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Hygienists call for direct access to patients

11th Dec 2011

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A dental leader is calling on hygienists and therapists to influence the future of their profession.

Sally Simpson, president of the British Society of Dental Hygiene & Therapy (BSDHT) has urged members to get involved in the Office of Fair Trading (OFT) study in order to get the ball rolling on direct access.

In a direct letter to all members, she writes: ‘I'm keen that we should make the most of the time… to get our views across.' The OFT launched the study in September to examine if the private and NHS dentistry markets are working well for patients. And part of its remit is to invesigate the issue of professional restrictions on direct access to specialists or providers of auxiliary services, such as hygienists.

'The BSDHT welcomed the study and, last month, an OFT representative joined members of the society at the BSDHT Stand at the Oral Health Conference in Bournemouth to hear directly from delegates. The OFT suggests findings will be published March 2012.'

Sally says: ‘I'm keen that we should make the most of the time until then to get our views across. This is particularly important in relation to direct access where the OFT want to hear real rather than anecdotal examples of the impact – particularly the financial impact – the current lack of direct access has upon you and your patients.

‘So I'm writing personally to each and every member of BSDHT to encourage you to submit your views and comments to the OFT.'

Dental professionals can email dentistry@oft.gsi.gov.uk, or write to: Dentistry Market Study Team Services and Public Markets Group Office of Fair Trading Fleetbank House 2-6 Salisbury Square London EC4Y 8JX

Sally adds: ‘Please do your part by pledging your support for the removal of the requirement of a referral from a dentist to see a dental hygienist or dental therapist and where possible, by providing evidence of the negative impact denial of direct access has for you and your patients. Let's not miss this opportunity to influence the outcome of this study.'

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Comments

why not just get a dental degree, invest in a practice,carry the full risk financially as well as clinically and then you won't need a referral.

Posted by gordie 12/12/11 at 07:26

Gordie,

Hmmm, I can sense some resentment here. Let us look at the three points you have made.

1. I never had the chance and at 41 it has left me behind. Whilst I can understand that some feel that a DH's training is not sufficient and no one will attempt to compare the two (DipDH vs BDS), the suggestion coming from us is that we be allowed to see patients once we have completed sufficient secondary training. The access would be limited and anything out of our Scope would be referred back to our dentist colleagues. Indeed, I do this on a daily basis.

2. There are some out there that have already done this. Google them, they are there. Me personally? I do not want a practice, never have, but if I was accepting DA patients I see no reason why I wouldn't work with an associate type contract and take the hits with everyone else.

3. I am more than happy to take full clinical responsibility for my errors or omissions. As long as I work to a prescription (that usually reads "Ref Hyg") I cannot be held responsible. It will not be me in the litigation courst whilst this scenario persists.

I could go on, but I won't

Posted by shaunhowe 12/12/11 at 12:08

no resentment-I was making the point that if they want to set up and work on their own without prescription, then do so. The cost set up and running costswill be the same as a dental practice, and they will then be subject to the same liabilities and risks of being sued as dentists while in all likelyhood not having anything like the same fee income. Just can't see it working.

Posted by gordie 12/12/11 at 12:49

I don't think there are that many that want to set up alone. Most of us just want to see our own patients. I think you should look at the somewhat grown up discussion on GDPUK

Posted by shaunhowe 12/12/11 at 12:58

Shaunhowe
What do you mean by seeing "your own patients and how will that benefit the patients?

An independent practice run by a Dental hyg. where the patients go to be examined without prescription would mean that you would have to take legal responsibility for all the aspects of the examination of the patient's dentition and not just problems related to OH and perio. Do the hyg. and therapists have the necessary training to do that? Some will mention that they will ref. "upwards" to a Dentist, but the issue here will be the necessary knowledge to be able to detect the need for a ref. or will they decide to refer anything slightly suspicious? Off course a practice run by a Dental hyg. can always employ a Dentist or Dentists but then that would be just a bussiness and we will not need the debate about direct access to hyg. and therapists.
My main question is, how will this benefit the patients?
Is there anyone out there thinking that direct access to a Medical nurse is a great idea. and then if need be a ref. to a GP?

