Direct access – a fine balance
In another article from Dental Protection, dento-legal adviser, Joe Ingham, investigates if direct access is on the right track when it comes to patient care and the working patterns of the dental team.
Dental Protection has experience of direct access in countries where it has existed for some time, such as Australia. The decision not to increase UK subscriptions for dental care professionals (DCPs) operating under direct access arrangements has been truly vindicated.
So far, there has been no evidence of any increase in the number of complaints or negligence claims when working under direct access.
The dichotomy between providing ethical healthcare to patients and running a viable business is an ever-present conundrum for practice owners. A balance has to be found between making a profit and delivering the highest quality care, irrespective of any financial cost to the practitioners involved.
To claim payment for activity under the present NHS arrangements, it is a requirement for the patient to be examined by a dentist who is on the NHS Performer’s List. Currently, it is not possible for a hygienist or therapist to be on that list.
Dental Protection has received numerous enquiries from worried DCPs who have been asked by their practice owner to see patients for ‘check-ups’ in their own right, under direct access, with a view to claiming NHS activity in the form of UDAs (units of dental activity).
This is usually, though not exclusively, in relation to the treatment of children.
Dental Protection is keen to stress that this is a clear breach of NHS regulations and should not be encouraged. Activity accrued in this way would be subjected to a claw back of fees – if and when it came to light. There could also be sanctions for both the dentist and DCPs if the GDC (General Dental Council) became aware of the situation. It would almost certainly include a charge of dishonesty that, in turn, could put a GDC registration at risk.
Truly standalone hygiene or therapy practices are still relatively rare in the UK when compared to the more traditional dentist-owned practice. Nevertheless, direct access has no doubt helped those practices now able to see patients directly without needing a prescription from a dentist.
One such practice owner and hygienist member said: ‘Direct access has made my practising life much simpler from an administrative point of view. I was recently able to accept a family of five for hygiene treatment, directly on recommendation from an existing patient.
‘Prior to the introduction of direct access, I would have had to insist that they saw a dentist first and then wait for a written prescription for each of them. They regularly see their own dentist and are now happy for me to look after their hygiene requirements. I can easily liaise with their dentist if the need arises. I think that direct access has empowered patients in terms of choice.’
Anecdotal evidence would seem to suggest that the majority of care is still being delivered in the traditional practice setting in which dentists and DCPs work alongside each other. Some dentists initially feared that they would be undermined by the introduction of direct access and the notion that there would suddenly be a plethora of DCP-led direct access practices springing up, has simply not materialised. As previously mentioned, it would not be possible to provide NHS services in this situation, which means that any such practice would have to rely entirely on private income. Buying or setting up a dental practice remains a stressful and expensive exercise and not one without an element of financial risk.
There are some legal barriers that still prevent true direct access for patients. It seems that to a certain extent matters have been simplified, although the involvement of a dentist in the planning and delivery of a patient’s care is still required in most cases. It is important to realise that the GDC does not make ‘laws’ as such. The Medicines Act is an example of how regulation, enshrined in law can appear, at first glance, to be at odds with the implementation of direct access.
Local anaesthetics are classified as ‘prescription only medicines’ and as such may only be administered by a doctor or dentist. A DCP is not on the list of the professionals who may administer prescription only medicines of their own volition. They must rely on a written prescription (known as a patient-specific direction) from a dentist. There is, however, another way for DCPs to administer a local anaesthetic – by the use of a patient group direction (PGD). This extensive document allows certain prescription only medicines to be administered provided that certain criteria have been fulfilled. The difficulty is that patient group directions were designed for use in a hospital setting where a pharmacist is integral to the process of developing the direction. It has come to light that many practices are unable to secure the services and sign-off from a pharmacist which renders a PGD unworkable.
It should be remembered that European regulations insist that the first cycle of use for any tooth whitening substances containing more than 0.1% hydrogen peroxide has to be done under the direct supervision of a dentist.
There is also an on-going problem regarding the issue of radiographs. It appears that the training for hygienists and therapists varies considerably, depending on which dental school provided their training. The GDC is currently trying to assess exactly what training is currently being given with a view to clarifying the situation. Until such clarification is provided, Dental Protection would advise hygienists and therapists to exercise caution in relation to the prescription, interpretation and reporting on dental radiographs.
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