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GUIDANCE ON DIRECT ACCESS

‘Direct Access’ means giving patients the option to see a dental care
professional (DCP) without having first seen a dentist and without a
prescription from a dentist.

From 1 May 2013, some dental care professionals will be able to see
patients direct. This means that the requirement to carry out certain
treatments under prescription from a dentist is removed.

This guidance note explains to registrants what will and will not change
with direct access and sets out what the GDC expects from registrants who
choose to practise in this way.

Dental hygienists and dental therapists

What it means
Dental hygienists and dental therapists will be able to carry out their full
scope of practice except toothwhitening without needing a prescription
from a dentist (more information about toothwhitening is set out below).
Providing treatment in this way will be an option and those registrants who
prefer to continue to provide treatment on prescription may do so.

Employers should not expect hygienists or therapists to see patients

direct if they do not feel confident to do so.

All registrants, including those operating in practices which provide

treatment via direct access, must act in the best interests of patients at all
times and comply with the GDC’s standards.

Training
Hygienists and therapists who wish to provide treatment direct to patients
must be sure that they are trained and competent to do so.

Those who trained since 2002 should find that their initial training
covered their full scope of practice. However, all registrants intending to
provide services direct to patients should review their training and
continuing professional development to assure themselves that they have
the necessary skills.

Indemnity
Registrants wishing to provide treatment direct to patients should confirm
with their indemnifiers or professional insurers that they are covered
accordingly.

April 2013
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Information for patients

Clear information for patients is vital. Practices which offer treatment via direct access should make sure that
their 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 hygienist or therapist; and
• what will happen if the patient needs treatment which the hygienist or therapist cannot provide.

It would also be helpful to have clear information prominently displayed in the practice about members of the
team and their roles.

Consent
Consent must be obtained from the patient for all treatment undertaken and for any referral to other
members of the dental team.

Diagnosis
Hygienists and therapists practising under direct access are not expected to make a diagnosis beyond their
scope of practice. They should refer to a dentist (or other relevant healthcare practitioner) when they identify
areas of concern or when treatment is required that is out of their scope of practice.

Referrals
Dental hygienists and dental therapists offering treatment via direct access will need to have clear
arrangements in place to refer patients on who need treatment which they cannot provide. In a
multi-disciplinary practice where the dental team works together on one site, this should be straightforward. In
a multi-site set-up where members of the dental team work in separate locations, there should be formal
arrangements such as standard operating procedures in place for the transfer and updating of records,
referrals and communication between the registrants.

Where hygienists and therapists choose to practice independently (i.e. in a situation where there is no dentist
as part of the team), 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. If a patient requires a referral to a dentist with whom the hygienist or therapist does not have an
arrangement, the DCP should set out for the patient, in writing, the treatment undertaken and the reasons why
the patient should see their dentist.

In all cases, the need for referral should be explained to the patient and their consent obtained. 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 to a dentist, the possible consequences of this should be explained to them and a
note of the discussion made in the patient’s records.

April 2013
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What is not covered

The changes made by the GDC do not extend to certain areas of practice which are governed by other
legislation which the Council does not have the power to change. The following areas of treatment still require
the prescription of a dentist:
• Toothwhitening;
• Radiographs;
• Carrying out Botox treatment

Local anaesthesia requires either a prescription or a Patient Group Direction.

Further information on each of these is set out below:

Toothwhitening
Under the Cosmetic Product (Safety) (Amendment) Regulations 2012, products containing or releasing
between 0.1% and 6% hydrogen peroxide can only be sold to dental practitioners and can only be made
available to patients following an examination, with the first episode of treatment being provided by a dentist,
or by a hygienist or therapist under supervision of a dentist (i.e. within the same dental setting). After this the
products can be provided to the patient to complete the cycle of use. This means that dental hygienists and
dental therapists will still need to carry out toothwhitening on prescription from a dentist and that a dentist
should be on the premises when the first treatment is carried out.

Prescribing radiographs
The Ionising Radiation (Medical Exposure) Regulations 2000 or IR(ME)R recognise some professions as
operators (i.e. as being able to take radiographs) and some as prescribers. Dental hygienists and dental
therapists are recognised as operators but not as prescribers. The GDC considers that prescribing
radiographs is an appropriate additional skill for hygienists and therapists but, at present, the dentist remains
the only member of the dental team who can prescribe radiographs.

Local anaesthesia
Local anaesthetic is a prescription-only medicine (POM) which means that under the Medicines Act 1968 it
can only be prescribed by a suitably qualified prescriber – usually a doctor or a dentist. However, it can be
administered by both dental hygienists and dental therapists either under a written, patient-specific
prescription or under a Patient Group Direction (PGD).

