Direct Access Q&As
What is 'direct access'?
1. What is ‘direct access’?
'Direct access’ means giving patients the option to see a dental care professional (DCP) without having to see a dentist first and without a prescription from a dentist.
2. Who can treat patients direct?
Dental hygienists and dental therapists can see patients direct. The only exception to this is toothwhitening, which must still be carried out on prescription from a dentist.
Dental nurses can participate in preventative programmes without the patient having to see a dentist first.
Orthodontic therapists can carry out Index of Orthodontic Treatment Need (IOTN) screening without the patient having to see a dentist.
Clinical dental technicians can see patients direct who have no teeth direct, or dental implants, for the provision and maintenance of full dentures.
Dental technicians will continue to carry out most of their work to prescription, except repairs.
3. Is direct access compulsory?
No. If a dentist and a dental care professional are happy with their current working arrangements, they can continue them. Employers should not expect a registrant to see patients direct if they do not feel competent to do so. Some registrants may set up a practice to offer direct access, but in other practices it should only be offered to patients where there is mutual agreement between the dentist and the dental care professional(s).
4.Does direct access mean anyone can do anything?
No. All registrants must work within their scope of practice and do only those things that they are trained, competent and indemnified to do. Direct access means dental hygienists and dental therapists are allowed to do what they are trained and competent to do without the patient having to see a dentist first. Where diagnosis or treatment is outside their scope of practice and competence they should advise patients they need to be referred to a dentist.
Questions 5 to 10 explain what all DCPs can do under direct access.
Who can do what?
5. What treatment or services can a dental hygienist provide directly to patients?
Dental hygienists can carry out their full scope of practice (except toothwhitening) without needing a prescription from a dentist.
6. What treatment or services can a therapist provide direct to patients?
Dental therapists can carry out their full scope of practice (except toothwhitening) without needing a prescription from a dentist.
7. What treatment or services can a dental nurse provide direct to patients?
Dental nurses who are trained, and competent to do so can see patients direct if they are taking part in structured programmes which provide dental public health interventions.
A dental nurse who applies fluoride varnish to a patient as part of a structured programme, should advise the patient to inform their dentist (if they have one) that they have been treated under the programme.
8. What treatment or services can an orthodontic therapist provide direct to patients?
Orthodontic therapists who are trained, competent and indemnified can carry out Index of Orthodontic Treatment Need (IOTN) screening direct to patients or as part of a structured public health programme led by a specialist in orthodontics, a consultant in Dental Public Health, a specialist in Dental Public Health or a general dental practitioner.
The rest of their work is carried out on prescription from a dentist.
9. What treatment or services can a Clinical Dental Technician provide direct to patients?
The provision and maintenance of full dentures for patients who have no teeth and no implants.
Any treatment provided for patients with teeth or implants is done on prescription from a dentist.
10. What treatment or services can a dental technician provide direct to patients?
Only repairs. The rest of their work must be done following instructions from a dentist or clinical dental technician.
11. Who can give oral health advice direct to patients?
All dental professionals can provide oral health advice direct to patients. A prescription is not required for this.
12. Who can visit schools as part of a preventative and advice programme?
Dentists, dental hygienists, dental therapists, dental nurses and orthodontic therapists can go to schools as part of a preventative and advice programme. They should only provide treatment and advice that is within their scope of practice and competence.
Different treatments and products
13. What about toothwhitening?
Dental hygienists, dental therapists and clinical dental technicians can be trained in toothwhitening as an additional skill. However, even with direct access, toothwhitening still needs to be carried out on prescription from a dentist. This is due to the Cosmetic Products (Safety) Amendment Regulations 2012, which implement EU Directive 2011/84 EU.
The Regulations state that toothwhitening can only be carried out on the prescription of a dentist, and toothwhitening products containing or releasing between 0.1% and 6% hydrogen peroxide (or its equivalent) can only be sold to dental practitioners. However, the first use of each cycle can be carried out by dental hygienists, therapists or clinical dental technicians under the direct supervision of a dentist (that is, with a dentist on the premises) The dentist needs to be assured that the hygienist / therapist/CDT is trained and competent to carry out this treatment on the patient. After this, the products can be provided to the patient to complete the cycle of use.
14. Can dental hygienists and dental therapists prescribe local anaesthesia (LA)?
No. Local anaesthetic is a prescription-only medicine (POM) which means that under medicines legislation it can only be prescribed by a suitably qualified prescriber – usually a doctor or a dentist. However, both dental hygienists and dental therapists can administer LA either under a written, patient-specific prescription or under a Patient Group Direction (PGD).
A PGD is a written instruction which allows listed healthcare professionals to sell, supply or administer named medicines in an identified clinical situation without the need for a written, patient-specific prescription from an approved prescriber. PGDs can be used by dental hygienists and dental therapists in:
NHS practices in England, Wales and Scotland and their equivalent in Northern Ireland;
Private dental practices in England registered with the Care Quality Commission;
Private dental practices in Wales providing the individual dentists are registered with the Health Inspectorate Wales;
Private dental practices in Northern Ireland registered with the Regulation and Quality Improvement Authority.
