Direct Access. What doe this mean? What are the advantages? What the disadvantages?

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2 Direct Access What doe this mean? What are the advantages? What the disadvantages?

3 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.

4 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

5 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 within their scope of practice

6 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

7 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

8 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)

9 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

10 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

11 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

12 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

13 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

14 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 services under the new contract?

15 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 that your employer is vicariously liable

16 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 responsible for your own acts and omissions.

17 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 without obtaining it.

18 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 Some Deaneries do provide VT scheme for DT

19 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). Dental Protection agrees

20 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 2. A patient group direction (PGD)

21 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

22 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.

23 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

24 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 Contact indemnity provider for further advice

25 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 number

26 Prescription LA Botox Restrictions remain on the prescription of radiographs by hygienists unless they are compliant with the core requirements of the IRMER and are confident to do so

27 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

28 BSDHT Panel 2013 Direct access - for or against For: 85% Against: 15% Do you believe patient safety is a major issue? Yes: 46% No: 46% Don t know: 9%

29 BSDHT Panel 2013 Would you consider opening your own private practice? Yes, definitely: 24% Maybe: 33% Not sure: 13% No, never: 30%

30 BSDHT Panel 2013 Have you experienced access problems? (i.e. have patients turned up to see you for their appointment only for you to find you have not got a valid prescription?) Often: 47% Occasionally: 35% Rarely: 14% Never: 5%

31 BSDHT Panel 2013 Would you consider accepting an NHS performer contract (as the contract stands right now)? Yes: 22% No: 42% Don t know: 35%