Introduction

The British Society of Dental Hygiene and Therapy (BSDHT), in collaboration with the British Association of Dental Therapists (BADT), is currently going through a robust process of applying for prescribing rights with exemptions, for the benefit of all members of the dental team and, most importantly, for patients. This was reported in BDJ Team in June (http://go.nature.com/2srBfma).

Credit: ©William Perugini/Cultura/Getty Images Plus

Immediate BSDHT Past President Michaela ONeill is working closely with BADT Immediate Past President Fiona Sandom as joint project lead. Dental Health (DH) caught up with Michaela (MON) and asked if she would mind explaining the process.

NB: Dental Health is BSDHT's scientific journal: http://www.bsdht.org.uk/publications/dental-health.

DH: Michaela, BSDHT is engaged in a process to obtain prescribing rights, for which we have asked our members for help and support. Can you please explain what you mean by ‘exemptions’ in relation to prescribing for our patients?

MON: Having exemptions in place means that our profession would be exempt from needing a prescription for certain prescription-only medicines (POMs). So we could use anything on our list of exempt medicines (after certain training) in our daily practice without a prescription, Patient Specific Directive (PSD) or Patient Group Directive (PGD).

DH: It seems ludicrous that we are unable to prescribe local anaesthesia (LA) or fluoride varnish. Why can we not prescribe in the same way a dentist does?

MON: Unfortunately, we don’t have the same capacity that doctors and dentists do. No Allied Healthcare Professional does. We cannot prescribe LA and then use it on the patient, as a dentist does. If we had independent prescribing the patient would have to take the prescription we have written to a pharmacist and then return with the required LA for us to use. This is quite a convoluted procedure and not conducive to a time managed clinic.

DH: Having the ability to prescribe the necessary medication and medicaments is obviously essential. Can you share some of the background to the process?

MON: The 1999 Crown ‘Review of Prescribing, Supply and Administration of Medicines’ was pivotal in expanding medicines mechanisms of supply, administration and prescription to non-medical statutory regulated professions. This work led to a revision of the medicines legislation, both in respect of available legal frameworks and specific professions entitled to work under the arrangements. Ultimately this was for the purposes of ‘bringing advantages to patient care, including timely access to treatment, a reduction in patient waiting times and an appropriate use of professional skills’ (Crown 1999).

After a few years of lobbying for a change in the dental hygienist and therapists’ ability to use POMs, BSDHT and BADT jointly met with NHS England and were included in a scoping project to assess if our professions’ needs in this area warranted inclusion in the next batch of proposals to change the legislation.

In January 2016 BSDHT and BADT started working towards exemptions by gathering information and putting together a case that exposed the limitations of our existing arrangements. Our needs were explained by examples collated by both professional organisations.

As a result of an internally commissioned Chief Professions Officers’ Scoping Project: Medicines Prescribing, Supply and Administration Mechanisms (2009), a number of recommendations were made for further work.

A report from the programme board recommended that a number of healthcare professions be considered for supply and administration of medicines mechanisms, with prioritisation being given to professions which would demonstrate benefits to a wide patient population and are aligned with the Five Year Forward View and NHS England's business priorities for 2017/18, resulting in a decision to progress the work towards the use of exemptions by dental therapists and dental hygienists.

The results of this identified that we were to go through to the next stages in a stream of Allied Healthcare Professionals (AHPs) called phase A. There were other AHPs in the scoping project that have been allocated different phases. We were one application in a group of ten from various AHPs undertaken by NHS England and Chief Professionals Office who are the programme board.

There are ten professions at various stages of application for either prescribing responsibilities or supply and administration of medicines at this time. Currently:

  • Paramedics and diagnostic radiographers are applying for independent prescribing

  • Pharmacy technicians are going through a scoping project

  • Physiotherapists and podiatrists are reviewing the limited drugs they can independently prescribe

  • Paramedics are reviewing their exemptions list

  • Clinical scientists, biomedical scientists and ODTs are applying for PGD

  • We are applying for exemptions.

DH: Can you tell us who will be involved and working on our behalf?

