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UK readers will, of course, be aware that the UK has entered its third lockdown at the time of writing. However, third time around, what will the levels of compliance be? It has been considered that high levels of compliance in the first lockdown appear to have been driven by a sense that it is right to comply with the restrictions to ‘save lives and protect the NHS’, that it is normative to do so, and that it is a legal requirement.1 There have been questions regarding ‘lockdown fatigue’ as we enter the third lockdown. Nevertheless, those flaunting the restrictions seem to be few, albeit that there have been high-profile cases in which the police broke up illegal gatherings, such as house parties and unlicensed music events, and, most notably, the case of two women walking in Derbyshire whose tea break was classified as a picnic, and they were duly fined, although that was later retracted. There is no question that lockdown restrictions (eg social distancing) remain centrally important if the COVID-19 pandemic is to be brought under control, and the public has largely displayed voluntary compliance. Thankfully, it has been decided that dental practices are not a vector for infection: they never were. The profession should be proud of their infection control before and during the pandemic, and how they learned to cope (to some degree) with the additional infection control measures that have been needed to be put in place.
The pandemic brought new powers for the police, as explained by the Police Federation of England and Wales and other police bodies, which, in conjunction with the UK Government, drew up the Public Health Regulations 2020 bill, which came into effect on Monday 23 March 2020. The guidelines are said to follow a common-sense approach known as ‘4 Es’ – Engage, Explain, Encourage and Enforce, defined as follows:
It has been considered that the ‘4 Es’ are based on evidence that people are more likely to comply after a police encounter if they feel that they have been treated fairly, have received an explanation, and have been given the opportunity to give their view. As a result, police officers seeing members of the public breaking quarantine powers have the authority, on a sliding scale, to issue an instruction to go home, leave an area or disperse, to give fixed penalty notices and, finally, to arrest, where deemed necessary.
Are comparisons possible between the sterling work of the dental profession and the sterling work of the police in respect of the 4 Es guidance received by the police and what we do on a regular basis?
Our engage cycle depends on a patient attending our practices, either aware, or unaware, that they have a dental problem. Our practice staff are, hopefully, empathic from the moment that a new patient arrives in our waiting rooms, the idea being that the ambiance of the practice and its team will enable the patient to engage. The patient has to be compliant if they are to proceed to the next stage, namely, an explanation of their problem, and education (another E!) with regard to any treatment that is indicated. Again, our practices are geared to this, with recent research indicating that intra-oral photography is used routinely in 29% of UK dental practices,2 with one use being to facilitate the patient's understanding of their dental needs. It is then part of the dental team's responsibility to encourage patients to be compliant with measures, such as improved oral hygiene, smoking cessation or a less cariogenic diet. Clinicians invariably hope that their advice and encouragement will lead to a change in behaviour, but we are all in the real world in the battle to achieve patient compliance: we know that we don't always win!
It is in the last of the 4 Es where there is a divergence between the police and the dental profession, insofar as we have no direct powers of enforcement over our patients. I know that the police documentation stresses that this enforcement activity is a last resort, only to be used if other approaches fail. However, in a stealthy and empathic way, we can advise patients on the consequences of non-compliance with our advice. We can also be more direct, in advising patients clearly that they will most certainly lose teeth if their behaviour doesn't change. In policing, it has been considered that the severity of sanction appears to have an almost irrelevant effect on behaviour, as quoted in a series of short papers developed by the University College London Jill Dando Institute and the Methodology Department of the London School of Economics, written to support the police services during the current pandemic.1 They add that deterrence-related factors (fear and severity of punishment) have been shown to be only weakly correlated with compliance in many situations.1 Is it the same in dentistry? Is the ‘threat’ of losing teeth something that will matter to patients? It will, undoubtedly, matter to some, but not all.
The question that is increasingly asked during the third lockdown is – how long will compliance last? Bradford and colleagues1 have written that the only way that democracies can be policed is via consent. This is where the police, dentistry and the 4 Es are singing from the same song sheet. We are practising in difficult times for both the clinician and the patients, some of whom do not attend because of anxieties about going to public buildings or worries about practice infection control. We need national publicity to reassure our public that dental practices are as safe and welcoming as always. And, despite the added problems posed by the pandemic, we should continue to treat our patients in keeping with the principles of the 4 Es, or should it be three?
PS Readers will be aware of the extensive media coverage given to the treatment of elderly patients during the pandemic. Dentistry, of course, is not exempt from treatment of such patients during the pandemic. This issue therefore includes two complementary and authoritative articles, by Barrow and Ashley and by Bradley, on the treatment of older patients. I hope that they are of value to readers.