DIRECT ACCESS FOR DENTAL THERAPISTS AND HYGIENISTS – WHEN DO WE REFER? CHARLOTTE WAKE1
T
he subject of direct access (DA) is one of the most talked-about topics in dentistry. Whether you are a dentist or a dental care professional (DCP), it means that the future is changing and this brings with it some new, practical questions. For DCPs, the introduction of DA means that you have the option to work (in certain circumstances) without the prescription of a dentist.
This is clarified in the statement by the GDC: “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. Dental hygienists and dental therapists must be confident that they have the skills and competences required to treat patients direct 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 since 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 those 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.”1
No therapist or hygienist should be made to feel that they have to work with DA, but if you wish to use direct access then you must check with your indemnity provider to ensure that you are covered before work commences. Some dental therapists and hygienists will wish to continue to obtain a written prescription from the dentist. Direct access does not make any changes to the current working system obligatory; however, therapists and hygienists wishing to work with DA are now able to do so. It may be that you choose to use DA in set circumstances; for example, when a new patient wishes to attend the practice and see both the dentist and the hygienist on the same day. Before DA, the patient would have to see the dentist
V O L 3 N O 2 M AY 2 0 1 4
first, which would not be possible if the appointment book only had a gap with the hygienist first, or if the dentist was running late. Using DA means that the patient can see the DCP first, then go in for their examination with the dentist afterwards. It may be that you only use DA on the occasions when perhaps a dentist is on annual leave or is unwell; rather than cancel the patients who require treatment, you have the choice to see them with DA. Other DCPs may use DA on a daily basis, seeing a patient, undertaking all treatments that are within their scope of practice and their own competency, and sending the patient to the dentist afterwards. Whatever the circumstances, there are some key points which need to be considered prior to deciding whether you wish to choose to work with direct
1
Charlotte Wake
dental therapist and dental hygienist
77
Caption–here? PERIODONTAL HEALTH CHALLENGES IN RESTORATIVE DENTISTRY
situations in which it can be used. Dental therapists and hygienists will not pose a threat to the dentist’s workload as they cannot work outside of their scope of practice. Equally, DA is unlikely to impede on the dentist’s rapport with the patients; many patients will expect the dentist to undertake certain procedures as that is the way it has always been. There is nothing wrong with this: after all, DA is about patient choice. So this situation then poses the question: when do we refer to the dentist when seeing a patient directly?
Within the NHS
access. I personally believe that DA is only likely to be successful in situations with a support network, including a dentist who understands and is willing to work with you using DA. A robust practice referral procedure should be in place between the DCP and the dentist. Your patients should be made aware that this is the case. DA is inherently about the patient, and the patient has the right to withdraw their consent at any time. A referral procedure is necessary so that all clinicians, staff and patients know and understand how DA works within your practice.
Sole traders DA is ideal as part of a team-based approach, but should a therapist or hygienist wish to work independently, there are other considerations. The GDC has recommended that those working independently should have the emergency drugs that are held in practice. This presents a very real problem, as midazolam, epinephrine,
78
salbutamol and glyceryl trinitrate (GTN) spray are prescription-only medications (POMs). They either require a prescription or need to be covered by a patient group directive (PGD). There are also situations that will require a referral to a GDP. These will vary depending on your competency, your working environment and your own personal choice regarding DA.
A team effort The choice to work with DA should be taken seriously, the process should be well structured, and the whole dental team needs to be well informed. If the practice is not sure how DA works, then we cannot expect our patients to be able to provide true informed consent if they are equally confused. It is hoped that DA will provide better access to dental care for patients and a choice as to who provides that care. Although DA has been passed by the GDC, there are limitations to the
Currently it is only possible for a dentist who has a performer number to open and close a course of NHS treatment, so at present it is not possible for a dental hygienist or therapist to see a patient directly under the NHS. This means that at present, working with DA is more suited to a private-sector environment. There are still times when a referral is necessary, so when do we refer? When a patient requests the work to be undertaken by a GDP Patients have the right to choose who does their treatment. In order to obtain informed consent, the patient should have no doubt at any stage what treatment is being carried out, and by which clinician. If there are any soft tissue anomalies present When seeing patients, regardless of referral procedure, we have the ability to diagnose or recognise signs and symptoms within our scope of practice. If there is anything outside of our scope, confidence or competence then a referral should be sought.
