As of 1 May 2013, direct access came to be, enabling certain dental care professionals to see patients directly without them seeing a dentist first. These useful FAQs explain the new rules and how dental provision is affected.
Does direct access affect the use of local anaesthesia by hygienists and therapists?
The administration of local anaesthetics is governed by The Human Medicine Regulations. The GDC has no influence over this legislation and it is quite separate from the new direct access regulations.
Prescription-only medicines (for example local anaesthetics) may be administered by a dental hygienist or dental therapist either by using:
1. A patient-specific direction (in other words a written prescription for that particular patient) or
2. A patient group direction (PGD)
A PGD allows the administration of named medicines in an identified clinical situation without the need for the referring dentist to provide an individual written prescription. The regulations state that the practice should be registered with the Care Quality Commission (in England) or HIW in Wales and that the PGD is appropriately drawn up and signed by the relevant individuals. Due to there being variations in the regional regulations associated with patient group directives, we recommend that DCPs should familiarise themselves with the regulations that are applicable in their chosen region(s) of practice.
Further information on PGDs is available from gov.uk and NHS Education for Scotland.
Read our briefing document on Direct Access.
How long should I be qualified before I can practise with direct access?
You will be aware that dental graduates are obliged to undertake a year’s Foundation Training, following which they may apply to join the Performers’ List which enables them to provide NHS dental services. Many dental graduates feel that this 12-month period provides a welcome bridge between the relatively sheltered environment of dental school and the more challenging situations which they are likely to face as an independent practitioner.
When direct access was introduced, the GDC decided that DCPs would not be obliged to undertake an equivalent year of Foundation Training. There was no legal mechanism for the GDC to make such a change. However, there are some deaneries which do provide a Foundation Training scheme for dental therapists. The GDC’s view is that whilst there may not be a formal requirement to work to a dentist’s prescription, it strongly recommends that newly qualified dental hygienists and dental therapists should take the opportunity to practise in a sheltered environment, working on prescription in a supportive team. It has been suggested by the GDC and the British Society of Dental Hygiene and Therapy that this period could be 12 months. From a risk management perspective, Dental Protection would welcome a move to formalise this recommendation.
The GDC places the onus on the registrant to be capable of demonstrating that they have the necessary competencies to work under direct access, with an added requirement that these competencies can be evidenced on demand. This is particularly important for those DCPs who qualified prior to 2002 as they may not necessarily have had the chance to study for the extended duties which became part of the curriculum in 2002.
Click here to read our briefing document on Direct Access.
Can I ask the dentist(s) who I work for to continue examining patients before they see me, and prescribing the treatment that they wish me to carry out?
Yes. Direct access is now available as an option, but in no sense compulsory. The staff of each workplace are free to make up their own mind, whether to implement direct access and if so, how and to what extent. Some of them may not want to do so at all. Dental Protection’s experience of direct access in other countries is that most of the time, for most practices, very little changed. What it does do is make life easier for practices that use hygienists and therapists, and remove some of the obstacles to patient access to certain forms of dental care.
Whether or not the dentists you work with will want to continue examining patients for the sole purpose of referring them to you for specified treatment is a matter for mutual discussion and agreement. One of the major advantages for dentists is that they no longer need to do this, especially in circumstances where they could not receive any NHS remuneration for having done so.
Click here to read our briefing document on Direct Access.
If a DCP is not working to a dentist’s prescription, what happens about consent?
You should always ensure that a valid consent has been obtained from the patient (and/or parent in the case of a minor), whether or not you are working to a prescription produced by a registered dentist. This is part of your duty of care to each and every patient you treat.
In this situation the responsibility to obtain a valid consent is wholly yours and you would be legally, ethically and professionally accountable if you treat a patient without obtaining it. Members are referred to our Advice Booklet on this subject (a different version exists for members practising in Scotland) which can be downloaded here.
Read our briefing document on Direct Access
I am a self-employed hygienist working in a general practice with two dentists. What difference does direct access make to me?
There may be a limited difference in practical terms, but there are two important changes that you should bear in mind. Firstly, direct access means you no longer need a written prescription from a dentist before carrying out treatment for a patient, but without such a prescription you are wholly responsible for a diagnosis and any treatment you carry out. This arrangement is best suited to treatment provided privately, since the current NHS contract still requires the patient to have been examined by a dentist if the treatment is being provided under NHS contract.
