ARE WE THERE YET? HMM… NOT QUITE JULIE ROSSE
U
nless you have been living on the moon for the past year, you are probably aware that direct access for dental hygienists and therapists for their full scope of practice came into effect on 1 May 2013, and although this is most definitely a positive step for both the patients and the profession, it would be fair to say that in some areas it has thrown up more questions than it has answered.
What have we achieved so far? Since the implementation of direct access there have been significant changes to the GDC’s Scope of Practice document and much lobbying from organisations such as the British Society of Dental Hygiene and Therapy (BSDHT), but I am pleased to say that for us dental hygienists and therapists, these changes mean that: • Diagnosis is now possible as long as it is within our scope of practice. • Radiography taking, processing and interpreting is also now possible as long as we have had the required training, and are confident, competent, and indemnified to do so. However, we still have some way to go with prescribing – I still find it hard to believe that we still do not have limited prescribing rights for certain medications for our patients. Ridiculous, some might say? Why would dental hygienists and therapists need to be able to prescribe anything? Well, you might be surprised…
AUTHOR
Julie Rosse RDH, CEB Dip Dent Hygiene FAETC President of the British Society of Dental Hygiene and Therapy. Dental Hygienist at Bramley Dental Practice, South Yorkshire
30
So, what are the restrictions on prescribing medications? A prescription-only medicine (POM) means that under the Human Medicines Regulations 2012 it can only be prescribed by a suitably qualified prescriber – usually a doctor or a dentist. This includes the everyday things we use for our patients such as local anaesthetic, topical anaesthetic and fluoride. Currently, there are two ways in which dental hygienists and dental therapists are able to obtain the use of local anaesthetics, fluoride and antimicrobials for their patients, and these are either by a Patient Specific Direction (PSD) or a Patient Group Direction (PGD). PSD • The dentist writes a specific prescription for each patient that you see who requires local anaesthetic, fluoride, or other POMs. This must include the agent to be used, the dose and route of administration. • The PSD/prescription is usually written in the patient’s notes/treatment plan. A PSD is required before any medicine can be given to a patient as part of their private or NHS dental treatment, and many dentist-led practices continue to work in this way. PGD • This is the written instruction for the sale, supply and/or administration of named medicines in an identified clinical situation. It applies to groups of patients who may not be individually identified before presenting for treatment. • It allows named dental hygienists and dental hygienist-therapists to administer or supply medicines to patients via a legal framework without the need for a PSD (or written prescription) from a dentist.
Since 2010, dental hygienists and dental therapists have been recognised as ‘registered healthcare professionals’ and are able to work under a PGD. The ‘Human Medicines Regulations 2012’ details the individuals allowed to work under a PGD in Part 4 of Schedule 16.
How do I go about obtaining a PGD? To get a PGD signed off for use in your practice, it must be drawn up and signed by: • a dentist who should have been involved in developing the direction, and • a pharmacist who should have been involved in developing the direction, and • a representative of the NHS body, eg. the local primary care organisation for NHS patients (often the clinical governance lead) or • a representative of the registered provider (dental business registered with the Care Quality Commission) for private dental practices/clinics. NB. The last two items above are ‘or’ and this would depend on the type of practice (NHS or private), but the first two are compulsory to make it a legal document. Additionally, but not required by law, a senior dental therapist or hygienist should be involved in setting up the PGD and, if involved, must sign it. PGDs are quite common in the health service but you do need the services of a pharmacist who has competency in working with dental prescribing.
Shortage of pharmacists Finding a pharmacist was easy under the old Primary Care Trust (PCT) system, but with the demise of the PCTs in England we have been forced to lose 151 PCTs which have been replaced with only 27 local area teams. However, there should
P R I M A R Y D E N TA L J O U R N A L
With direct access, trained dental hygienists and therapists can take, process and interpret radiographs
These medicines do not require a prescription and may be administered by anyone as long as they are trained, competent and confident to do so. All the medicines on the dental emergency drugs list (Table 1*) except for Midazolam, for which a PGD is required, may be administered without a PGD.
be far more pharmacists than the 27 found in the area teams as each PCT would surely have had a suitable contact prior to the changes, wouldn’t they? It is worth remembering that the NHS dental contract is managed by the area teams, so they will have the responsibility of signing a PGD if it is for use in an NHS practice, but not if it is for a private practice. This means that if you are working in a private practice, it might be easier to commission a pharmacist to work on your behalf.
