), there appears to have been a reduction(7) in those patient’s requiring admission and treatment in secondary care for acute admissions for dento-facial infections. There has been a reported decrease of patients in the attendance in oral and maxillofacial departments for dental related issues with the advent of urgent care centres(8, 9). Politi et al(7) reported that during 2020 no patients presented with a post-extraction infection and suggested that this was due to the number of extractions being carried out in UDC’s as opposed to general dental practitioners. There was however an increase in the percentage of those requiring admission who presented with infection during lockdown. With respect to the management of paediatric patients requiring exodontia under general anaesthesia, during the first two months of lockdown 1,456 children had their appointments cancelled and although activity resumed later in the year(3) services are insufficient to manage the backlog and continued increase in numbers of children on the waiting list.
In this study we have demonstrated large changes in referrals to oral surgery services, which at the end of the study period remain very different from the pre-pandemic levels. This is within the context that the pandemic would not have an immediate impact on the pattern of clinical disease that would typically trigger an oral surgery referral, given that access to routine care was suspended and therefore patients would develop dental disease over time which may then require oral surgery care. However, the longer the period of disruption to pre-pandemic patient pathways, there is an increased likelihood of delayed clinical presentations that place an increased burden on the delivery of care in primary care and by specialist services.
The data reveals 3 phases to a disrupted pattern of referrals following the onset of the pandemic: immediate drop (March – April 2020), gradual increase (May 2020 – Jan 2021) and accelerated increase (Feb – Nov 21).
The immediate dramatic drop in referrals at the start of the first national lockdown reflects dental practices suddenly closing for face-to-face care and a switch to telephone consultations and advice without the benefits of clinical examination(2). Although face-to-face dental care didn’t cease until 25th March 2020, there was a general awareness in dentistry and amongst the public of the potential issues relating to COVID-19 and this may account for the decline in referrals immediately prior to practice closures. Concerns in oral surgery that the early stages of the pandemic would see an increased need to manage patients with acute dental infections, including as in-patients, did not materialise(7). The early introduction of the advice, analgesia and antibiotics (AAA) approach coupled with establishment of Urgent Dental Care Centres (UDC) are likely to have been key initiatives. For other patients, who represent the majority, the suspension of non-urgent oral surgery care would need to be delivered in the future consistent with a broad theme recognised across many areas of healthcare. Key initiatives in relation to this would include ongoing dental care and an emphasis on prevention.
The re-opening of general dental practices for face-to-face care was expected to generate a rise in referral activity and by the middle of 2020 referrals were gradually increasing along with the capacity of oral surgery services to deliver routine care even though both remained reduced compared to pre-pandemic levels. Mitigations to reduce the risk of transmission of COVID-19 associated with general dental and oral surgery practice were developing and represented a shift from the earliest stages of the pandemic when oral and maxillofacial procedures were categorised as ‘high-risk aerosol generating procedures’(10). Changing public attitudes to COVID-19 would also have been a factor in their willingness to seek general dental and specialist oral surgery care as the pandemic evolved.
The accelerated increase in referrals that started in early 2021 and was sustained throughout the year was dramatic, unexpected and is likely to reflect a variety of factors. The period immediately before included the pre-Christmas 2020 national lockdown and the introduction of the national COVID vaccination programme. Early in the accelerated phase the vaccination roll-out progressed well but there was a need for a third national lockdown. Through 2021 the vaccination programme brought a new confidence to many living in England within an increased understanding of how to medically manage those who became unwell due to COVID. Patient throughput in dental practices increased reflecting a switch from crisis measures to planned recovery.
It should be noted that in December 2021 there was a reduction in both referrers and referrals which corresponds with the identification of the Omicron variant of COVID-19(11) and the implementation of further restrictions including working from home wherever possible, although face-to-face dental care continued. Overall, the data demonstrates that the average referrals received per month pre-pandemic were 25,498 compared to an average of 84,953 in the period July 2020 to December 2021. This increase of 57% per month over a sustained period with a peak 8.5-fold excess over pre-pandemic average numbers in November 2021 that represents a huge and unprecedented challenge for services that are already stretched and continue to be disrupted by multiple factors.
At the end of 2021 and the end of the study period there is a noticeable downturn in referral numbers. It is unknown if this represents the peak of the accelerated referral phase. This coincided with identification of the rapidly transmissible COVID-19 Omicron variant(11) and the implementation of restrictions including working from home wherever possible, although face-to-face dental care continued. The seasonal holiday period and better understanding of the effectiveness and limitations of the national vaccination programme may also have been factors.
Overall, the data demonstrates that pre-pandemic referral numbers were predictably stable within a narrow range with an average of 25,498 received per month for the 11-month period starting March 2019. By contrast, the pandemic period has been characterised by large scale changes in referral numbers with an average of 84,953, with referrals ranging from 10,573 in July 2020 to 217,646 in November 2021.
To better understand the dramatic changes to referral numbers made over the study period we investigated the numbers of referrers. On average there were 5,871 individual healthcare professionals referring each month prior to the pandemic, and since the pandemic this has reduced by 4% to 5,399 per month. Accordingly, fewer referrers made more referrals. The reasons for this are likely to be multifactorial and may include a reduced capacity to deliver patient care within dental practices including fewer patient treatments being delivered by each dentist and a reduction in the total number of GDPs across the referral network. Other contributory factors may include delayed clinical presentations or co-morbid health issues that mean that care needs are increasingly complex and prompt onwards referral. We have previously reported that pre-pandemic there was a wide variation in the number of referrals made per practitioner with a small subset accounting for a high number of referrals(12). This may also be a contributory factor but was not one investigated in this study.
The variations in oral surgery referral patterns place a huge strain on oral surgery services across England. We investigated if the increased referral numbers affected the rejection rate at clinical triage. Pre-pandemic an average of 1.5% of referrals were rejected, but since August 2020 this has risen to 2.7%. Whilst this has increased, it will have a minimal impact on the overall strain on oral surgery service delivery. The increased referral numbers coincide with the NHS in England setting ambitious targets to manage the backlog in routine care created by the pandemic(13).
In addition to the disruption experienced by patients, there are also consequences for workforce development and how foundation, core and specialty trainees are supported to develop their skills appropriately in oral surgery(14). This data highlights the need for considered planning of workforce development to ensure that the disrupted referral patterns presented do not have a long-term destabilising impact.
The pandemic disruption had the potential to disproportionately disadvantage individuals in areas of highest deprivation. The IMD data presented confirms a disproportionate use of oral surgery services by those in lower deciles across the time periods studied. During the initial lockdown period those with a lower IMD score (i.e., more deprived) were not disproportionately disadvantaged in accessing oral surgery care, within the context of an overall reduction in numbers of referrals received. The Health Foundation(6) reported that 45,187 oral surgery treatment pathways were completed in April 2019 compared to 12,989 in April 2020. They also reported that between 2019 and 2020 the number of completed treatment pathways fell by 9,162 per population in the most deprived areas of England, compared with a fall of 6,765 in the least deprived areas. It therefore suggests that pre-existing inequalities did have had an impact of the patient’s healthcare experience during the initial period of the pandemic.
In summary, analyses of 1.75M referrals to oral surgery services in England have highlighted the ongoing impact of the pandemic and the need for active management to minimise the adverse impacts on patients, NHS services and the workforce. This study also demonstrates the need for the more effective use of healthcare data to inform future planning of healthcare services and in preparation for future pandemics or other disruptive events.