The second change is that even if the dentist(s) you work with is/are still referring patients to you, with a request to provide certain treatment, you are no longer limited to carrying out the treatment they have asked you to perform. If you decide to carry out further treatment without reference to a dentist – as you would be fully entitled to do, assuming this is treatment that you are trained and competent to provide – you would be personally accountable for those decisions as well as for the actual treatment.
Click here to read our briefing document on Direct Access.
I work part-time in two practices as a dental hygienist and therapist. I have always assumed my employer is ultimately liable for the work I carry out if one or both of us gets sued.
Is that no longer the case now, and what happens in the other practice where I work two sessions a week on a self-employed basis?
In some circumstances your employer can be held to be vicariously liable for any negligent acts and omissions on your part. That remains the case even if patients see you without first seeing a dentist, and even if a dentist is completely unaware of the treatment you are providing for a patient. While this does not prevent a patient suing you too (i.e. naming you personally as a defendant to the claim), it is likely that a patient would direct a claim to your employer in the first instance.
The situation in the other practice, where you are working on a self-employed basis, could well be different as it is likely that the practice would disclaim any liability for your actions, in particular where treatment was carried out without input from another clinician. If you choose to carry out treatment in the absence of any direction from a registered dentist, you are solely responsible for your own acts and omissions.
Click here to read our briefing document on direct access.
What has the GDC said about patients having direct access to DCPs and how will the general public be protected?
The GDC has stated that the new arrangements have been made with patient safety as an up-most priority. Registrants treating patients directly must only do so if appropriately trained, competent and with adequate indemnity or insurance arrangements in place. They should also ensure that there are adequate onward referral arrangements in place and they must make clear to the patient the extent of their scope of practice and not work beyond it.
It should be remembered that to ensure patient safety:
- All registrants must be trained, competent and indemnified for any tasks they undertake
- All registrants must continue to work within their scope of practice regardless of these changes
- All registrants must continue to follow the GDC’s Standards for Dental Professionals
- Dental care professionals do not have to offer direct access and should not be made to offer it
Dental hygienists and dental therapists
Dental hygienists and dental therapists can carry out their full scope of practice without prescription and without the patient having to see a dentist first. They must be confident that they have the skills and competences required to treat patients directly before doing so. A period of practice working to a dentist’s prescription is a good way for registrants to assess this.
Registrants who qualified after 2002 covered the full scope of practice in their training, while those who trained before 2002 may not have covered everything. However, many of these registrants will have addressed this via top-up training, CPD and experience. Those who qualified before 2002, or who have not applied their skills recently, must review their training and experience to ensure they are competent to undertake all the duties within their scope of practice.
Dental nurses
Dental nurses can participate in preventive programmes without the patient having to see a dentist first.
Orthodontic therapists
Orthodontic therapists can continue to carry out the majority of their work under the prescription of a dentist and can carry out Index of Orthodontic Treatment Need (IOTN) screening without the patient having to see a dentist first.
Clinical dental technicians
Clinical dental technicians can continue to see patients directly for the provision and maintenance of full dentures only and should otherwise carry out their other work on the prescription of a dentist. However, the GDC stated that with the potential for further training for CDTs this decision could be reviewed.
Dental technicians
The work of a dental technician (other than repairs) should continue to be carried out on the prescription of a dentist. There has been no change to their Scope of Practice.
More detailed guidance on the implications for individual DCP registrant categories is provided on the GDC website (Guidance on Direct Access).
Click here to read our briefing document on Direct Access.
How will direct access affect the role of an orthodontic therapist?
1. Does the new Direct Access Guidance affect whether an Orthodontic Therapist needs to work under the supervision of an orthodontist?
The GDC guidance on direct access relates to whether DCP’s can work without a patient initially being seen by a dentist and a prescription provided. The guidance does not make any reference as to whether orthodontic therapists should be supervised when working and, as previously, orthodontic therapists are perfectly entitled to work without a dentist on the premises. The decision as to when an orthodontic therapist can work without a dentist being present is, to a large extent, a matter of personal choice depending upon treatment being provided, competency and experience.