So why do dental hygienists need to be able to prescribe? Take the subject of chlorhexidine mouthwash for a start. As a dental hygienist, I can give a patient a chlorhexidine rinse in the surgery; I can also give them a bottle to take home, but if they have forgotten their wallet or just don’t have the means to pay for it, I cannot write them a prescription for it. This to me seems ridiculous and certainly not akin to working in the best interests of the patient. Similarly, take the widespread idea of dental hygienists and therapists being utilised to reach the vulnerable and needy groups in care homes and similar institutions. This proposed scenario of utilising the wider skill mix will fall flat if we are not given the tools we need to be able to reach these areas of the population. For instance, if I were to go and see a patient who is quite obviously having discomfort and trouble eating and drinking due to an episode of
angular cheilitis, I would have to go right back to the surgery to obtain a prescription from a dentist for something as simple as an antifungal cream to relieve these symptoms. And the inconvenience of having to get a dentist to write a specific prescription for local anaesthetic or fluoride varnish is not easy either when you both have an increasing number of patients lined up in the waiting room. Dental nurses can now apply fluoride (albeit only if working to a protocol overseen by a consultant or registered specialist in Dental Public Health), so why can’t I as a highly-trained, competent health professional be able to paint a bit of fluoride on if I see the need?
Even the emergency drugs kit is daunting… In medicines legislation,1,2 PGDs are required for: • the administration of all parenteral POMs. • the administration of Midazolam (a controlled drug). • the supply directly to patients of all POM and pharmacy medicines. Medicines legislation does not require PGDs for: • administration of non-parenteral POMs. • administration of pharmacy or general sales list (GSL) medicines. • supply of GSL medicines directly to a patient. Medicines legislation exempts certain parenteral POMs from the requirements if used in an emergency to save a life.
VOL 3 NO 4 NOVEMBER 2014
A protocol can be implemented to administer medicines that are pharmacy or GSL. This may also apply for medical gases, none of which are POM. In conclusion, although there is nothing to stop an organisation or practice opting to use PGDs for all emergency drugs, they are not a legal requirement except for the administration of Midazolam. However, use of robust protocols would be good practice, and it is worth remembering that: • Any individual expected to choose and administer a medicine in an emergency situation should have been trained and assessed as competent to do so. • Although administration of medicines, other than parenteral POMs and controlled drugs, is not directed by The Human Medicine Regulations 2012, it is strongly recommended that, for legal and governance purposes, all medicines should either be prescribed, be administered under a PGD (when legally appropriate) or be administered under a protocol agreed locally by the employing organisation. The organisation has a legal responsibility for the actions of its employees. When it comes to injecting or administering drugs in a medical emergency, the GDC believe you should act in the best interest of your patient. This means that if a patient needed a drug to save their life, you would be acting in their best interests to administer it.
Conclusion Limited prescribing rights already exist for other healthcare professionals such as midwives, nurses and podiatrists – in my opinion, dental hygienists and therapists
31
ARE WE THERE YET? HMM... NOT QUITE
TA B L E 1
DENTAL EMERGENCY DRUGS Drug
Licensed status
PGD required for administration
Adrenaline injection (Epinephrine injection), adrenaline 1 in 1000, (adrenaline 1 mg/mL as acid tartrate), 1-mL amps
Parental POM that can be administered by anyone for the purpose of saving a life in an emergency
Not if used in an emergency
Aspirin dispersible tablets 300mg
GSL
No
Glucagon injection, glucagon (as hydrochloride), 1-unit vial (with solvent)
Parental POM that can be administered by anyone for the purpose of saving life in an emergency
Not if used in an emergency
Glucose (for administration by mouth)
Not a medicine
No
Glyceryl trinitrate spray
Pharmacy medicine
No
Midazolam Buccal Liquid, midazolam 10mg/mL or Midazolam injection (for buccal administration), midazolam (as hydrochloride) 5 mg/mL, 2-mL amps
Schedule 3 Controlled Drug (CD) POM that may be supplied under a PGD (other schedule 3 CDs may not)
Yes
Oxygen
GSL medicine
No
Salbutamol aerosol inhalation, salbutamol 100 micrograms/metered inhalation
Non-parenteral POM
No
*Table supplied by Christine Randall, Senior Medicines Information Pharmacist, North West Medicines Information Centre/Yellow Card Centre North West
should have been tagged onto this list when the changes were made in August 2013 to allow limited prescribing for physiotherapists and podiatrists. We should be following the medical model and getting dental hygienists and therapists out there in the community to look after those patients they would normally see in a surgery setting. In the surgery, they should be given the tools and the extra knowledge required to be able to effectively treat those conditions they are trained to recognise or diagnose. In Canada, dental hygienists have been able to prescribe for their patients since 2006. In fact, it took only three years to develop a six-to-nine-month course which enables them to prescribe a number of antimicrobials, antibiotics, and fluoridecontaining products. Surely this model could be copied in the UK to make life easier for patients and clinicians alike?