PGDs cannot currently be used in private dental practices in Scotland although this may change once there is a start date for their registration with Health Improvement Scotland.
15. Who can hold and administer emergency medicines?
Some emergency drugs are prescription-only medicines (POM), controlled drugs, or pharmacy medicines. This means that, like local anaesthetic, they are subject to restrictions imposed by medicines legislation. This legislation states who can legally obtain, hold, and administer particular medicines.
Dentists are allowed to purchase any medicine. However, the legislation does not allow other DCPs to purchase or procure any POM, pharmacy medicine, or controlled drug, which includes some medicines on the emergency list. However, the administration of some of these drugs can be covered by a Patient Group Direction (PGD).
Dental therapists and hygienists
Hygienists and therapists working independently must have the recommended list of emergency drugs available in the practice. Prescription-only and pharmacy medicines for emergency use can only be legally obtained if ordered by a dentist, however they can be held and administered by hygienists and therapists without a dentist on the premises.
Controlled drugs can only be administered by a dentist, on the prescription of a dentist or under a PGD by a hygienist or therapist.
Clinical Dental Technicians
Under medicines legislation, CDTs are not able to purchase or hold all of the medicines contained in an emergency drugs kit. Therefore, the GDC does not expect CDTs who practice independently to have an emergency drugs kit.
However, CDTs must have a defibrillator onsite, and be trained to use it.
16. Can dental hygienists and dental therapists prescribe radiographs?
Yes. Under the terms of the Ionising Radiation (Medical Exposure) Regulations 2000 or IR(ME)R (and further update in 2006), registered dental hygienists and therapists are able to take on the roles of 'operator', 'practitioner' and 'referrer'. If the dental hygienist or therapist is self-employed, they may have further responsibilities under IR(ME)R and it is their responsibility to ensure they comply with these.
However, dentists remain the only member of the team who can ‘report’ on all aspects of a radiograph. This is unlikely to be a problem in practices where a dentist is available to report on the radiograph, however independent DCP practices would need to make sure that there are appropriate referral arrangements in place so that a dentist is available to report on radiographs and ensure patients receive appropriate advice and subsequent treatment.
17. Can dental hygienists and dental therapists administer or supply fluoride supplements and toothpaste?
Only under a Patient Group Direction (PGD) or under a written, patient-specific prescription provided by a suitably qualified prescriber. A PGD allows dental hygienists and dental therapists to sell or supply fluoride supplements and toothpastes with a high fluoride content (2800 and 5000 parts per million).
18. Can dental hygienists and dental therapists carry out Botox treatment direct?
No. Whilst hygienists and therapists can administer Botox if they are trained, competent and indemnified to do so, they cannot carry out Botox treatment direct. This is because Botox is a prescription-only medicine (POM) and needs to be prescribed by a registered doctor or dentist who has completed a full assessment of the patient.
19. Does direct access work in all settings?
Direct access works best in a team setting, partly because of legal restrictions such as those around prescribing, which are not imposed by the GDC, but also for more immediate practical arrangements for records, referrals and second opinions. A team setting should give patients more routes of entry into treatment. However there is no reason that direct access cannot work in many types of settings provided that appropriate safeguards are in place including referral arrangements.
20. Who is taking the overall responsibility for the patient's care in the direct access model?
It depends who is treating the patient. If the patient is only seeing a dental care professional, then that registrant would be responsible. If the patient is under the care of the dental team, including a dentist who is prescribing the treatment, then the dentist would have overall responsibility.
21. Who is responsible for patient consent?
Consent must be obtained from the patient for all treatment undertaken and for any referral to other members of the dental team. Therefore every dental professional is responsible for obtaining the patient’s consent when they are in their care.
22. What referral arrangements should be in place?
Dental hygienists and dental therapists offering treatment via direct access will need to have clear arrangements in place to refer patients to dentists if those patients need treatment which only dentists can provide. In a multi-disciplinary practice where the dental team works together on one site, this should be straightforward. In a multi-site set-up where members of the dental team work in separate locations, there should be formal arrangements such as standard operating procedures in place for the transfer and updating of records, referrals and communication between the registrants.
Where hygienists and therapists choose to practise independently (i.e. in a situation where there is no dentist as part of the team), they should have clear referral arrangements in place in the event that they need to refer a patient for further advice or treatment and those arrangements should be made clear in their practice literature. If a patient requires a referral to a dentist with whom the hygienist or therapist does not have an arrangement, the DCP should set out for the patient, in writing, the treatment undertaken and the reasons why the patient should see their dentist.
In all cases, the need for referral should be explained to the patient and their consent obtained. The reason for the referral and the fact that the patient has consented to it should be recorded in the patient’s notes. Relevant clinical information, including copies of radiographs, should be provided with the referral.
If a patient refuses a referral to a dentist, the possible consequences of this should be explained to them and a note of the discussion made in the patient’s records.