A PGD is a written instruction which allows listed healthcare professionals to sell, supply or administer named
medicines in an identified clinical situation without the need for a written, patient-specific prescription from an
approved prescriber. PGDs can be used by dental hygienists and dental therapists in:
• NHS practices in England, Wales and Scotland and their equivalent in Northern Ireland;
• Private dental practices in England registered with the Care Quality Commission;
• Private dental practices in Wales providing the individual dentists are registered with the Health
Inspectorate Wales;
• Private dental practices in Northern Ireland registered with the Regulation and Quality Improvement
Authority;

PGDs cannot currently be used in private dental practices in Scotland although this is due to change once
there is a commencement date for their registration with Health Improvement Scotland.

Further advice on PGDs and the regulations relating to them can be obtained from your indemnity provider or
professional association.
April 2013
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Fluoride supplements and toothpaste

PGDs can also be used to allow dental hygienists and dental therapists to sell or supply fluoride
supplements and toothpastes with a high fluoride content (2800 and 5000 parts per million).

Botulinum Toxin (Botox®)

The administration of Botox is not the practice of dentistry and so it does not appear in the GDC’s Scope of
Practice document. Botox is a prescription-only medicine (POM) and needs to be prescribed by a registered
doctor or dentist who has completed a full assessment of the patient. Hygienists and therapists cannot,
therefore, carry out Botox treatment direct.

Injectable dermal fillers

Injectable dermal fillers are classed as medical devices and so do not require a prescription. Hygienists and
therapists who choose to provide these treatments to patients must be sure that they are trained, competent
and indemnified to do so.

Registration with a systems regulator

Hygienists and therapists who set up in independent practice will need to register with the Care Quality
Commission (in England), Health Inspectorate Wales (in Wales) or the Regulation and Quality Improvement
Authority (in Northern Ireland) as appropriate. Health Improvement Scotland has not yet announced when it
will begin registering private service providers in Scotland.

NHS Contracts
Current legislation does not provide for hygienists and therapists to hold health service contracts. There will
need to be changes to the regulations governing the provision of NHS treatment in England and Wales, while
Scotland and Northern Ireland would require changes to primary legislation should their legislative bodies wish
to facilitate direct access under the NHS and its equivalent in Northern Ireland.

Experience requirement
There is no requirement for a hygienist or therapist to have been in practice for a certain amount of time
before providing treatment direct to patients. However, registrants who wish to practise in this way should
review their training, skills and continuing professional development to be sure that they are confident that they
have the skills and competences required. While it is not a requirement, a period after qualification spent
practising on prescription will help to build a registrant’s confidence and experience before practising direct.

April 2013
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Dental nurses

Dental nurses can see patients direct if they are taking part in structured programmes which provide dental
public health interventions.

Dental nurses who wish to practise in this way should be sure that they are trained, competent and
indemnified to do so.

Training can be external and accredited, or could be carried out in-house. If training is not externally accredited
in some way, it should be recorded and verified by the registrant providing the training, for example by
completing a log book.

If a dental nurse applies fluoride varnish to a patient as part of a structured programme, he or she should
advise the patient to inform their dentist (if they have one) that they have been treated under the programme.

Orthodontic therapists
Most of the work of an orthodontic therapist will continue to be carried out on prescription from a dentist.

The change is in relation to Index of Orthodontic Treatment Need (IOTN) screening. From 1 May 2013,
orthodontic therapists will be able to carry out IOTN screening as part of a structured public health programme
led by a specialist in orthodontics, a consultant in Dental Public Health, a specialist in Dental Public Health or a
general dental practitioner.

Orthodontic therapists who wish to carry out IOTN must be sure that they are trained, competent and
indemnified to do so.

Training can be external and accredited, or could be carried out in-house. If training is not externally
accredited in some way, it should be recorded and verified by the registrant providing the training, for example
by completing a log book.

Dental technicians

There is no change in relation to dental technicians, who will continue to carry out their work (other than
repairs) on prescription from a dentist or a clinical dental technician.

Clinical dental technicians

There is no change in relation to clinical dental technicians. They will continue to be able to treat edentulous
patients direct for the provision and maintenance of full dentures. Otherwise they will continue to work under
prescription from a dentist for dentate patients.

Dentists
Dentists remain the only member of the dental team who can carry out the full range of dental treatments and
prescribe radiographs, local anaesthesia and a full range of prescription only medicines.

April 2013