32
According to recent statistics,3 10 million people in the UK are over 65 years old. The latest projections are for 5.5 million more elderly people in 20 years’ time and the number will have nearly doubled to around 19 million by 2050. We all know that we have an increasing ageing dentate population, and with that will come other problems such as periodontal disease and root caries. I think it would be fair to say that it’s not
all going to be dentures in the future. There is a massive implant market out there, and someone is going to have to look after those implants as the patients get older. Surely the complicated mix of an increased medical and dental history will benefit from the wider skills and knowledge of dental hygienists and therapists in the future? I guess the question on everyone’s lips should be: ‘How would I like to be looked after?’
REFERENCES 1
2 3
The Human Medicines Regulations 2012. The National Archives website. Available at: www.legislation.gov.uk/uksi/2012/1916/pdfs/uksi_20121916_en.pdf Accessed: September 9, 2014 The Misuse of Drugs Regulations 2001. The National Archives website. Available at: www.legislation.gov.uk/uksi/2001/3998/made. Accessed: September 9, 2014 The ageing population. UK Parliament website. Available at: www.parliament.uk/documents/commons/lib/research/key_issues/Key-Issues-The-ageingpopulation2007.pdf. Accessed: September 9, 2014.
P R I M A R Y D E N TA L J O U R N A L
U
nless you have been living on the moon for the past year, you are probably aware that direct access for dental hygienists and therapists for their full scope of practice came into effect on 1 May 2013, and although this is most definitely a positive step for both the patients and the profession, it would be fair to say that in some areas it has thrown up more questions than it has answered.
What have we achieved so far? Since the implementation of direct access there have been significant changes to the GDC’s Scope of Practice document and much lobbying from organisations such as the British Society of Dental Hygiene and Therapy (BSDHT), but I am pleased to say that for us dental hygienists and therapists, these changes mean that: • Diagnosis is now possible as long as it is within our scope of practice. • Radiography taking, processing and interpreting is also now possible as long as we have had the required training, and are confident, competent, and indemnified to do so. However, we still have some way to go with prescribing – I still find it hard to believe that we still do not have limited prescribing rights for certain medications for our patients. Ridiculous, some might say? Why would dental hygienists and therapists need to be able to prescribe anything? Well, you might be surprised…
AUTHOR
Julie Rosse RDH, CEB Dip Dent Hygiene FAETC President of the British Society of Dental Hygiene and Therapy. Dental Hygienist at Bramley Dental Practice, South Yorkshire
30
So, what are the restrictions on prescribing medications? A prescription-only medicine (POM) means that under the Human Medicines Regulations 2012 it can only be prescribed by a suitably qualified prescriber – usually a doctor or a dentist. This includes the everyday things we use for our patients such as local anaesthetic, topical anaesthetic and fluoride. Currently, there are two ways in which dental hygienists and dental therapists are able to obtain the use of local anaesthetics, fluoride and antimicrobials for their patients, and these are either by a Patient Specific Direction (PSD) or a Patient Group Direction (PGD). PSD • The dentist writes a specific prescription for each patient that you see who requires local anaesthetic, fluoride, or other POMs. This must include the agent to be used, the dose and route of administration. • The PSD/prescription is usually written in the patient’s notes/treatment plan. A PSD is required before any medicine can be given to a patient as part of their private or NHS dental treatment, and many dentist-led practices continue to work in this way. PGD • This is the written instruction for the sale, supply and/or administration of named medicines in an identified clinical situation. It applies to groups of patients who may not be individually identified before presenting for treatment. • It allows named dental hygienists and dental hygienist-therapists to administer or supply medicines to patients via a legal framework without the need for a PSD (or written prescription) from a dentist.
