On 1 May 2013, Direct Access was introduced by the General Dental Council as a direct result of a report by the Office of Fair Trading and following support for the proposals from the Westminster Government.
The decision, which effectively removed the restriction for some DCPs to treat patients without the prescription of a dentist, was met with equal parts enthusiasm and scepticism within the profession. Proponents saw it as recognition of DCPs’ ability and training, while others expressed concerns, not least the British Dental Association (BDA), which said the GDC’s decision was “misguided and undermines best practice in patient care”.
Nearly 18 months after the restrictions were removed, how has Direct Access affected dentists, DCPs and patients in Scotland? Scottish Dental brought seven dental professionals together to discuss their experiences of Direct Access in practice, as well as what they see as the potential stumbling blocks to wider acceptance.
As a dual-qualified hygienist/therapist, Lorraine Keith nailed her colours to the pro camp early on, pointing out that her students follow the same intended learning outcomes as BDS students. She said: “I know that, through these intended learning outcomes, we are meeting the criteria that will more than adequately provide the education and enough experience for a hygienist/therapist to undertake Direct Access within their scope of practice.”
Carol Clark, who has two Direct Access clinics within dental practices in Tayside, indicated that although she has relished the challenge of setting up on her own, her years of experience have been invaluable.
“If I was newly qualified, I think I might have thought that I have bitten off more than I could chew,” she said.
“I think my experience has definitely helped and it has opened up new doors for the dentists I’m working with as well. If a patient doesn’t have a dentist, I can strike up that conversation with them.”
Carol explained that of 130 patients currently on her books, only 10 weren’t registered with a dental practice when they came to see her. She has managed to encourage eight of those to register with a practice and the two remaining are severely dental phobic, but she has hopes of convincing them in the future.
And, while many dentists have started referring to her, she is still encountering some resistance from practices. She said: “I’m not trying to take business away from the dentists with hygienists – that’s not my remit. I just want to give an option, another service for the patient.”
However, the lack of referrals is not the only stumbling block. “Even buying emergency drugs is an issue,” said Carol.
“Because I am not a dentist, I can’t buy emergency drugs. I also tried to refer a patient to Dundee Dental Hospital and I was told that they didn’t think that I could do that.”
Margaret Ross, senior lecturer for dental care professionals at the University of Edinburgh, replied that she certainly should be able to.
“So there are all these things that have to be ironed out,” said Carol. “Because it is a bit unfair. The patient had to write a report out and then his dentist referred him to Dundee Dental Hospital.
“There just has to be a lot more clarity of what we can and cannot do and how we put the patients first.”
Edinburgh dentist Stuart Lutton said that, while he can see the positives in Direct Access, he wasn’t convinced it provided the “gold standard” for patient care. He added: “I think to control things for a perfect patient journey, you could have Direct Access, but I’d prefer it all within one practice.
“So, it is all treatment planned from the dentist to a certain extent and somebody can monitor things, ultimately be in control and make sure that the quality is controlled in house.”
He revealed that he has worked with fellow Round Table panellist Robert Leggett and had a very positive experience of his CDT practice: “I do feel it can work very well where patients – who might not have come to see a dentist in the first place – can see Robert, and it has opened up avenues where they have been accepting to other types of treatment.”
However, he insisted that it would be preferable if Robert’s position was inside a bigger practice where “he has also got the support network of the practice around him, and he doesn’t feel so isolated and remote”.
Lorraine took issue with Stuart’s implication that dentists should always oversee the work that DCPs carry out.
She said: “I think that is undermining to us, as a profession, that you have to oversee any treatment which has been carried out by us to make sure it is of sufficient standard for yourself.”
To which Stuart asked: “But dentists’ work is monitored. If it’s a private setting for Direct Access, who monitors the patients?”
Lorraine and Margaret both pointed out that the DCPs would be both GDC-registered and a member of a protection society. “And, as a registrant, you are culpable for any treatment you have carried out,” said Lorraine.
Robert, who has two CDT clinics, one in Glasgow and another in Edinburgh, argued that one of the major stumbling blocks for him has been the lack of knowledge about what he actually does. He said: “The biggest problem I have as a CDT, and CDTs have in general, is that dentists and the wider dental profession know nothing about it. They have never been to a CDT practice and they don’t know what we are allowed to do. They have probably pictured in their mind that we have a chair in a lab somewhere that is dusted off and there is no support network.”
He explained that he has worked hard to build relationships with local practices and generate his own support network for his businesses, despite getting what he described as a “mixed response of either ‘that’s interesting’ or a shrug of the shoulders” from some of the dentists he visited.
Margaret then revealed that a recent study that she has been working on has shown that: “One year after Direct Access, there is still a huge lack of awareness of the clinical ability, competence and education of non-dentists who are undertaking dentistry.”
She said that she has still experienced VTs saying things like: “Hygienist/therapists don’t have the fundamental education to be able to treat patients as well as dentists can.”
She continued: “So, I think it is a case of creating an awareness and educating not only the public about the other people that are there and can provide clinical services, but also about educating the profession.”
Helen Kaney, dento-legal adviser based at Dental Protection’s Edinburgh office, stated that Dental Protection’s position is that as long as an individual is working within the guidance and their scope of practice – and are properly trained, competent and indemnified – it has no issue with Direct Access. However, she did admit that very few of her colleagues in Scotland knew of hygienists or hygienist/therapists who were working in a Direct Access situation. “So, we are all very curious actually as to how it is going and what the profession thinks of it,” she said.