There should also be referral arrangements in place to make sure a dentist is available to ‘report’ on all aspects of a radiograph to ensure patients receive appropriate advice and subsequent treatment.
23. Will direct access reduce the need for dentists?
Most patients will continue to have a primary relationship with their dentist. There is a whole range of complex conditions which only dentists can diagnose and treat. Members of the dental team must work within their scope of practice and competence. Although patients may have a greater choice about which member of the dental team they visit.
24. Only dentists are trained to diagnose all conditions so how can dental care professionals see patients direct?
Dental care professionals (DCPs), depending on their different roles, are trained to a varying extent to identify abnormalities, undertake screening roles and give oral health advice. The DCP should identify any issues of concern and refer the patient to the dentist for diagnosis and treatment. In some cases they may be able to treat the patient and refer to a dentist later. In other cases, they may need to defer treatment and refer the patient to a dentist. Referrals may only be made with the patients’ consent and if that consent is withheld, DCPs will need to explain the potential consequences, as far as they are able to do so, and to make a full record of the discussion with the patient.
Hygienists and therapists can diagnose within their scope of practice and competence, but even those practising under direct access cannot, and would not be expected to, make a diagnosis beyond their scope of practice.
25. Could the role of a dentist change if dental care professionals are treating patients direct?
It is too early to tell what effect direct access will have on the traditional relationship between patients and dentists. Any changes would be subject to many factors such as the setting in which the dentist works, the location, how many DCPs do, or will practice independently nearby, and any referral arrangements with DCPs. If dentists have referral arrangements with DCPs then there may be an increase in requests for second opinions, prescription requirements or direct referrals due to treatment required being outside of the DCP’s scope of practice. This is especially the case in areas where patients who have not had dental treatment for a significant amount of time, choose to get back into the dental healthcare system through direct access.
Should the types of appointments and patients change as a result of a colleague practising direct then this may provide more appointment time for complex and specialised treatment that can only be carried out by a dentist.
26. How does a patient know which dental professional they can see direct?
It is unlikely that the majority of patients will know about the changes for some time until it crosses into the care that they need or are looking for. Practices which offer treatment via direct access should make sure that their practice publicity (e.g. leaflets, brochures and websites) is clear about what treatments are available, the arrangements for booking an appointment and what will happen if the patient needs treatment which a dental care professional cannot provide. It would also be helpful to have clear information prominently displayed in the practice about members of the team and their roles.
27. Will the GDC be keeping a record or annotating the register to identify those who can have direct access?
No. Relevant dental care professionals can see patients direct if are trained, competent and indemnified to do so, and work within their scope of practice.
28. Will a newly qualified dental hygienist be able to open a practice?
Yes – but then DCPs were able to own practices before direct access and could see patients referred to them by dentists. A DCP seeking to open a DCP-only practice must work within the limits imposed by current legislation and regulations (see questions 13, 14 and 29 for examples).
It is also recommended by the GDC and some professional associations that newly qualified dental hygienists and hygienist-therapists should spend a period after qualification practising on prescription which will help to build a registrant’s confidence and experience before practising direct.
29. Will DCPs have to register with any other body or regulator?
Dental hygienists and dental therapists who set up their own practices in England need to register with the Care Quality Commission, and those in Northern Ireland with the Regulation and Quality Improvement Authority. Dental care professionals in Wales are currently unable to register with Health Inspectorate Wales, although the relevant regulations are currently under review. Health Improvement Scotland has not yet announced when it will begin registering private service providers in Scotland.
DCPs seeing patients direct in an existing practice already registered with the CQC or equivalent body do not have to register with any other body or regulator.
30. Will dental care professionals need different or additional indemnity cover?
All registrants should ensure that they are indemnified for any tasks that they undertake. Therefore dental care professionals planning to offer treatment and services direct to patients should check with their indemnity provider that they have appropriate indemnity; whether it is for certain tasks or, in the case of dental hygienists and dental therapists, for the whole scope of practice and to provide treatment direct.
31. What happens with patient records?
Every dental professional is responsible for keeping accurate patient records. If a patient needs to be referred then relevant clinical information, including copies of radiographs, should be provided with the referral.
DCPs who are setting up their own, independent practice could find that their status with regards to data protection law will change and they will have more responsibility. As with all laws and regulations that affect their work, DCPs should remember to check how data protection laws apply to them in their new role.
32. What about medical emergencies?
All registrants must be trained in medical emergencies, including resuscitation. Direct access does not alter this requirement.
What may change, however, are the roles that members of a dental team take in the event of a medical emergency. For example, in the event of a medical emergency in a practice, a dentist might lead the response and a dental nurse assist. If this dental nurse is providing care outside the usual surgery arrangement, the nurse's role may change, and may be more significant. Members of the dental team must ensure they are sufficiently trained and competent to take on the medical emergency role which their new work setting may require.
You must follow the guidance on medical emergencies and training updates issued by the Resuscitation Council, so please visit their website for the latest training requirements.