28 Feb 2019
By rick.craven
Tags: 
Team Meetings
Dental

What is Direct Access?

Direct Access is giving patients the option to see a Dental Care Professional (DCP) without having first seen a Dentist.

This requirement was removed in May 2013 by the GDC, which has allowed some Dental Care Professionals (DCPs) to provide a range of services directly to patients without a prescription from a Dentist which is within their scope of practice.

Which Dental Care Professionals (DCPs) does this effect?

While this does not affect all Dental Care Professionals ( Clinical Dental Technicians have been able to provide complete dentures direct to patients since 2008 ) it has given Dental Hygienists and Dental Therapists the ability to carry out their full scope of practice. 

Guidance from the GDC:

Orthodontic Therapy continues to be carried out on prescription from a Dentist. However, this now includes carrying out Index Of Treatment Needed (IOTN) screening directly to patients or as part of a structured public health programme led by a specialist in Orthodontics, a consultant in Dental Public Health, a specialist in Dental Public Health or a general Dental practitioner.

Guidance given by the British Association of Dental Nurses:

Dental Nurses can participate in preventative programmes without the patient having to see a Dentist.

Treatment provided under Direct Access can only be provided if Dental Care Professionals (DCPs) are trained, competent, and indemnified to do so.

Scope of practice, click here >

What training and experience is needed?

Dental Hygienists and Dental Therapists must be confident that they have the skills and competencies to treat patients under Direct Access.

Hygienists and Therapists who qualified since 2002 should have covered the full scope of practice in their training, while those who trained before 2002 may not have covered everything. If registrants are unsure if there are gaps in their training they must contact the dental school where they received their qualification.

Registrants who:

  • Qualified before 2002
  • Have identified gaps in their training
  • Have not applied their skills recently

Must review their training and continuing professional development to assure themselves that they have the necessary skills.

Guidance given from the British Society of Dental Hygiene & Therapy:

Where there is no requirement for a Dental Hygienist or Therapist to have been in practice for a certain amount of time before providing treatment under direct access to patients, British Society of Dental Hygiene & Therapy (BSDHT) recommends a minimum period of 12 months spent practising on prescription in line with the  Foundation Dentist Scheme.

This period after qualification spent practising on prescription will help to build a registrants confidence and experience before practising under direct access.

What treatment is not covered?

The changes made by the General Dental Council do not extend to certain areas of practice which are governed by other legislation which the Council does not have the power to change. The following areas of treatment still require a prescription of a Dentist: 

Tooth Whitening 

The GDC state that Dental Hygienists and Dental Therapists can be trained in tooth whitening as an additional skill. However, even with Direct Access, tooth whitening still needs to be carried out on prescription by a Dentist.

This is due to the Cosmetic Products (Safety) Amendment Regulations 2012, which implement EU Directive 2011/84 EU. 

The regulations state that tooth whitening can only be carried out on the prescription of a Dentist, and tooth whitening products containing or releasing between 0.1% and 6% hydrogen peroxide (or its equivalent) can only be sold to dental practitioners. 

The first use of each cycle can be carried out by Dental Hygienists and Dental Therapists under the direct supervision of a Dentist (that is, with a Dentist on the premises)

The Dentist needs to be assured that the Dental Hygienist and Dental Therapist is trained and competent to carry out this treatment on the patient. After this, the products can be provided to the patient to complete the cycle of use.

Radiography

Guidance given from the British Society of Dental Hygiene & Therapy:

Under the terms of the Ionising Radiation (Medical Exposure) Regulations 2000 or IR(ME)R (and further update in 2006), registered Dental Hygienists and Therapists are able to take on the roles of 'operator', 'practitioner' and 'referrer'. 

Dentists remain the only member of the team who can ‘report’ on all aspects of a radiograph. This is unlikely to be a problem in practices where a Dentist is available to report on the radiograph.

Botox Treatment

Guidance given by the GDC:

The GDC state the administration of Botox is not the practice of Dentistry, and so it does not appear in the GDC’s Scope of Practice document. Botox is a prescription-only medicine (POM) and needs to be prescribed by a registered Doctor or Dentist who has completed a full assessment of the patient. Hygienists and Therapists cannot, therefore, carry out Botox treatment directly.