She added that she understands the frustrations of DCPs who are not getting the referrals from dentists, but explained that dentists can only be invited, not required, to refer to a DCP working under Direct Access arrangements and that there may be very valid reasons why a dentist would choose not to refer, perhaps because the treatment required is available ‘in-house’.
Carol responded: “I think it is about building relationships and I think that trust h
as to be built. You have to be seen to be doing things that are correct. I will say to every patient who comes in, ‘Go back to your dentist and tell them about your experience.’”
Despite pointing out that he and his fellow dental technicians are probably the least affected by Direct Access, Leca Dental Laboratory owner Martin Leca supports it. “I think is a good thing,” he said. “I think it’s diversifying, it’s offering another avenue.
“My own opinion on Direct Access – and I get to to do this as I don’t have the same pressures that you guys have – is that we are all in this for patient care. It doesn’t matter that you are a therapist, hygienist, a CDT, dentist or a dental technician, the end goal is all about the patient and I believe there is a role for absolutely everyone within that.”
Robert then brought up the thorny issue of technicians working illegally. He said: “One of the difficulties we have is dental technicians working outwith their scope of practice as CDTs. The Fitness to Practise process doesn’t stop them working, and there have been lots of occasions where dental technicians have been in front of the GDC for working illegally and nothing happens.”
Martin agreed and described a meeting with a CDT at an event some years ago who boasted that “he had been fined eight times by the GDC, the fine was only £5,000 and he is making so much money that it was nothing”.
Robert sounded a note of optimism: “You would hope that dental technicians these days would go through the right avenues. I suppose that is all you can really do and these people who have been working
illegally will retire at some point. The market will take care of it as well, because, where would you rather go?”
The discussion then moved to the question that always seems to be asked around Direct Access: “What if somebody misses something like an oral cancer?”
Margaret answered: “Whether you are a dentist, hygienist, hygienist/therapist or CDT undertaking Direct Access, nobody can absolutely diagnose oral cancer without appropriate referral and investigation by a specialist. What you can do is detect something that deviates
from normality and know when to refer.
“And, if you speak to very high-powered people in the oral medicine world, they will tell you that it is often hygienists who have more time to look around the mucosa and identify abnormalities that may or may not be malignant.”
The question was then posed as to what the major stumbling blocks might be for the future of Direct Access. Helen said: “I’ve have two thoughts. One is the legal situation, in that Direct Access is not currently possible under the NHS in Scotland, and we will see how that evolves in the future.
“The second thought is the level of desire on the part of DCPs to work in that situation as there may well be management issues that not every DCP would want to deal with.”
Martin Leca then confirmed a concern highlighted earlier by Robert. He said: “I didn’t know fully what you [DCPs] did and I have been working in this industry for a long time. I had no idea.”
As well as raising awareness among dentists as to what a Direct Access hygienist clinic could do for their practices, patient awareness was a key concern for Carol. She said: “There are so many people out there who don’t understand what is going on in their mouths and why it is happening.”
Stuart reiterated his concerns from earlier. “I think I still have some uncertainty about who is ultimately responsible for the patient care,” he said. “Also, I think, as a business model I’m not sure how it can be viable as a stand-alone clinic.”
“From an education point of view, I still firmly believe that we should have teamwork as much as we possibly can. Nobody wants to break down teams with Direct Access at all – quite the contrary,” added Lorraine.
“And I think it is just people that need to learn a little bit more from one another about the benefits of things like Direct Access and the team’s qualities.”
Margaret moved to round up proceedings by highlighting a piece of research carried out by her colleague Steve Turner.
She said: “He completed an independent review of Direct Access, commissioned by the GDC, and found that there is no evidence of any detrimental effect to people out there by Direct Access and dentists not prescribing, treatment planning and so on. There is absolutely no evidence of harm to the patient, which is what we are all interested in.”
Margaret then summarised the debate by highlighting that there are still several issues that have to be addressed, particularly in relation to regulations which restrict Direct Access in an NHS environment.
“Given the fairly radical changes that have occurred in dentistry in terms of increased skill mix and changing workforce patterns, perhaps now is the time to consider the structure of services we provide,” she said.
“Only then can Direct Access be fully implemented in the way it was initially envisaged.”
Around the table:
Senior lecturer for dental care professionals and programme director of the BSc Oral Health Sciences programme at the University of Edinburgh.
Owner of Leca Dental Laboratory, Hillington, Glasgow. Qualified, GDC-registered dental technician.
Dually-qualified dentist and solicitor, now dento-legal adviser for Dental Protection, based in the Edinburgh office.
Clinical dental technician, studied on the first UK course in 2009. Owner of Scottish Denture Clinic, with practices in Edinburgh and Glasgow.
Sheffield graduate, former owner of Ivy Dental Practice, now dental associate at Ivy Dental.
Dental hygienist, qualified in 1981. Works in two Direct Access practices, one in Perth andone in Dundee.
Hygienist/therapist, qualified in 1995 in hygiene and 2006 in dental therapy. Outreach tutor in a large facility in Coatbridge and also an associate lecturer for Glasgow Caledonian University.