In the last few months, we have received many calls about hygienists and therapists treating patients under direct access. Some of the confusion has been sparked by the recent guidance issued by NHS England.

However, these concerns are not just about providing NHS treatment in England. Here we cover some of the main issues that we've helped members navigate, which we hope helps to clear up some of the confusion surrounding them.

Scope of practice for overseas dentists

One area that can cause confusion is the scope of practice of an overseas qualified dentist who has been registered with the GDC as a therapist.

If someone is registered as a therapist, they must restrict the treatment they provide to that of a therapist - they are not allowed to provide any care or advice about other treatments they might have been trained to perform. As with any other hygienist or therapist, it's vital to be clear with patients about the care and advice you can and cannot provide.

Some dentists might choose to limit their scope of practice to that of a hygienist or therapist. This can be done, but if you're registered with the GDC as a dentist you mustn't call yourself a hygienist or therapist, and you won't be able to provide NHS care under direct access as a hygienist or therapist. As a registered dentist, you will only be able to provide NHS treatment under direct access if you are on the Performers List.

Making an NHS claim for treatment

If a dental hygienist or therapist undertakes the whole course of NHS treatment in England, they will be identified on the claim form by their GDC registration number. However, a performer number must also be included - and because they are not performers, DCPs can't make the claim themselves.

Because they can't be on the Performers list, dental hygienists and therapists have no contractual relationship with the NHS, and are therefore outside the NHS disciplinary process as well as outside the NHS procedures for breach of the GDS contract.

This means that NHS England could only take action against the performer who has allowed their number to be used on any claim, or the contract provider. Accordingly, the performer under whose number the claim is made, plus the provider as the contract holder, should be aware that they are accepting responsibility under the NHS regulations for the course of treatment.

Mixing NHS and private care

In many dental practices, NHS patients are offered hygiene treatment under the NHS with a dentist, or privately with a dental hygienist or therapist as an alternative. If a dental hygienist or therapist undertakes the whole course of NHS treatment, they will also need to provide any necessary hygiene treatment under the NHS.

Both the NHS and GDC disapprove of any misleading advice to patients over the availability and quality of NHS treatment, so are likely to take disciplinary action if it comes to their attention that a patient has been misinformed about the availability of NHS care.

Direct access

A dental therapist providing the whole course of treatment will, by definition, be seeing the patient under direct access arrangements. It's a condition of the GDC's direct access guidance that a dental hygienist or therapist treating patients who need care beyond their scope of practice or competence must have an established pathway to refer those patients to a dentist.

Any practice providing direct access care will need to make sure there is enough dentist capacity to ensure these referrals are seen quickly enough for the course of NHS treatment to be completed within a reasonable period. This might be particularly relevant when there is a lack of access to NHS care from a dentist.

The responsibilities of the dental hygienist or therapist

Whatever a practice owner's assessment of a dental hygienist's or therapist's competence and confidence to undertake their full scope of practice, the hygienist or therapist is also under a GDC obligation to self-assess, and not to undertake any work they consider to be outside their training, competence, and their own level of confidence.

When the GDC issued its initial guidance on direct access treatment, it made it very clear that DCPs should never be forced to provide direct access care.

Giving information to patients

It's important to provide patients with full information before and at the time of booking a direct access appointment, so they know who they are seeing and the possible limitations of direct access. There should be clear and consistent communication across the whole practice team to try and prevent any confusion arising.

Prescription only medicines (POMs)

Dentists are currently the only members of the dental team legally allowed to prescribe POMs, which include local anaesthetics and high concentration fluoride preparations.

A dental hygienist or therapist can only administer either a local anaesthetic or a high concentration fluoride preparation under a patient specific direction (PSD), written by a dentist and usually recorded in the clinical notes, or under a patient group direction (PGD).

If a practice already has a PGD in place, it might not be valid for NHS care. There's more advice on PGDs on our main website, as well as from NICE.

Referrals

A dental hygienist or therapist working under direct access should be able to make a direct referral to secondary care, when they are confident of their provisional diagnosis and the need for a referral to secondary care. If on the other hand they are unsure of how the patient should be managed, because the patient's condition is outside their scope or competence, they should use their established referral pathway to a dentist, who can then refer onwards if appropriate.

Indemnity

Under an NHS contract, the provider agrees to take responsibility for delivering it, including the quality of care delivered to fulfil their contractual obligations. DDU practice principal and practice owner members can access indemnity for claims based on the non-delegable duty of care and vicarious liability. You can find out more on page eight of the DDU member guide.

DDU hygienist and therapist members have access to indemnity for all the work set out in the GDC's scope of practice for their registrant group, together with any other work specifically approved by the GDC, either on referral of under direct access.

We simply ask that members tell us if they are working under direct access (whether privately or via the NHS) so that we have accurate details of their work circumstances - but we don't charge any extra for this.