The regular queries we receive from dental hygienists and therapist members indicate there is still some continuing confusion over treatment on prescription and Direct Access. Here we dispel some of the misunderstandings, and clarify when these two methods of accepting patients are appropriate.

Dental hygienists and therapists can only treat patients under two arrangements; under the prescription of a dentist who has examined the patient and has specified the treatment to be carried out in a written prescription or treatment plan, or under Direct Access.

Hygienists and therapists can't 'flip-flop' between treatment on prescription and treatment under direct access. A patient referred for treatment on prescription remains as such until that treatment is completed by the hygienist or therapist or the patient withdraws from it.

Similarly, a patient accepted under direct access remains a Direct Access patient unless and until they are referred to a dentist by the hygienist or therapist, refer themselves to a dentist, or withdraw from care.

This means that if a hygienist or therapist is not treating a patient under direct access, they must have a written prescription or treatment plan from a dentist who has examined and referred the patient for all the investigations and treatment for the hygienist or therapist to carry out.

There is no limit to the duration of a dentist's prescription/treatment plan for a hygienist or therapist, but if the dentist re-examines the patient, the existing treatment plan should be reviewed and either renewed or amended as necessary.

When treating a patient on referral from a dentist, the patient's consent to undergoing treatment by a hygienist or therapist does not in any way remove the need for a written prescription from that dentist.

Direct Access

By definition, hygienists and therapists treating a patient under direct access won't have a written prescription/treatment plan from a dentist, because the patient hasn't been referred (although they may still have a dentist).

A patient becomes a direct access patient if they make a direct approach for treatment by a hygienist or therapist and don't want to see a dentist first. In those circumstances, if the hygienist or therapist is willing to accept the patient under direct access (and they shouldn't be obliged to do so), the hygienist or therapist takes prime responsibility for the examination, treatment planning and treatment of the patient - provided it is within their Scope of Practice as set out by the GDC, and within their training and competence.

One of the conditions of direct access is that the hygienist or therapist must have a clearly established pathway to refer the patient to a dentist if any aspect of their care lies outside their Scope of Practice or competence.

Hygienists and therapists cannot provide Direct Access examinations, investigations or treatment under the NHS General Dental Services (NHS GDS). Under the NHS GDS Regulations, only a dentist can be a performer.

This means that only a dentist can examine and treatment-plan a patient, so a hygienist or therapist can only work to the prescription of a performer dentist who has examined the patient. Because of this, direct access treatment outside an NHS Trust can only be provided privately.

Scope of practice

A hygienist or therapist is permitted to carry out anything within the GDC's Scope of Practice provided they are appropriately registered, trained, competent and indemnified to do so, and they have a properly established referral pathway to a dentist for any case which lies outside their competence.

While the GDC's Scope of Practice allows dental therapists to carry out more tasks than dental hygienists, both are permitted to carry out the following in relation to examination and treatment planning:

• carrying out a clinical examination within competence
• completing a periodontal examination and charting and using indices to screen and monitor periodontal disease
• diagnosing and treatment planning within competence
• prescribing radiographs
• taking, processing and interpreting various film views used in general dental practice
• planning the delivery of care for patients.

The Scope of Practice allows a hygienist or therapist working on prescription from a dentist to 'vary the detail but not the direction of the prescription according to patient needs' - so for example, a hygienist might decide to change the number and/or frequency of the visits for oral hygiene instruction and reinforcement, scaling, polishing, and root surface instrumentation.

Competence and planning treatment

It's important to note that hygienists and therapists can't plan treatment outside their Scope of Practice and competence. For example, a dental therapist cannot perform a root canal treatment on or extract permanent teeth, so it would be hard to justify planning such treatment, or treatment leading to either procedure.

Similarly, therapists can't provide crowns, bridges or dentures, so again, offering a treatment plan for these procedures, or treatment leading to the provision of crowns, bridges or dentures, would be outside the Scope of Practice.

Because of this, a dental hygienist or therapist cannot justifiably provide a comprehensive examination and treatment plan for a patient, and so it's vital to give patients full information about the limitations of the care that can be provided, before and at the time of booking a Direct Access appointment.

Some practices ask patients to sign a form agreeing to Direct Access treatment, but this isn't mandatory. Verbal consent is sufficient, but it is a GDC requirement to make a full record of the consent process in the patient's notes, whether or not a consent form is used, and to give them a written treatment plan and fee estimate before any treatment takes place.

This allows the patient to be aware of the limitations and either accept the appointment, or choose to see a dentist for their examination.