Direct Access
What doe this mean?
What are the advantages?
Direct Access
It should be remembered that to ensure patient safety:
Must be trained, competent and indemnified for any tasks they undertake
Must continue to work within their scope of practice regardless of these changes
Must continue to follow the GDC’s Standards for the Dental Team
DCPs do not have to offer direct access and should not be made to offer it.
Direct Access
DH&T can carry out their full scope of practice without
prescription and without the patient having to see a dentist first
Must be confident that they have the skills and
competences required to treat patients direct before doing so
A period of practice working to a dentist’s prescription is a good way for registrants to assess this
Direct Access
Registrants who qualified since 2002 covered the full scope of practice in their training, while those who trained before 2002 may not have covered everything
DH&T will have addressed this via top-up training, CPD and experience
Qualified before 2002, or those who have not applied their skills recently, must review their training and experience to ensure they are competent to undertake all the duties
Direct Access
You no longer need a written prescription from a dentists before carrying out treatment for a patient
But without such a prescription you are wholly responsible for any diagnosis and treatment decisions that you make, and any treatment that you carry out
This arrangement is best suited to treatment provided privately since the current NHS contract still requires the patient to have been examined by a dentist if the treatment is being provided under NHS contract
Direct Access
The second change is that even if the dentists you work with are still referring patients to you, with a request to provide certain treatment, you are no longer limited to carrying out the treatment that they have asked you to perform
If you decide to carry out some kind of further treatment without reference to a dentist you would be personally accountable for those decisions as well as for the actual treatment
Literature Review
May 2012
Potential Benefits
:
Increased access to preventive and restorative care
No evidence of a risk to patient safety
High satisfaction among patients receiving care
from DCPs
Cost savings to the public and the public purse
(Turner et al 2012)
Literature Review
Potential risks and challenges
Some evidence of over referring from the DCP to
the dentist
Reported deficiency in knowledge and support to
patients regarding smoking cessation, diabetes
and child/domestic abuse (DCPs and dentist)
Poor knowledge regarding the implications of
direct access to DCPs among professionals and the
public
FGDP
“We have concerns about DCPs training to identify disease, communication with patients and the possible impact on patients' likelihood to keep up regular dental recall
appointments (which evidence shows improve oral health) and the transfer of patient information between practices”
Within a practice or a formal network we see fewer
problems and feel fairly confident that the partnership between dentists and DCPs on site or at satellite sites would maintain care standards. However with a total
separation of dentists and DCPs on the high street could affect continuity of care
Training and Referral
Identifying the training needs and limitations - screening for all oral diseases, communicating findings to patients, oral health promotion/disease prevention including links to other diseases in the body
Specifying the referral/collaboration required after DCP treatment so that patients don't 'fall through the gaps' of the system - continue visiting a dentist at recommended recall periods to manage their wider oral health
Clinical Governance
Robust system of clinical governance of DCP's
patient care including establishing the patients'
needs, appropriate examination, consent,
treatment outcomes, onward referral
Concerns regarding DCPs not following a care
pathway and implementing holistic prevention
protocol
Dental Nurses
Public health intervention programmes (eg in a school) are a broad-brush approach.
DN particularly effective at reaching those individuals or families who do not currently access dental services
regularly and in the context of offering advice on diet/oral
No perceived risks dental care from nurse led activity within these parameters
Questions Remain
How will Direct Assess fit into the new NHS
contract
How will it affect dentist manpower requirements
and workforce planning?
How will it affect the commissioning of DCP
Who is responsible?
Employed:
Any dentist who actually employs you can be held to be
vicariously liable for any negligent acts and omissions on your part
That remains the case even if patients see you without first
seeing the dentist, and even if the dentist is completely unaware of the treatment that you are providing for a patient
This does not prevent a patient suing you too (ie. naming you personally as a defendant to the claim), but it means that a claim against you can usually be successfully defended on the basis
Who is responsible?
Self-employed can’t demonstrate “master and servant” relationship, exists between you and the dentist
A true employer-employee relationship is one of several well-established ways of confirming the existence of such a relationship
No written prescription from a dentist - no form of “direction” sufficient to draw the dentist into legal proceedings
“Direction” is no longer a legal requirement, so if you
choose to carry out treatment in the absence of any such direction from a registered dentist you are solely
Consent
You should always ensure that a informed consent has been obtained from the patient (and/or parent in the case of a minor)
Whether or not you are working to a prescription
This is part of your duty of care to each and every patient you treat.
In this situation the responsibility to obtain a informed consent is wholly yours and you would be legally, ethically and professionally accountable if you treat a patient
Experience
Dentist foundation training (VT)
Many dentist feel that this 12 month period provides a welcome bridge between the relatively sheltered
environment of dental school and the more challenging situations
Not be obliged to undertake an equivalent year of foundation training
There was no legal mechanism for the GDC to make such a change
Experience
GDC’s view – although no formal requirement that newly qualified DH&T should take the opportunity to practise in a sheltered environment
Working on prescription in a supportive team for 12 months (GDC and BSDHT).
LA
The administration of local anaesthetics is governed by The Medicines Act 1968
GDC has no influence over this legislation and it is quite separate from the new direct access regulations
POM may be administered by a DH&T using
1. A patient specific direction (in other words a written prescription for that particular patient) or
Prescription
Tooth whitening
The Cosmetic Products (Safety) (Amendment) Regulations
2012 continue to determine the legality of providing tooth
whitening in dental practice
They state that products may only be sold to dental practitioners
The first cycle of use must be by dental practitioners or under their direct supervision- ie. that a dentist should be on the premises when the first treatment is carried out
Advertising
Clear information for patients is vital.
Ensure that practice publicity (e.g. leaflets, brochures and websites) is clear about:
What treatments are available via direct access
The arrangements for booking an appointment with a DH&T
What will happen if the patient needs treatment which the DH&T cannot provide
It would also be helpful to have clear information
prominently displayed in the practice about members of the team and their roles.
Referral
Where DH&T practice independently and there is no dentist present, 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
Should set out for the patient, in writing, the treatment undertaken and the reasons why the patient should see their dentist
Need for referral should be explained to the patient and their consent obtained
Referral
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, the possible consequences of this should be explained to them and a note of the
discussion made in the patient’s records
Examination
It is not currently within your scope of practice to see patients on either an NHS or private basis to perform
check-ups or examinations, regardless of the circumstances
It follows from this that at the moment you cannot provide check-ups for patients under your dentist’s performer
Prescription
LA
Botox
Restrictions remain on the prescription of radiographs by hygienists unless they are compliant with the core
Indemnity
No additional subscription increases are being made as a result of direct access
Different if you own and operate a practice, employ staff
and/or contract with third parties for the commissioning of services to be provided by others
Good practice to inform the indemnity provider
DCP (practice owner) that does not have a dentist within the team it is also necessary to ensure that their indemnity is sufficient for their vicarious liability as an employer as well as for their own clinical activity as a DCP