2. By allowing direct access to orthodontic therapists does this mean that they can provide Index of Orthodontic Treatment Need (IOTN) screening in private dental practice or only as part a public health initiative?
The Direct Access Guidance introduces the option for orthodontic therapists to carry out IOTN screening, without a prescription from a dentist, subject to having completed appropriate training but it also refers to this being as part of a structured public health programme.
The GDC has now clarified that orthodontic therapists can carry out IOTN screening direct to patients (should a practice chose to organise their service in such a way) or as part of a structured public health programme. The intention of the recommendation to Council was for the task itself – that orthodontic therapists can undertake IOTN screening without the patient having to see a dentist first. The GDC’s website has been altered to include this clarification.
3. Will my membership subscription increase if I expand my role to undertake IOTN screening?
Not if you continue to work the same hours and your position has not changed in terms of whether or not you own and operate a practice of your own, employ staff and/or contract with third parties for the commissioning of services to be provided by others. Our dental subscription rates are reviewed annually, and members are notified of the new subscription at the time of their membership subscription renewal. No additional subscription increases are being made as a result of direct access.
4. What training do I need to undertake before I am able to undertake IOTN screening?
The GDC guidance stresses the need for orthodontic therapists to be trained and competent to undertake IOTN. They have advised that training can either be undertaken through an accredited course, or can be carried out in-house. When accredited external training is not undertaken, any in-house training taken should be carefully documented, noting the dates it was undertaken and what the training involved at each stage. Additionally, irrespective of whether initial training is external or in-house, it would be appropriate to keep a log of a number of cases initially on which IOTN scoring was reviewed by another experienced colleague to demonstrate competency.
As IOTN scores may form the basis on which a patient may, or may not, be accepted for orthodontic care; where an IOTN score is borderline, it may be sensible to seek a second opinion, irrespective of the amount of training or experience of undertaking IOTN scoring.
Click here to read Our briefing document on Direct Access.
Can a dental hygienist or therapist undertake examinations and provide treatment for NHS patients under my dentist’s performer number?
When new guidance is introduced this can produce a period of uncertainty for registrants, as they seek to understand how the changes may affect their practice.
Under direct access it is possible for dental hygienists and therapists to see a patient for treatment that would be within your normal scope of practice without first obtaining a prescription from a dentist. But, certain treatment, for example the use of local anaesthetic and tooth whitening, will still require a dentist’s prescription.
The procedures that you can provide under direct access have to be interpreted with reference to the existing guidance. GDC’s Guidance Scope of Practice is still current and this document specifies that hygienists / therapists cannot diagnose disease. Therefore, it is not currently within your scope of practice to see patients on either an NHS or private basis to perform check-ups or examinations, regardless of the circumstances. It follows from this that at the moment you cannot provide check-ups for patients under your dentist’s performer number.
Click here to read our briefing document on Direct Access.
The GDC has also produced a statement in relation to direct access together with frequently asked questions and you may wish to review this information.
How should hygienists and therapists respond to a patient requesting treatment that they cannot provide?
Dental hygienists and dental therapists offering treatment via direct access need to have clear arrangements in place to refer patients who need treatment which they cannot provide. In a multi-disciplinary practice where the dental team works together on one site, this should be straightforward. In a multi-site set-up where members of the dental team work in separate locations, there should be formal arrangements such as standard operating procedures in place for the transfer and updating of records, referrals and communication between the registrants.
Where hygienists and therapists choose to practice independently and there is no dentist present, they should have clear referral arrangements in place in the event that they need to refer a patient for further advice or treatment and those arrangements should be made clear in their practice literature.
If a patient requires a referral to a dentist with whom the hygienist or therapist does not have an arrangement, the DCP should set out for the patient, in writing, the treatment undertaken and the reasons why the patient should see their dentist.
In all cases, the need for referral should be explained to the patient and their consent obtained. The reason for the referral and the fact that the patient has consented to it should be recorded in the patient’s notes. Relevant clinical information, including copies of radiographs, should be provided with the referral.
If a patient refuses a referral to a dentist, the possible consequences of this should be explained to them and a note of the discussion made in the patient’s records. It may be helpful for members to contact Dental Protection for further advice.
Click here to read our briefing document on Direct Access.