The legal eagle – skill mix and direct access

John Makin clears up some confusion about making effective use of direct access.

John Makin clears up some confusion about making effective use of direct access.

It is almost 10 years since the General Dental Council (GDC) abolished the requirement for a referral from a dentist before a patient could see a dental care professional (DCP). A decade on, there’s been a recent move to encourage the use of skill mix in NHS general dental practice.

Over the years since its introduction, the DDU has advised many dental hygienist and therapist members on a variety of topics relating to direct access.

As I explained last year, guidance in September 2022 by the Chief Dental Officer (CDO) prompted many more queries. Further guidance issued by NHS England in January this year has had a similar effect.

For many years, there was a general acceptance that NHS regulations didn’t allow dental hygienists and therapists to provide a course of NHS treatment under direct access, and that only a dentist with an active performer number could do so.

NHS England has indicated that this was based on a ‘widespread misunderstanding’. If suitably qualified, competent and indemnified, hygienists and therapists can provide NHS care under direct access.

However, the recent guidance is based solely on minor administrative changes and a new interpretation of existing NHS regulations. Thus, we would recommend a careful risk assessment by all parties before embarking on changes to working practices. 

Assessing competency for direct access

GDC guidance makes clear that DCPs shouldn’t have an expectation to see patients direct if they don’t feel competent doing so. The CDO guidance makes clear that contractors should have a ‘conversation’ with DCPs to ascertain levels of confidence and competence and to provide support. Assessing competency may require specific skills.

Responsibility for a course of treatment

Changes to the FP17 form mean DCPs can provide some or all of a course of NHS treatment and be identified by their GDC number.

However, the provider and possibly a dentist whose performer number is associated with the claim, will retain ultimate responsibility under NHS contractual complaints and disciplinary regulations for that course of treatment. This could be the case even if they have not seen the patient.

Referring on to a dentist

GDC direct access guidance makes clear that a dental hygienist or therapist treating patients who need care beyond their scope of practice or competence must have an established pathway to refer those patients to a dentist.

Practices need to ensure sufficient dentist capacity so that such referrals are seen quickly enough for the course of NHS treatment, once opened, to be completed within a reasonable period. This may be challenging if access to an NHS dentist is scarce – one of the very reasons for the initiative.

Informing direct access patients

Patients should be given full information before and when booking a direct access appointment. That way, they know who they are seeing and the possible limitations. There should be clear and consistent communication across the whole practice team to try and prevent any confusion arising.


Working under direct access, whether patients are treated privately or under NHS arrangements, has no impact on DDU members’ subscriptions. We simply ask that they let us know and there is no charge for this. 

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