P R I M A R Y D E N TA L J O U R N A L
When local anaesthetic is needed and no PGD is in place DA does not change the need for a local anaesthetic prescription, either as a written prescription from a dentist or by having a PGD. Should LA be required when no PGD is in place, then a referral should be sought. When radiographs are required Following training, therapists and hygienists can prescribe and take radiographs, as long as the need can be justified and you are able to interpret them. However, the dentist is then required to write a report for them. When prescription-only medications (POMs) are indicated Should a therapist or hygienist feel that a POM is indicated, be this the need for antibiotics or the use of a POM such as Ledermix or Duraphat, then a written prescription is still required. Use of fluoride Should a patient seen directly need fluoride treatment such as fluoride varnish or high-fluoride toothpaste, these are all POMs and must be prescribed by a dentist. There are other clinical situations that are not affected by the introduction of DA. Should an exposure occur, it is still necessary that the therapist dress the tooth and refer the patient back to the dentist. Should work be needed outside of our competency or scope of practice, then a referral is required. If a basic periodontal examination indicates that a specialist periodontal referral should be sought, then the referral may come from the therapist/hygienist, or the patient may prefer a referral from the dentist.
is good for dentistry or not, DA is primarily about the patient. The GDC has decided that therapists and hygienists are safe to undertake their scope of practice without the need for a prescription. The therapists and hygienists themselves have the choice whether to use DA in their working environment, and the patients now have a choice as to who provides certain treatments. My personal view is that if direct access means that one patient is seen by a therapist or hygienist, who otherwise would not have seen any dental professional because of access issues, or perhaps fear, then this has to be an improvement. DCPs are not dentists; the profession knows this, but more importantly, so do patients. In my experience, patients will ask questions of a dental therapist or hygienist that they may think are too trivial to ask the dentist. I often hear “this might be a stupid question but…” If patients see DCPs as the bridge between themselves and the dentist, and in some cases may be willing to see us rather than to “bother the nice dentist with this little ulcer” then DA may make the ultimate difference to that patient.
All views are those interpreted and understood by the author alone. All clinicians are encouraged to discuss direct access with their indemnity provider.
REFERENCES 1
It is for all these reasons that I think direct access works best with a team approach. Whether you believe that DA
V O L 3 N O 2 M AY 2 0 1 4
General Dental Council. Dental access. GDC website. Available at:
https://www.gdcuk.org/Dentalprofessionals/ Standards/Pages/DirectAccess.aspx. Accessed: 7 Apr 2014
2
GDC clarifies drugs kit question for dental care professionals. Dental Practice 2014;51(10):1
79
T
he subject of direct access (DA) is one of the most talked-about topics in dentistry. Whether you are a dentist or a dental care professional (DCP), it means that the future is changing and this brings with it some new, practical questions. For DCPs, the introduction of DA means that you have the option to work (in certain circumstances) without the prescription of a dentist.
This is clarified in the statement by the GDC: “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. Dental hygienists and dental therapists must be confident that they have the skills and competences required to treat patients direct 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 since 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 those 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.”1
No therapist or hygienist should be made to feel that they have to work with DA, but if you wish to use direct access then you must check with your indemnity provider to ensure that you are covered before work commences. Some dental therapists and hygienists will wish to continue to obtain a written prescription from the dentist. Direct access does not make any changes to the current working system obligatory; however, therapists and hygienists wishing to work with DA are now able to do so. It may be that you choose to use DA in set circumstances; for example, when a new patient wishes to attend the practice and see both the dentist and the hygienist on the same day. Before DA, the patient would have to see the dentist
V O L 3 N O 2 M AY 2 0 1 4
first, which would not be possible if the appointment book only had a gap with the hygienist first, or if the dentist was running late. Using DA means that the patient can see the DCP first, then go in for their examination with the dentist afterwards. It may be that you only use DA on the occasions when perhaps a dentist is on annual leave or is unwell; rather than cancel the patients who require treatment, you have the choice to see them with DA. Other DCPs may use DA on a daily basis, seeing a patient, undertaking all treatments that are within their scope of practice and their own competency, and sending the patient to the dentist afterwards. Whatever the circumstances, there are some key points which need to be considered prior to deciding whether you wish to choose to work with direct
1
Charlotte Wake
dental therapist and dental hygienist
77
Caption–here? PERIODONTAL HEALTH CHALLENGES IN RESTORATIVE DENTISTRY
situations in which it can be used. Dental therapists and hygienists will not pose a threat to the dentist’s workload as they cannot work outside of their scope of practice. Equally, DA is unlikely to impede on the dentist’s rapport with the patients; many patients will expect the dentist to undertake certain procedures as that is the way it has always been. There is nothing wrong with this: after all, DA is about patient choice. So this situation then poses the question: when do we refer to the dentist when seeing a patient directly?
