Membership information 0800 561 9000
Dentolegal advice 0800 561 1010

Prescribing

  • Q
    In NHS general practice I can prescribe from the list in the Dental Practitioners’ Formulary. What are the regulations with private prescriptions?
    +
    21 August 2014

    I'm aware that in NHS general practice I can prescribe from the list in the Dental Practitioners’ Formulary, in a hospital setting I can prescribe any drug in the British National Formulary(BNF). What are the regulations with private prescriptions?

    A dentist’s right as a professional to prescribe medication is laid out in the Medicines Act. As you have already pointed out, to prescribe medication within the NHS in general dental practice there are NHS prescription forms and dentists are restricted to prescribing from the Dental Practitioners’ Formulary (DPF), the list of which appears at the back of the British National Formulary (BNF)

    In general terms you may be right that you can prescribe any drug in the BNF in a hospital setting. However, usually in a hospital environment, prescribed medication is dispensed from the hospital pharmacy under the local rules of the hospital and under the umbrella of a consultant who may be medically trained and is responsible for patient care.

    If a private patient requires a prescription in general practice, dentists are not permitted to provide an NHS prescription form; they are required to write a private prescription. Privately, there are no limitations on the type or dose of medicines you choose to prescribe. However, you should be aware of the ethical obligations as laid down by the General Dental Council in its Standards document.

    Dentists are required to be trustworthy and to treat patients within their best interests. In addition, the GDC’s guidance details the obligations for dentists to prescribe responsibly and in the best interests of patients.

    Drugs not included in the DPF list should only be prescribed if there is a genuine dental need which can be fully justified. If there is any question over the genuine dental need for a prescription, it would be advisable to liaise with the patient’s medical practitioner.

    It would be viewed as inappropriate and unacceptable to prescribe medications for personal use (self-prescribing). It could also be viewed as inappropriate to prescribe medications for close friends or family. Pharmacists do have an obligation to raise any concerns they have if they consider prescriptions to be inappropriate.

    Dental Protection’s risk management module 36, Drugs and Prescribing, is available from our Prism educational platform

  • Q
    A patient has asked a clinical dental technician to remake his partial denture on my prescription, but I am worried about my position if the new denture is subsequently found to be unsatisfactory.
    +
    05 May 2015

    According to the General Dental Council's Scope of Practice, a clinical dental technician (CDT) can provide complete dentures directly to a patient. However, patients requiring a partial denture must be seen by a dentist before a CDT can provide treatment, and only then following the issue of a prescription.

    All appliances provided by a CDT are done so under private contract and therefore if the patient was in any way dissatisfied, the CDT would be expected to have a suitable process for handling complaints. The Dental Complaints Service is available to the patient. The dentist who provides the treatment plan could be challenged if the treatment plan was considered inappropriate.

    You would be entitled to refuse to provide the patient with a prescription if for some reason you felt a particular type of denture would not be in their best interests and could justify such a decision.

    In general terms a prescription request such as this can be treated in the same way as a referral for treatment; it is a correspondence between two professionals directly concerned in the provision of dental care to a particular patient. Under these circumstances, the patient’s consent would be implied by the professional relationship.

    A prescription request could also be seen as a request by the patient for a treatment plan. Following a full mouth assessment by a dentist, the patient should be provided with a treatment plan. The patient is at liberty to take this treatment plan to any appropriate registered dental professional who can, within the overall limits of the plan and their competence, treat the patient. Therefore, a patient would be entitled to take their treatment plan for a denture to a CDT.

    To be seen to be obstructive is likely to attract considerable criticism and possibly invite investigation from the GDC should the matter come to its attention.

    Who is responsible for the partial denture design?

    This is not an easy question to answer as the GDC’s guidance does not make this clear. One could argue that as the dentist is providing the treatment plan and prescription, he or she should be the person to design the denture. Alternatively one could argue that as the CDT is the clinician making the denture, the design should really fall to them.

    In reality, however, it is likely to be a collaboration. The lead would depend on training and expertise. Either way, the records should reflect the discussions and decisions made.

    Who is responsible if something subsequently happens to the natural dentition as a result of the design?

    The responsibility will probably lie with the dentist who examined the patient and provided the treatment plan in the first place as it would be for them to indicate any areas of concern they might have clinically. The CDT would also be liable as although he or she is not trained specifically to identify caries and periodontal problems, they would be expected to recognise such problems and to raise any relevant concerns before the treatment begins. It would however be quite different if the CDT had not followed the advice of the dentist.

    Who is ultimately responsible for the patient?

    The ultimate responsibility for any patient’s treatment lies with the clinician who undertook that particular element of the treatment. That does not mean, however, that the dentist (who perhaps only provided the treatment plan) has no responsibility at all.

    Can a dentist refuse to provide a treatment plan?

    The GDC’s guidance makes it very clear that individual registrants should act together in the best interests of the patient and as a consequence a dentist would have to have a good clinical or ethical reason for failing to provide a treatment plan. If that refusal was simply as a matter of ‘protectionism’, the GDC would not be too impressed.