Posted by Expat 12/12/11 at 14:21

It really is a lengthy discussion that would take lots of space, time and effort here. I'll post later, but in the meantime, I'll again refer to GDPUK

Posted by shaunhowe 12/12/11 at 14:54

Oh and by the way, this really does refer to Hygienists services only (as far as I am concerned)

Posted by shaunhowe 12/12/11 at 14:56

It talks about therapists so presumably you want to see them taking responsibility for diagnosing decay and their restorations as well. As usual hygienists look at it that they are receiving less than 50% of the fee and think the dentist trousers the rest. Relying on hygienist fees alone is a non starter to run a business and expat is right where's the benefit for the patient. I predict the lawyers would have a field day.

Posted by gordie 12/12/11 at 16:38

I think it refers to those that are dually qualified. It has to be remembered that they hold two registrations.

As I alluded to earlier, there are those who have successfully set up and run hygienist only practices. Not employing dentists, but hygienists.

Gordie, your view seems to focus on one thing only and if your hygienists are not profitable then perhaps you need to look at it again? I am fully employed in practice and do not receive anything near 50% its about 24% and I know of very hygienists that receive that level of remuneration.

I do not want my employed status to change either. I sat for 5 years on the GDC FtP panel and I know exactly how to get in front of said Committee, but conversly, I know how to avoid it too. OK, so a few weeks ago I ahd a patient who had not attended the practice for close on two years. This gentleman is a GP, unfortunately I was unable to see him because there was no valid prescription and he had to rebook in with his GDP and then me. We lost two appointments because of it.

I could not see him because this would have been against the GDCs guidance, but I can tell you he was not impressed.

A silly scenario, but very real.

Hmmm you predict the lawyers will have a field day, how so? Go to the Dental Law Partnerships website and read their case histories of perio neglect. their biggest payout was £60k and if we guess at both sides fees I reckon we're up to £250k. Seems there are plenty of my dentist colleagues that are doing a fabulous job without my help. I do not want any GDP/Hyg/Ther or any other registrant end up in the Courts or at the GDC so we work together to ensure that patients are offered the very best care. I do not believe we should live in a blame culture and should support each other. There are some errant GDPs out there, but that does not necessarily mean I believe they should be erased from the register

The reality is that I rarely work with a diagnosis. Ref Hyg is (for the majority) all I have had for 18 years. It works fine for me because it shows that the GDPs I work with have complete faith in my ability to assess, educate and treat the patient the way I see best for the patient. It has never caused a problem yet.

I'd ask Gordie, do you give your hygienists a definative diagnosis and clearly laid out care pathway when you refer? Or do you rely on their training and "expertise" in their chosen field?

Do they ever refer onwards or sideways? By this I mean onwards to a periodontologist or back to you? I do this if not on a daily basis then certainly weekly. I have no requirement to let the GDP know i have referred on, but because we work as a close knit team that cares that our patients get the very best care, I of course tell them.

To suggest that I do not know what looks normal or not is ridiculous. I know what a hole looks like in a tooth, but I do not want to treat it, I will refer back to my GDP colleague, and guess what? I do, frequently. The same applies to lesions that have not already been mentioned in the patient notes.

Gordie and Expat, when you present an argument that is not business based I may choose to respond, but for now, thats my lot.

