Introduction

Dental team working where skill mix is widely used has been shown to be beneficial for individual clinicians, teams, practice owners and patients. However, some of the greatest benefits and flexibility in terms of skill mix have been in private dental practice where, since 2013, dental care professionals have been able to work privately to their full scope of practice, providing direct access to patients without people needing to see a dentist first.

Until October 2022, it was commonly accepted that direct access was only possible for privately provided dental care. This was because there was a widespread misunderstanding that an NHS course of treatment could only be opened and closed by a dentist on the NHS performer list for England, precluding direct access to dental therapy and dental hygiene work by a dental care professional (DCP).

As part of 2022/2023 NHS dental contract reform, NHS England sought clarity on the effects of the General Dental Council’s (GDC’s) legal and guidance framework, worked with the Department of Health and Social Care (DHSC) to review the Regulations, and obtained legal advice to clarify legal and regulatory positions about direct access to care from DCPs within NHS primary dental services.

NHS England is satisfied that dental therapists (DTs) and dental hygienists (DHs) can provide direct access to NHS care where that care is within the GDC scope of practice, if they are qualified, competent, and indemnified to do so. However, to date, administrative barriers have prevented DCPs from recording their contribution to NHS dental care.

1. Changes to the FP17 claim form

From October 2022:

• FP17 amendments allow the DCP’s role and their GDC number to be inputted, allowing DTs and DHs to open and close a course of treatment (CoT).
• Until additional proposed changes are finalised and completed, a dentist’s ‘Performer ID’* will still be required on the FP17, even if DTs or DHs have completed all the CoT. Practices will need to agree a suitable approach. We anticipate that it will be a contract holder’s performer ID that is input onto the form, where possible.
• Where delegation of part of a course of treatment occurs, the contribution of the DCP to that treatment should be included on the FP17.
• DCP data fields should be used to record the clinician/s who have provided one or more components of treatment for the patient. Other dental staff, for example dental nurses providing chairside assistance, should not be recorded here.
• Guidance from the NHS Business Services Authority (BSA) on completion of FP17 forms can be found on their website.

*The Performer ID is a number that is issued and used by Compass, the NHS dental contract management system. It is the number that identifies the performer on an FP17. It is not directly related to the performers List. However, a dentist will need to be on the performers list to get a performer ID number in Compass. It is separate from the dentist’s number on the GDC register.

2. Scope of practice

All clinical decision-making and treatment should only be provided if it is within the professionals’ scope of practice. The GDC determines the scope of practice that each registrant group can work within.

It remains the case that people should only perform tasks or make treatment decisions if they are trained, competent and indemnified to do so. All examinations, clinical decision-making, and treatments which fall outside any registrants’ scope of practice should be referred to an appropriately qualified professional.

More information on scope of practice can be found on the GDC website.

3. Liability

The administrative changes enabling DCPs to open and close a course of treatment delivered as part of NHS contracted activity do not alter existing liability arrangements.

The GDC states that where a course of treatment is delivered by a DCP only, that registrant is responsible for the care that they provide. Where care is delegated to them by a dentist, that dentist maintains overall responsibility for the course of treatment.

Additionally, when a dental practice holds an NHS contract, they agree to take responsibility for delivery of that contract, including the quality of care delivered to fulfil their contractual obligations. Clinicians and contract holders should continue to ensure that they have sufficient indemnity in place.

4. Supply and administration of medicines

Dentists remain the only members of the dental team who can carry out the full range of dental treatments and supply and administer a full range of prescription-only medicines (POMs), including local anaesthesia.

NHS England and DHSC, in collaboration with British Society of Dental Hygiene and Therapy (BSDHT) and The British Association of Dental Therapists (BADT), are reviewing the Human Medicines Regulations 2012, regarding DTs and DHs supplying and administering certain medicines within their clinical practice and professional competence. Until further notice, however, POMs can only be administered by DCPs under two mechanisms:

1. Patient specific directions

These are typically provided when dentists produce a written treatment plan for patients, including the prescribing of medicines; DCPs can then administer the prescribed medicine once treatment has been delegated to them.

Where DCPs accept referrals and provide care under the prescription of a dentist, we do not anticipate existing medication prescribing arrangements changing.

This remains the only route for dental nurses with extended duties who are certified in application of fluoride varnish. This is because they are not listed under the types of healthcare staff who can work under patient group directions.

2. Patient group directions (PGDs)

These are written instructions for the supply or administration of named medicines by named professionals, for groups of patients, under stated circumstances. PGDs have been used to enable direct access for DCPs. Only dental hygienists and dental therapists can work under PGDs.

Schedule 19 of the Human Medicines Regulations 2012 lists medicines that anyone can administer in an emergency – these include adrenaline which must be held within all dental practices.

Schedule 19 medicines: in an emergency anyone can administer the medicines listed in Schedule 19 of the Human Medicines Regulations 2012. This includes the administration of adrenaline for anaphylaxis.

Guidance on developing a PGD can be found on the National Institute for Health and Care Excellence (NICE) website, or at the NHS Specialist Pharmacy Service (NHS SPS).

Summary

Until October 2022, administrative processes have created a barrier to NHS dental teams maximising the full potential of DCPs. Changes delivered as part of NHS dental contract reform have altered the FP17 to enable DCPs to record their contribution to providing NHS care, including to open and close a course of treatment under NHS contract arrangements.