Since 2010, dental hygienists and dental therapists have been recognised as ‘registered healthcare professionals’ and are able to work under a PGD. The ‘Human Medicines Regulations 2012’ details the individuals allowed to work under a PGD in Part 4 of Schedule 16.
How do I go about obtaining a PGD? To get a PGD signed off for use in your practice, it must be drawn up and signed by: • a dentist who should have been involved in developing the direction, and • a pharmacist who should have been involved in developing the direction, and • a representative of the NHS body, eg. the local primary care organisation for NHS patients (often the clinical governance lead) or • a representative of the registered provider (dental business registered with the Care Quality Commission) for private dental practices/clinics. NB. The last two items above are ‘or’ and this would depend on the type of practice (NHS or private), but the first two are compulsory to make it a legal document. Additionally, but not required by law, a senior dental therapist or hygienist should be involved in setting up the PGD and, if involved, must sign it. PGDs are quite common in the health service but you do need the services of a pharmacist who has competency in working with dental prescribing.
Shortage of pharmacists Finding a pharmacist was easy under the old Primary Care Trust (PCT) system, but with the demise of the PCTs in England we have been forced to lose 151 PCTs which have been replaced with only 27 local area teams. However, there should
P R I M A R Y D E N TA L J O U R N A L
With direct access, trained dental hygienists and therapists can take, process and interpret radiographs
These medicines do not require a prescription and may be administered by anyone as long as they are trained, competent and confident to do so. All the medicines on the dental emergency drugs list (Table 1*) except for Midazolam, for which a PGD is required, may be administered without a PGD.
be far more pharmacists than the 27 found in the area teams as each PCT would surely have had a suitable contact prior to the changes, wouldn’t they? It is worth remembering that the NHS dental contract is managed by the area teams, so they will have the responsibility of signing a PGD if it is for use in an NHS practice, but not if it is for a private practice. This means that if you are working in a private practice, it might be easier to commission a pharmacist to work on your behalf.
So why do dental hygienists need to be able to prescribe? Take the subject of chlorhexidine mouthwash for a start. As a dental hygienist, I can give a patient a chlorhexidine rinse in the surgery; I can also give them a bottle to take home, but if they have forgotten their wallet or just don’t have the means to pay for it, I cannot write them a prescription for it. This to me seems ridiculous and certainly not akin to working in the best interests of the patient. Similarly, take the widespread idea of dental hygienists and therapists being utilised to reach the vulnerable and needy groups in care homes and similar institutions. This proposed scenario of utilising the wider skill mix will fall flat if we are not given the tools we need to be able to reach these areas of the population. For instance, if I were to go and see a patient who is quite obviously having discomfort and trouble eating and drinking due to an episode of
angular cheilitis, I would have to go right back to the surgery to obtain a prescription from a dentist for something as simple as an antifungal cream to relieve these symptoms. And the inconvenience of having to get a dentist to write a specific prescription for local anaesthetic or fluoride varnish is not easy either when you both have an increasing number of patients lined up in the waiting room. Dental nurses can now apply fluoride (albeit only if working to a protocol overseen by a consultant or registered specialist in Dental Public Health), so why can’t I as a highly-trained, competent health professional be able to paint a bit of fluoride on if I see the need?
Even the emergency drugs kit is daunting… In medicines legislation,1,2 PGDs are required for: • the administration of all parenteral POMs. • the administration of Midazolam (a controlled drug). • the supply directly to patients of all POM and pharmacy medicines. Medicines legislation does not require PGDs for: • administration of non-parenteral POMs. • administration of pharmacy or general sales list (GSL) medicines. • supply of GSL medicines directly to a patient. Medicines legislation exempts certain parenteral POMs from the requirements if used in an emergency to save a life.