 

Local Anaesthesia

Guidance given from the British Society of Dental Hygiene & Therapy:

The GDC state that local anaesthetic is a prescription-only medicine (POM) which means that under the Medicines Act 1968 it can only be prescribed by a suitably qualified prescriber – usually a Doctor or a Dentist. However, it can be administered by both Dental Hygienists and Dental Therapists either under a written, patient-specific prescription or under a Patient Group Direction (PGD). 

A PGD is a written instruction which allows listed healthcare professionals to sell, supply, or administer named medicines in an identified clinical situation without the need for a written, patient-specific prescription from an approved prescriber. PGDs can be used by Dental Hygienists and Dental Therapists in: 

  • NHS practices in England, Wales, and Scotland, and their equivalent in Northern Ireland;
  • Private dental practices in England registered with the Care Quality Commission;
  • Private dental practices in Wales providing the individual Dentists are registered with the Health Inspectorate Wales;
  • Private dental practices in Northern Ireland registered with the Regulation and Quality Improvement Authority. 

PGDs cannot currently be used in private dental practices in Scotland although this is due to change once there is a commencement date for their registration with Health Improvement Scotland. 

Further advice on PGDs and the regulations relating to them can be obtained from your indemnity provider or professional association.

 

Is Direct Access compulsory?

Direct Access should only be offered to patients where there is a mutual agreement between the Dentist and the Dental Care Professional(s).

Practices should not expect a registrant to see patients directly if they do not feel competent to do so. 

Standards for the Dental Team state:

7.2 You must work within your knowledge, skill, professional competence and abilities.

Standards for the Dental Team, click here >

Does Direct Access work in all settings?

Guidance given from the British Society of Dental Hygiene & Therapy:

Direct Access works best in a team setting, partly because of legal restrictions such as those around prescribing, which are not imposed by the GDC, but also for more immediate practical arrangements for records, referrals, and second opinions.

A team setting should give patients more routes of entry into treatment. However, there is no reason that direct access cannot work in many types of settings provided that appropriate safeguards are in place including referral arrangements.

When should I refer a Direct Access patient to a colleague?

Guidance given from Dental Protection:

Dental Hygienists, Dental Therapists and Clinical Dental Technicians 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. 

Direct Access within the NHS

Direct Access is still not practicable under NHS contracts as currently only Dentists can open and close a unit of dental activity, and an examination of the patient is still required by the Dentists to ‘open’ a form.

Guidance given from the British Society of Dental Hygiene & Therapy:

Current legislation does not provide for Hygienists and Therapists to hold health service contracts. There will need to be changes to the regulations governing the provision of NHS treatment in England and Wales, while Scotland and Northern Ireland would require changes to primary legislation should their legislative bodies wish to facilitate direct access under the NHS and its equivalent in Northern Ireland if this was to change. 

What impact does this have on Practices?

Practices which offer treatment via Direct Access should ensure this is made clear to all patients and they are fully informed which treatments are available, this can be in the form of patient leaflets, posters, practice website, or verbally by the reception teams when making an appointment.

In the event treatment cannot be carried out by a Dental Hygienist , Dental Therapist or Clinical Dental Technicains under Direct Access, a pathway for referral needs to implement to see a Dentist with appropriate guidance is given to all patients. 

Practices need to ensure that the dental team are fully aware of this process and appropriate training is given.

As with all dental treatment, consent needs to be obtained for treatment provided under Direct Access, this responsibility does remain the responsibility of the Dental Care Professionals (DCPs) to ensure this is always obtained.

The GDC state: all registrants, including those operating in practices which provide treatment via Direct Access, must act in the best interests of patients at all times and comply with the GDC’s standards.

What about indemnity?

Dental Care Professionals (DCPs) planning to offer treatment and services under Direct Access to patients should check with their indemnity provider that they have appropriate indemnity; whether it is for certain tasks or, in the case of Dental Hygienists and Dental Therapists, for the whole scope of practice and to provide treatment direct.

The GDC expects you to ensure you are indemnified for any tasks that you undertake and advises you are properly indemnified for all the work you undertake. 

 

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