MON: The professional bodies represented on the programme working group are responsible for the collection and collation of the relevant information. This comprises: Senior Responsible Owner, Janet Clarke Deputy CDO England; a programme lead; a programme manager; professional bodies representation, Fiona Sandom and myself; a programme co-ordinator and a programme officer. NHS England Medical Directorate has financed the project for all except the professional bodies’ time.

Janet Clarke will also represent our working group on the programme board which is responsible for steering all of the various applications through this process.

DH: What are the main objectives of this working group?

MON: We have identified several objectives. Essentially, the project will:

  • Engage experts and resources to work up a clear case of need which will include an outline of clear accountability and governance arrangements for use of exemptions

  • Define clear scenarios where the use of exemptions by dental therapists and dental hygienists would benefit patient care without compromising safety

  • Build the case for change and opportunities for improvements associated with the use of specific exemptions in medicines legislation by dental therapists and dental hygienists

  • Gain confirmation from NHS England medical directorate senior management team that the case of need is aligned with NHS England objectives and priorities

  • Have the proposal considered by the Department of Health Non-Medical Prescribing (NMP) board to prepare a case for presentation to ministers to gain approval for further work to be undertaken to progress to public consultation

  • Undertake a public consultation and present the findings to both the NHS England medical directorate senior management team and the Department of Health Non-Medical Prescribing board, to support changes to medicines legislation

  • Present the case for change to gain approval for changes to medicines legislation to the Commission on Human Medicines (CHM).

DH: This looks like a lot of work. What happens next?

MON: It is! And there are six more stages in this process. The next stage is to demonstrate a case of need and for this we will be calling on our members for help.

We need an overview of our profession to give context. This will include: population demographics, professions settings (private, mixed, NHS, special needs, etc) policy, oral health statistics, impact of poor or delayed access to dental services and its strain on healthcare.

An explanation of our profession is required, including statutory regulation, numbers in professions, how we are regulated, education pathway/entry to register, and annotation of further qualifications, etc. We also need to address our professional body's membership, purpose, standards, education, etc. Also the role of the dental hygienist and dental therapist to include any specialist/advanced practice roles, the workforce of the future - including how exemptions would enhance role and patient care.

We need to look at what we use currently for medicines and give evidence of its strengths and weaknesses plus draft a list of medicines to be used under exemption and categorised.

Then we need to look at patient safety, how to improve safety with medicines, the training needed both postgraduate and undergraduate, indemnity, governance, evidence of our existing safety record and especially any medicine related errors with guidance on how this will be avoided in future.

As this is funded largely by NHS England we need to assess value for money and productivity to demonstrate how exemptions will improve value for money.

To do this we will need evidence and case examples from our members.

This piece of work then goes through an approval process where the AHP Medicines Programme Board, NHS England internal approval process and the Department of Health Non-Medical Prescribing Board assess the case before referring to receive Ministerial approval to commence preparation for a public consultation.

DH: Once you have completed each of these stages are we then able to prescribe?

MON: No, I am afraid we are not finished yet. We then go to public consultation - a UK-wide public consultation which is usually 12 weeks in duration - and in preparation for that we must pull together a consultation document.

Again this will involve many agencies including patient and public engagement exercises. There will be another approval process by AHP medicines programme board, DH NMP board, NHS England internal approval process and Ministerial approval.

Once the consultation has been approved and the 12 week period completed then the Commission on Human Medicines (CHM) will assess it. For this presentation of consultation findings and case for change patient safety is paramount.

Following this, recommendations will be made to Ministers regarding changes to legislation in line with our proposal. Then we await the Ministerial decision and announcement. There will need to be changes made to regulations matters for each of the devolved administrations.

The Home Office (Advisory Council on the Misuse of Drugs) then follow a process of implementation and evaluation. They will publish a summary of consultation findings and final versions of supporting documents, raise awareness with key stakeholders, troubleshooting – questions and queries and commission research to evaluate impact of legislative change.

DH: This is obviously a task that will take a great deal of commitment and skill.

MON: As you can see it is not an easy process and there are many levels where we may need more time. We do expect this to be a more concise effort as we can learn from previous projects.

