Tom Norfolk, general dental practitioner and Vice-Chairman of the Dental Defence Union's (DDU's) board of management and Greta Barnes, senior claims handler at the DDU, explain some of the key considerations surrounding direct access and scope of practice.

figure 1
figure 2

At the DDU, we have recently received more queries relating to direct access and scope of practice following guidance issued by NHS England earlier this year.1

In 2013, the General Dental Council (GDC) introduced direct access, which was to enable patients to have access to dental hygienists and therapists without having to see a dentist first. Since then, many dental hygienists and therapists have gone on to successfully provide direct access treatment.

figure 3

©Malte Mueller/fStop/Getty Images Plus

However, for many years it was believed that the NHS regulations didn't allow dental hygienists and therapists to provide a course of NHS treatment under direct access, as the only person who could open a course of treatment was a dentist who had an active performer number. These regulations have now been clarified to confirm that dental hygienists and therapists can see NHS patients under direct access.2

With this in mind, the DDU recommends that a practice carries out a careful risk assessment before any hygienist or therapist starts providing NHS care under direct access. It's also important for both the NHS contract providers and/or practice owners and the dental hygienist or therapist to assess whether the work is within their training and competence.

Firstly, a dental professional must not undertake any treatment that falls outside the GDC's scope of practice for the relevant registrant group.

When the GDC issued its initial guidance on direct access treatment,3 it made it clear that dental care professionals (DCPs) should never be forced to provide treatment under direct access, so it's essential to consider if a DCP feels confident to perform the treatment even if it falls within their scope of practice. If treatment is not being carried out under direct access, there must be an appropriate referral from a dentist who has examined, diagnosed and treatment planned the patient.

Next, it is important to assess the training each DCP has received. There are additional skills a hygienist and therapist can acquire post qualification, so the treatments each hygienist and therapist can provide might not be the same. If an individual's training, and therefore competency, to carry out an investigation or treatment were later questioned (such as within the context of a civil claim, a coroner's court or a GDC disciplinary investigation), they might have to prove they had undergone formal, structured, assessed, and certified training in that area.

It's important for both the NHS contract providers and/or practice owners and the dental hygienist or therapist to assess whether the work is within their training and competence.

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 such a referral. 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.

Additionally, it is essential that the correct indemnity arrangements are in place. Under an NHS contract, the provider agrees to take responsibility for delivering it, including the quality of care delivered to fulfil their contractual obligations. At the 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 or under direct access. If a hygienist or therapist is going to treat patients under direct access, they need to inform our membership department before starting direct access.

Finally, remember 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.