Many hygienists and therapists are now providing treatment to their patients under direct access and in the vast majority of cases this is working out well for both the patients and the hygienists/therapists.  

The main issues which can cause problems for our members when providing care under direct access revolve around managing patient expectations. There are also some practical difficulties which hygienists and therapists can encounter due to various pieces of legislation, highlighted below.

Managing patient expectations

It is essential that patients are aware of what you can and cannot provide under direct access before they come to see you. This means that the whole practice team, but especially all the reception staff, need to understand what direct access means, and which patients can be booked in to see you under direct access before you start providing care this way.  

If you are working in a practice where some of the hygienists/therapists are providing direct access and others are not, it is essential that patients are not booked in with the wrong person in error.

Providing treatment under the NHS

There is a barrier to direct access for NHS treatment by virtue of the NHS Regulations. In order for a course of treatment to be undertaken on the NHS, the patient must undergo a full examination. Only a dentist can carry out a full examination which will satisfy the NHS Regulations. Dental hygienists and therapists are restricted to carrying out an examination, diagnosis and treatment plan within their scope of practice, which is limited by the GDC’s Scope of Practice guidance, and by their training. 

Teeth bleaching

In September 2011, the EU Cosmetics Directive was amended to permit the use of tooth bleaching compounds containing or releasing up to 6% hydrogen peroxide, provided that: 

1. they are only sold to dental practitioners; 
2. for each cycle of use, the first use is by a dental practitioner or under their direct supervision if an equivalent level of safety is ensured; 
3. they may afterwards be provided to the consumer to complete the cycle of use; and 
4. they are not to be used on a person under 18 years of age.

Bleaching can still be carried out by registered dental hygienists and dental therapists, but the first treatment must be under the direct supervision of a dentist. This means a dentist needs to have examined the patient and provided the treatment plan for the bleaching. It also means that a dentist must be on the premises at the time of the first bleaching treatment, but this does not have to be the same dentist who formulated the treatment plan. 

Taking radiographs

Most hygienists and therapists will have been trained to take radiographs, but not all will have been trained to report on the radiograph. If you have not been trained to justify, take and report on a radiograph, you will need to have arrangements in place for any radiographs you take to be reported on by a dentist.

Providing prescription-only medicines (POMs)

A POM can be provided or administered to a patient by: 

1. a prescription for the individual patient written by somebody with general prescribing rights
2. a Patient Specific Direction by somebody with prescribing rights
3. a Patient Group Direction (PGD).

In the dental team, currently only dentists have general prescribing rights. If a hygienist or therapist needs to administer POMs, the dental practice or healthcare organisation must draw up its own PGD. A number of DDU members have reported difficulties in doing this, such as finding a pharmacist who is willing to sign the PGD. 

Guidance from the National Prescribing Centre sets out the requirements for producing and authorising a PGD. The BSDHT have produced templates for developing a PGD. In the absence of an approved PGD in a dental practice, a dental hygienist or therapist can only administer a POM under a Patient Specific Direction written by a dentist. 

In Scotland, only independent hospitals and hospices are currently registered under the Regulation of Care (Scotland) Act 2001. As yet, a commencement order for independent clinics and independent medical agencies has not been made. Until the legislation is changed in Scotland, PGDs can only be set up for use in independent hospitals and hospices. 

A PGD signed by a provider of an independent healthcare service registered in England and Wales cannot be used to authorise the supply or administration of medicines by its own staff in Scotland. However, a provider registered in England and Wales can enter into an arrangement with a pharmacist based in a Scottish community pharmacy to operate under a PGD. The same applies to the use of PGDs in England and Wales by a provider registered in Scotland.

Providing direct access in Wales

A number of Welsh members have reported to us that a question mark has been raised in various quarters over whether a dental hygienist or dental therapist needs to register with Health Inspectorate Wales (HIW) in order to provide any private treatment under Direct Access. Under the Private Dentistry (Wales) Regulations 2008, only dentists are 'prescribed persons' and only they are therefore required to register with HIW if they intend providing any element of private dental treatment. 

Unless and until these regulations are amended to encompass dental hygienists and dental therapists, there is no requirement for them to register in order to treat patients under direct access, whether in a practice owned by a dentist or in their own practice.