Navigating direct access as a dental therapist

Dental therapist and reader panel member Cat Edney explores becoming a direct access dental therapist and how to find your perfect pathway.

The author (left) with colleague

What is direct access?

Direct access was brought in following consultation by the General Dental Council (GDC) in 2013. Its purpose was to allow patients to see dental hygienists and therapists without having to see a dentist first. There were long discussions and many studies reviewed in order to reach the decision that dental hygienists and therapists could indeed examine, diagnose and provide treatment within their scope without the requirement of a referral from a dentist.

Since this ruling, many dental hygienists and therapists have gone on to successfully provide direct access treatment. Additionally, direct access has served to improve working relationships between dental care professionals (DCPs) and general dental practitioners (GDPs) due to the removal of the requirement for the dentist to provide a full and exhaustive treatment plan. However, trends still seem to favour direct access working for dental hygiene treatments over the additional skill set of dental therapists.

Why would you work in this way?

For many dental hygienists and therapists direct access was a big step forwards for the profession. Being able to treatment plan for themselves and provide the level of care and type of treatment they believe was in the best interests of the patients meant that they had autonomy and direction. Also, direct access gives the individual more ability to market themselves, increase income and develop their career. For practice owners it's a wonderful way of increasing productivity, supporting GDPs and boosting the patient numbers in practice.

Many dental therapists have cited lack of support as the reason why they often do not provide dental therapy services under direct access; however, during my research for this article I was very fortunate to speak with a number of dental therapists who are making direct access work for them and all with varying structures. Support for therapists is growing and confidence within the profession is too, with more and more therapists undertaking postgraduate training and hands-on courses.

Illustration: Direct access

Different direct access dental therapy working structures

Not all direct access hygienists and therapists work in the same way - the key is finding a working arrangement that works for you. Having extensively researched and spoken with numerous successful therapists about their structure, I have outlined some that seem to work well (further on in this article).

It is worth noting at this point that for most, having the support of an understanding and forward thinking dentist is invaluable. In order to achieve this, it could take a number of conversations, meetings and work on practice standard operating procedures - expect to put the time and effort in to these processes and make it clear from the start what your goals are. The key is coming to an understanding as to how this will work for you, your colleagues and your patients.

The full scope therapist

• Will conduct a full exam and radiographs

• Treatment plans all work within scope

• Refers to GDP for out of scope work - crowns, bridgework, implants and dentures

• Will refer complex cases to GDP on site.

The benefits of this are the chance to have a challenging and well varied working career. A good relationship with a busy GDP is essential - they will be given the opportunity to focus on more complex treatment and maximise their diary potential.

The cosmetic therapist

• Limits practice to cosmetic treatments - such as anterior composite bonding

• Conducts a full exam and radiographs but refers to GDP for hard tissue disease management prior to starting cosmetic work

• Markets as cosmetic and therefore attracts the patients that want this type of treatment

• Provides all additional periodontal treatment required prior to cosmetic procedures.

Great communication with the GDP is essential; the patients are often high expectation patients and team working is key. The GDP benefits from the referral, and in return is happy to treatment plan and prescribe for whitening procedures.

Working under direct access does not have to mean that you take on responsibility for all the treatment required by the patient, rather that you can signpost patients to other professionals...

The paediatric therapist

• Works alongside GDPs who are busy and find paediatric work more time consuming

• Is presented by the practice as providing children's check-ups and treatment in addition to adult periodontal care

• Will conduct full exam and treatment plan for deciduous teeth - referring any treatment they are unsure of.

Less support required by GDPs - referrals are often only made if there are congenital hypodontia issues or once ortho care is to be considered.

This sets more clearly defined boundaries with treatment within the practice but can be limiting for a therapist wishing to utilise their full scope.

The independent therapist

• Practice owner - usually working to full scope. Will refer to local dental practices for out of scope work

• Often works alongside a GDP who is paid to come for specific 'prescribing' days in order to maximise treatments available - such as whitening or botox treatments

• Working in this way offers full control over practice protocols, marketing, and treatment delivery. It can mean more stress due to owning the practice but will likely mean better income potential and more autonomy.

How do you want to work?

It is firstly important to look at how you personally feel about your work. If you have strengths in a particular area - are these strengths because you have practised a lot or because you have a special interest in this area? Are there areas of your training that you would like to be doing more of but currently do not get the opportunity? By outlining where your strengths and abilities lie and what you have a passion for, you will be able to focus on what kind of treatments you would like to be providing. This is your starting point.

Working under direct access does not have to mean that you take on responsibility for all the treatment required by the patient, rather that you can signpost patients to other professionals for the treatment that you cannot or do not feel confident to take on, eg if you are not confident in your deciduous extractions you will refer on to your dentist.

How to build a pathway

Use your strengths and abilities to decide who your perfect patient is and work towards attracting these patients to you. Your marketing could be as simple as an addition to the practice website or you may wish to conduct your own.

Team training

Taking time out to engage with your colleagues and ensure they are aware of how you will work and what your practice involves is one of the highest priorities you should have. Making sure that all those around you are on the same page and aware of your processes and protocols will mean you are more likely to have a smoother patient journey overall.

You may wish to create a handy protocol for reception to follow when booking patients in with you, or some criteria may be helpful, for example in the case of the paediatric therapist.

Create your protocol with the help of your colleagues and make sure you answer any concerns or queries they have. Be open to adapting and adjusting your protocols following feedback from your colleagues also.

Consenting

Ensure you have information on direct access readily available on the practice website and in the waiting area. Have your consenting process in hand including written consent and a treatment planning process. Ensure that your team are aware of what consent is required for each possible scenario and decide how this will be recorded. It is helpful to digitalise your consenting process where possible so that your patient can access the information prior to the treatment date and be given a cooling off period.