  • Q
    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?
    +
    11 May 2016

    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.

  • Q
    Can you tell me what dental hygienists cannot do under direct access?
    +
    11 May 2016

    The GDC makes it clear that the following treatments remain restricted in use and still require the direct involvement of a dentist or can only be provided by a dental hygienist against a prescription from a doctor or dentist:

    • Tooth whitening – the first application of tooth whitening treatment must be done by a dentist or by a dental hygienist or therapist under the direct supervision of a dentist (which means they should be on the same premises); any subsequent application can be done by a dental hygienist or therapist against a prescription from the dentist.
    • Prescribe local anaesthesia – as a ‘prescription only’ medicine it can only be prescribed by a suitably qualified prescriber,usually a dentist or doctor.
    • Botox – as a prescription-only medicine it can only be prescribed by a registered doctor or dentist who has completed a full assessment of the patient.

    Restrictions remain on the prescription of radiographs by hygienists unless they are compliant with the core requirements of the Ionising Radiation (Medical Exposure) Regulations 2000 (IR[ME]R) and are confident to do so.

    It should also be remembered that:

    • 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.

    Click here to read our briefing document on direct access.

  • Q
    Do DCPs need to inform Dental Protection if they intend to work without a dentist’s prescription or extend the scope of practice?
    +
    11 May 2016

    Members are reminded that they must only carry out procedures for which they have been trained and in which they are competent. The extended scope of practise does not circumvent this fundamental requirement. The GDC’s Scope of Practice document describes the additional skills that DCPs can acquire in order to extend the scope of their professional work.

    Click here to read our briefing document on Direct Access.

  • Q
    Do the recent changes by the GDC mean that Clinical Dental Technicians can now supply partial dentures directly to patients without a prescription from a dentist?
    +
    11 May 2016

    No – the GDC-approved scope of practice of CDTs remains unchanged in that full dentures are the only form of treatment that they can supply directly to the public. However, the GDC has indicated that this decision could be reviewed in the future.

    Click here to read our briefing document on Direct Access.

  • Q
    Does direct access affect the use of local anaesthesia by hygienists and therapists?
    +
    11 August 2016

    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.

  • Q
    How long should I be qualified before I can practise with direct access?
    +
    11 May 2016

    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.

  • Q
    I am a self-employed hygienist working in a general practice with two dentists. What difference does direct access make to me?
    +
    11 May 2016

    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.

  • Q
    I have elderly patients who come to me privately but who are eligible to receive free NHS prescriptions. Can I provide them with an NHS prescription?
    +
    17 March 2015
    An NHS prescription can only be written for a patient who is receiving an NHS course of treatment or treatment of an urgent condition under the NHS. If any of your patients are being treated on a private basis, and they require a prescription-only medicine, this must be prescribed privately, or dispensed at the practice.

     
    It is important when dispensing medication that the appropriate records are kept of what is given and the dosage, etc.

    Dental Protection has produced a risk management module, Drugs and Prescribing, which provides advice on prescribing, and is available to members from Prism, our e-learning learning library.

  • Q
    I'm a hygienist. If a GDP refers a patient to me and then leaves our practice, is the referral still valid? Or should a currently employed dentist rewrite the referral?
    +
    30 June 2015

    The referral from the GDP is still valid in this situation providing there has not been an unduly large time lag between the referral being written and the patient being seen by you.

    At the time of creating the original referral, the patient would have been examined and the GDP would have made a referral on the basis of those clinical findings. Those clinical findings and any associated tests and investigations form part of the patient’s clinical record and this does not automatically leave the practice when the dentist in question moves on.

    There may, in rare circumstances, be a wide variation between what is written in the original referral and what the new dentist considers should be written. However, care plans are not set in stone and can be modified. A simple discussion (documented within the notes) between the hygienist and the new dentist should be sufficient to ensure continuity and appropriateness of care.

    It is important to remember that the patient is at the centre of the process and their consent is required for any changes which may arise in respect of the originally planned treatment.

  • Q
    Since the tooth whitening regulations have changed, can patients come straight to me now, without the need for that initial visit with the dentist?
    +
    11 May 2016

    The introduction of direct access does not alter the legislation that was introduced in 2012 to allow tooth whitening to be undertaken using material that releases up to 6% hydrogen peroxide. The Cosmetic Products (Safety) (Amendment) Regulations 2012 continue to determine the legality of providing tooth whitening in dental practice. They state that products may only be sold to dental practitioners and that the first cycle of use must be by dental practitioners or under their direct supervision- ie. that a dentist should be on the premises when the first treatment is carried out.

    Dental hygienists and therapists would therefore need to work to a dentist’s written prescription if tooth whitening is undertaken, using products that contain or release more than 0.1% hydrogen peroxide.

    Further details on tooth whitening can be found in Our position statement ‘Bleaching and Tooth Whitening by DCPs’

    Click here to read our briefing document on Direct Access.