We are fortunate in our profession that we have many skilled individuals who are happy to help where needed but in order to run the project both societies voted to retain their past presidents to lead. During our terms of office as Presidents of our respective organisations, Fiona Sandom and I were involved at the beginning and our experience in the process and knowledge of the profession will be put to good use. We also have the benefit of orthoptists’ experience, who have recently achieved their goal of exemptions, and will be working closely with them.

DH: Ultimately, who will fund this process?

MON: NHS England will fund most of the project except for the professional body's involvement, which is traditionally funded by the professional body. After some discussion BSDHT felt that our society should not be solely responsible for funding this project. The ability to use certain POMs without a prescription will benefit not only our members but all dental hygienists and therapists in the UK plus many employing dentists. For this reason BSDHT and BADT collectively decided to raise some money via the JustGiving site.

NHS England has donated a sum of money. After some rough calculations it was proposed to find at least £50k to employ someone for two days a week for a two year period, plus have some residual for the necessary PR, travel, administration, banking, extras, etc. We know the workload will be more than two days a week from listening to other professional bodies who have gone through this process. If we are fortunate enough to have money left over we will use this to subsidise some education for our members.

Credit: ©Agence Photographique BSIP/Corbis Documentary/Getty Images Plus

DH: It would appear that you and Fiona have your work cut out for you. How can we help?

MON: Your help is essential to a task that will benefit all members of th dental team and, most importantly, our patients! There is lots that you can do:

Please email prescribing@bsdht.org.uk with your experiences of not having a suitable prescription and the impact it had on you, your patient and your practice. Speak to your colleagues, find out if this has affected them and tell us about it. There are no guarantees we will get what we want but we have to fight hard for what we need; please help us work hard to provide evidence for the future of our wonderful profession.

Philips Oral Healthcare will donate £2 to our campaign for every dental hygienist and therapist who enters their Shine On competition (http://go.nature.com/2w3y96i), or posts on social media (Twitter/Instagram only) using #Shineon, up to a total donation of £10,000. In addition, in every goody bag given away at Shine On events, and through Philips territory business managers, they will include a bespoke postcard explaining their support for the Subscribe to Prescribe campaign and encouraging everyone to enter it or post on social media to increase their donation.

If you are not already a member of your professional body, sign up. The more members we represent, the stronger our case of need.

Visit the BSDHT and BADT websites and keep up to date with our campaign: www.bsdht.org.uk / www.badt.org.uk

Further information

MECHANISMS FOR THE SUPPLY AND ADMINISTRATION OF MEDICINES

There are different mechanisms that can be used for the supply and administration of medicines:

  • Patient Specific Directions (PSDs)

  • Patient Group Directions (PGDs)

  • Exemptions (from the Human Medicines Regulations 2012).

And to prescribe medicines:

  • Supplementary prescribing

  • Independent prescribing.

We have had the ability to use PSDs (these are written instructions from a prescriber, for medicines to be supplied or administered to a named patient).

Many of us work to a PSD in practice but they need to be ‘specific’ and have no scope for a patient's changing need. They also do not support autonomous practice.

PGDs are a written instruction for the supply or administration of a licensed medicine (or medicines) in an identified clinical situation, where the patient may, or may not, be individually identified before presenting for treatment.

A PGD must be agreed/signed by a dentist and a pharmacist who is suitably experienced in PGDs and each PGD must be approved by the organisation in which it is to be used (hospital, clinic).

Training to use a PGD must be undertaken by anyone working with one. They do have their limitations and one of the major ones for dental practices in the UK is finding a suitable pharmacist to help develop one. They are time consuming to develop and approve, and require review every 1-2 years. In some clinical settings, the number of PGDs required makes the mechanism difficult to implement and impractical to administer.

As a society and in conjunction with BADT, BSDHT decided to pursue Exemptions. This means that we will be exempt from needing a prescription for certain medicines that have yet to be decided on. The decision on the type of drugs will come later in the process and we will need members’ input on this also. They will likely include LA, topical anaesthetic, fluoride and other daily POMs that we use in NHS treatments.

An exemption enables the relevant health professional to supply and/or administer the specific medicine listed in the exemption without a prescription. It is applicable to all the workforce where there is an identified need and can be included in undergraduate training over time.

As with any new responsibility there will be a need to update and train in the necessary discipline.