Initial appointments

Decide on what you would like to achieve in your initial appointments - will this be an exam appointment only or will you include periodontal maintenance for patients? How will you express this to patients booking in? What length of time will you allocate to these appointments? If you feel you are unable to provide the service required by the patient will you still charge them for the time?

Will you provide direct access hygiene appointments separately and advise these patients to book with you for an exam if they need further care?

One example I found was a direct access therapist offering free mini smile makeover consultations. This ensured the patient was not out of pocket if deemed unsuitable but also they were booked in around the already successful hygiene diary.

Referrals

Decide what types of treatment you will refer and who you will be referring to. Ensure that this person is happy to accept referrals and find out what their process is - will they want to repeat a full examination for the patient; what will the cost of their consultation be? This information is important as you will need to relay this to your patients.

Follow ups

What happens if you have provided a comprehensive treatment plan but then never hear from a that patient again? Give consideration to how you will follow up these patients - it is great to have a protocol in place for this to maximise the number of patients who book with you - but also to understand the reasons why some people decided not to go ahead with treatment. Use follow ups as a learning tool. It can be helpful to discuss this with colleagues, especially your reception team, who often have insights into where patients are at with their dental treatment.

Cat Edney with a patient

Testimonials

Try to get some testimonials and reviews from patients you have treated in order to demonstrate to other prospective patients what level of service they can expect. Testimonials can be a great tool for attracting new patients to your service and also give patients confidence when booking with you.

Fostering relationships with other professionals

Being on the same page as colleagues is paramount - whether the individuals you are referring to are working within the same practice or not, make time to discuss cases with them, expect to answer questions about your treatment plan and try to take the time to understand their working processes. Having a great relationship in this way is in the best interest of the patients and can also help to build and reinforce your professional reputation. You may find the referrals start coming to you too.

Direct access working can seem daunting, especially for therapists who may not have worked or trained in this way. There are a number of courses aimed at dental therapists and hygienists to help guide them on clinical examination, record keeping, prescribing radiographs, hands-on courses for direct restorations and periodontal care. The opportunities for therapists wishing to work under direct access are growing and I see this mode of working as soon becoming the new normal. Planning and structuring a patient pathway is a key step to a reduced stress and fostering a successful and fulfilling direct access career.

CASE STUDIES

Emily Hatfield - Cosmetic dental therapist

I have found social media platforms a fantastic way of directly showing potential patients before and after pictures of cosmetic dental treatments. This has linked with patients accessing treatment through direct access and is the route through which most patients find me for starting treatments and joining the dental practices I work in for their long term dental care.

I have managed to streamline treatment which has enabled me to focus on the cosmetic dental work I love to carry out, including composite bonding and composite veneers.

I see patients as their first point of contact for their initial examination and assessment, discussing treatment needs and desires. I then refer patients to GDPs (traditionally GDPs had always referred patients to hygienists and therapists), creating a fluid treatment path which includes seeing me as a cosmetic therapist then seeing a dentist at the practice for treatment that falls outside of a dental therapist's scope of practice, such as a prescription for tooth whitening and for any restorative work (crowns, bridges, root canal treatments etc). After this stage of general dental care has been completed I then see patients to carry out their cosmetic composite bonding and/or composite veneer work. This streamlines the process and allows the GDPs I work with to carry out the advanced, profitable treatments and allows me to take patients through the cosmetic treatments they have sought when directly contacting me through social media.

Patients directly accessing treatment and working closely with dentists at the practice has allowed for us to really make the most of the role of a cosmetic dental therapist with great patient care and providing beautiful cosmetic results for patients. The whole dental team are included, enabling us to be time efficient utilising each team member's skills when treatment planning and carrying out treatment.

Rebekah Lemmon - Dental therapist/practice owner

Having my own practice allows me to work within my full scope of practice. I am administering treatment plans that I have devised and personally the experience is liberating in that I am able to set my own terms when it comes to decisions such as time in the chair per patient and fee setting. I believe that following my own approach creates a more positive experience for my patient list and is hugely rewarding from both a clinical and holistic perspective.

I have an agreement with a dentist who I book to come in on a regular slot to carry out the prescribing for teeth whitening or Botox treatments and I also refer patients to the same dentist for treatment that is out of my full scope of practice.

Being in control over the day to day running of the practice and shaping the direction of travel for my business is very exciting: the benefits far outweigh any associated negatives.

Undoubtedly, there have been many challenges in just getting to the start line with my new venture, and many will attest that owning a business can be particularly stressful at times. However, I have found that being in control over the day to day running of the practice and shaping the direction of travel for my business is very exciting: the benefits far outweigh any associated negatives.

Andrea Powell - Community dental therapist

I love my job. I work in a community setting treating under 18s, at risk patients and vulnerable adults.

I work as a dental therapist using my skill set to examine, treatment plan and treat my patients all under direct access.

Working under direct access, you have to have a level of self-belief and confidence in your skills; you have to know when to refer, who to refer and who to refer to.

In my NHS community practice, I work with the most amazing nurse who makes my day run smoothly.

Due to working in an NHS setting, we cannot take before and after pictures or use social media to promote our service, so our bedside manner and professionalism needs to spread the word for us.

I really enjoy treating children and showing them how things can be with the right advice; educating the parents and carers as well as the children is very rewarding.

Having the ability to work under direct access allows me to build a rapport with families and they know that unless there are problems outside of my scope of practice, they can continue to see me without having to encounter the wider dental team. Building trust and having that continuity of care is why my patients return to see me every few months.