Within the NHS
access. I personally believe that DA is only likely to be successful in situations with a support network, including a dentist who understands and is willing to work with you using DA. A robust practice referral procedure should be in place between the DCP and the dentist. Your patients should be made aware that this is the case. DA is inherently about the patient, and the patient has the right to withdraw their consent at any time. A referral procedure is necessary so that all clinicians, staff and patients know and understand how DA works within your practice.
Sole traders DA is ideal as part of a team-based approach, but should a therapist or hygienist wish to work independently, there are other considerations. The GDC has recommended that those working independently should have the emergency drugs that are held in practice. This presents a very real problem, as midazolam, epinephrine,
78
salbutamol and glyceryl trinitrate (GTN) spray are prescription-only medications (POMs). They either require a prescription or need to be covered by a patient group directive (PGD). There are also situations that will require a referral to a GDP. These will vary depending on your competency, your working environment and your own personal choice regarding DA.
A team effort The choice to work with DA should be taken seriously, the process should be well structured, and the whole dental team needs to be well informed. If the practice is not sure how DA works, then we cannot expect our patients to be able to provide true informed consent if they are equally confused. It is hoped that DA will provide better access to dental care for patients and a choice as to who provides that care. Although DA has been passed by the GDC, there are limitations to the
Currently it is only possible for a dentist who has a performer number to open and close a course of NHS treatment, so at present it is not possible for a dental hygienist or therapist to see a patient directly under the NHS. This means that at present, working with DA is more suited to a private-sector environment. There are still times when a referral is necessary, so when do we refer? When a patient requests the work to be undertaken by a GDP Patients have the right to choose who does their treatment. In order to obtain informed consent, the patient should have no doubt at any stage what treatment is being carried out, and by which clinician. If there are any soft tissue anomalies present When seeing patients, regardless of referral procedure, we have the ability to diagnose or recognise signs and symptoms within our scope of practice. If there is anything outside of our scope, confidence or competence then a referral should be sought.
P R I M A R Y D E N TA L J O U R N A L
When local anaesthetic is needed and no PGD is in place DA does not change the need for a local anaesthetic prescription, either as a written prescription from a dentist or by having a PGD. Should LA be required when no PGD is in place, then a referral should be sought. When radiographs are required Following training, therapists and hygienists can prescribe and take radiographs, as long as the need can be justified and you are able to interpret them. However, the dentist is then required to write a report for them. When prescription-only medications (POMs) are indicated Should a therapist or hygienist feel that a POM is indicated, be this the need for antibiotics or the use of a POM such as Ledermix or Duraphat, then a written prescription is still required. Use of fluoride Should a patient seen directly need fluoride treatment such as fluoride varnish or high-fluoride toothpaste, these are all POMs and must be prescribed by a dentist. There are other clinical situations that are not affected by the introduction of DA. Should an exposure occur, it is still necessary that the therapist dress the tooth and refer the patient back to the dentist. Should work be needed outside of our competency or scope of practice, then a referral is required. If a basic periodontal examination indicates that a specialist periodontal referral should be sought, then the referral may come from the therapist/hygienist, or the patient may prefer a referral from the dentist.
is good for dentistry or not, DA is primarily about the patient. The GDC has decided that therapists and hygienists are safe to undertake their scope of practice without the need for a prescription. The therapists and hygienists themselves have the choice whether to use DA in their working environment, and the patients now have a choice as to who provides certain treatments. My personal view is that if direct access means that one patient is seen by a therapist or hygienist, who otherwise would not have seen any dental professional because of access issues, or perhaps fear, then this has to be an improvement. DCPs are not dentists; the profession knows this, but more importantly, so do patients. In my experience, patients will ask questions of a dental therapist or hygienist that they may think are too trivial to ask the dentist. I often hear “this might be a stupid question but…” If patients see DCPs as the bridge between themselves and the dentist, and in some cases may be willing to see us rather than to “bother the nice dentist with this little ulcer” then DA may make the ultimate difference to that patient.
All views are those interpreted and understood by the author alone. All clinicians are encouraged to discuss direct access with their indemnity provider.
REFERENCES 1
It is for all these reasons that I think direct access works best with a team approach. Whether you believe that DA
V O L 3 N O 2 M AY 2 0 1 4
General Dental Council. Dental access. GDC website. Available at:
https://www.gdcuk.org/Dentalprofessionals/ Standards/Pages/DirectAccess.aspx. Accessed: 7 Apr 2014
2
GDC clarifies drugs kit question for dental care professionals. Dental Practice 2014;51(10):1
79