VOL 3 NO 4 NOVEMBER 2014
A protocol can be implemented to administer medicines that are pharmacy or GSL. This may also apply for medical gases, none of which are POM. In conclusion, although there is nothing to stop an organisation or practice opting to use PGDs for all emergency drugs, they are not a legal requirement except for the administration of Midazolam. However, use of robust protocols would be good practice, and it is worth remembering that: • Any individual expected to choose and administer a medicine in an emergency situation should have been trained and assessed as competent to do so. • Although administration of medicines, other than parenteral POMs and controlled drugs, is not directed by The Human Medicine Regulations 2012, it is strongly recommended that, for legal and governance purposes, all medicines should either be prescribed, be administered under a PGD (when legally appropriate) or be administered under a protocol agreed locally by the employing organisation. The organisation has a legal responsibility for the actions of its employees. When it comes to injecting or administering drugs in a medical emergency, the GDC believe you should act in the best interest of your patient. This means that if a patient needed a drug to save their life, you would be acting in their best interests to administer it.
Conclusion Limited prescribing rights already exist for other healthcare professionals such as midwives, nurses and podiatrists – in my opinion, dental hygienists and therapists
31
ARE WE THERE YET? HMM... NOT QUITE
TA B L E 1
DENTAL EMERGENCY DRUGS Drug
Licensed status
PGD required for administration
Adrenaline injection (Epinephrine injection), adrenaline 1 in 1000, (adrenaline 1 mg/mL as acid tartrate), 1-mL amps
Parental POM that can be administered by anyone for the purpose of saving a life in an emergency
Not if used in an emergency
Aspirin dispersible tablets 300mg
GSL
No
Glucagon injection, glucagon (as hydrochloride), 1-unit vial (with solvent)
Parental POM that can be administered by anyone for the purpose of saving life in an emergency
Not if used in an emergency
Glucose (for administration by mouth)
Not a medicine
No
Glyceryl trinitrate spray
Pharmacy medicine
No
Midazolam Buccal Liquid, midazolam 10mg/mL or Midazolam injection (for buccal administration), midazolam (as hydrochloride) 5 mg/mL, 2-mL amps
Schedule 3 Controlled Drug (CD) POM that may be supplied under a PGD (other schedule 3 CDs may not)
Yes
Oxygen
GSL medicine
No
Salbutamol aerosol inhalation, salbutamol 100 micrograms/metered inhalation
Non-parenteral POM
No
*Table supplied by Christine Randall, Senior Medicines Information Pharmacist, North West Medicines Information Centre/Yellow Card Centre North West
should have been tagged onto this list when the changes were made in August 2013 to allow limited prescribing for physiotherapists and podiatrists. We should be following the medical model and getting dental hygienists and therapists out there in the community to look after those patients they would normally see in a surgery setting. In the surgery, they should be given the tools and the extra knowledge required to be able to effectively treat those conditions they are trained to recognise or diagnose. In Canada, dental hygienists have been able to prescribe for their patients since 2006. In fact, it took only three years to develop a six-to-nine-month course which enables them to prescribe a number of antimicrobials, antibiotics, and fluoridecontaining products. Surely this model could be copied in the UK to make life easier for patients and clinicians alike?
32
According to recent statistics,3 10 million people in the UK are over 65 years old. The latest projections are for 5.5 million more elderly people in 20 years’ time and the number will have nearly doubled to around 19 million by 2050. We all know that we have an increasing ageing dentate population, and with that will come other problems such as periodontal disease and root caries. I think it would be fair to say that it’s not
all going to be dentures in the future. There is a massive implant market out there, and someone is going to have to look after those implants as the patients get older. Surely the complicated mix of an increased medical and dental history will benefit from the wider skills and knowledge of dental hygienists and therapists in the future? I guess the question on everyone’s lips should be: ‘How would I like to be looked after?’
REFERENCES 1
2 3
The Human Medicines Regulations 2012. The National Archives website. Available at: www.legislation.gov.uk/uksi/2012/1916/pdfs/uksi_20121916_en.pdf Accessed: September 9, 2014 The Misuse of Drugs Regulations 2001. The National Archives website. Available at: www.legislation.gov.uk/uksi/2001/3998/made. Accessed: September 9, 2014 The ageing population. UK Parliament website. Available at: www.parliament.uk/documents/commons/lib/research/key_issues/Key-Issues-The-ageingpopulation2007.pdf. Accessed: September 9, 2014.
P R I M A R Y D E N TA L J O U R N A L