Posted by shaunhowe 12/12/11 at 17:34

--This post was last edited on 12/12/11 at 17:54--

Posted by shaunhowe 12/12/11 at 17:34

Shaunhowe
With all due respect for my Dental hyg. colleagues. I believe that you are a necessary part of a successfull treatment for our patients and you deserve our respect. Now to the points that you have made:
Everybody knows what a hole looks like in a tooth but can you diagnose early carious lesions in a fissure or on a bw of those teeth? (I know that I can't always using all my top of the line equipments and 17 years of clinical experience) Can you diagnose TMJ disorders? Bruxism? Malocclusions? When to refer for orthodontic treatment / consultation? If you take radiographs, can you interpret pathology on them and give the patients correct advice? (Presuming it is not perio related) Can you advise the pat. by examining their radiograph about the quality of their restorations, leaking margins, the need for Endo , re-doing RCT or apicectomy?
I think gordie is spot on, when he mentions hyg. might not be happy with their share of the fees (which is a completely different matter and can be addressed by setting up a practice and employing Dentist/s and run it as a bussiness) but you have not been able to explain the benefits to the patients with direct access here. The above mentioned GP should have been seen by a Dentist first for an exam (Surely a GP should understand why) after not attending for 2 years.
The issues with the GDC. Fit- practice committee and Dentists getting into trouble has nothing to do with the direct access debate.

Posted by Expat 12/12/11 at 20:01

well put expat.We have two hygienists who receive written referral-I trust them as they are both very good to do their jobs but the buck stops with me.There is a world of difference when you are ultimately responsible and frankly I doubt the majority would want thatlevel of responsibility. Heck the majority of dentists can't cope with it.You are correct that a large number of dentists ignore perio (at their peril) but that doesn't mean direct access would be any better. The arguments are indeed long but the bottom line is dentistry is a 5 yr course for a reason. Direct access is just an extension of the whitening and denturist debate-where does it end? I'm sure if the govt. thinks it can save a buck they'll allow creeping dilution of the profession but it will be a retrograde step.

Posted by gordie 13/12/11 at 08:05

'creeping dilution' - exactly. My mother was talking to her consultant opthalmic guy whilst getting her eyes 'lasered' recently. His dept has terrible problems as the other 'laser person' is on maternity leave. As he said, he's tripping over ward clerks/eye nurses/bottle-washers/Uncle Tom Cobley and all. But nobody else with the skills/qualifications/experience to actually operate the laser and do the work............

Posted by docholliday 13/12/11 at 08:26

creeping dilution - interesting term- I do not feel as a dental hygienist with over 20 years experience that my patients feel that.

I do not want to be a dentist, but I do believe that patients have a right to see a person who is best trained to treat them. If we consider the training at undergraduate level, there is nothing that seperates our training for dental hygiene with that of an undergarduate BDS apart from a few words- recognise/diagnose. In fact in terms of clinical hours spent you will find we win hands down in perio. How many clinical hours does an undergarduate BDS spend on perio?

Also what benefit is the undergraduate training in terms of business/people/practice management?

If disease, in particular periodontal disease, was successfully managed why do we still have such high levels of disease? Every perio meeting talks of BPE- such a simple tool to use?
I think you will find your hygienist is equally held responsible for the care of her patient if she fails to question a diagnosis that is wrong??

If a practice has over 10,000 patients - how many hygienist's hours would it take to manage those patients, or what of the 10% that supposedly need the services of a periodontist- how many specialists referrals does the average periodontist get (ref Adult Dental Health Survery). Most practices do not have a full time hygienist and some have none at all- where should these patients go if they cannot access services? They want healthy teeth and gums and are becoming more aware than ever.

50% of the population do not even go - fear, cost what ever- what about them? Do we keep whiplashing them into dental the same old way or offer the an alternative route back?

A route through a dental hygienist- 4,500 patients have walked through my door - looking for hygiene services.

I do employ a dentist- 2 in fact, to work with the prescription for those patients who are often denied it from their own dentist. A dental business is growing but the hygiene business alone grew by 45% last year- not a bad business model either.

Posted by chrischat 13/12/11 at 13:16

Chrischat,
Now this sounds like resentment !
Don't kid yourself for a second that you have the same level of knowledge compared to a Dentist after 2 years when you leave as an undergraduate.
If the patients were willing to pay the fees (The hourely rate to me) I would do it myself and i KNOW how to do it. How many clinical hours do you guys have on Cariology, Radiology, Occlusion, Peadodontics, Orthodontics, Endodontology, Oral surgery, Prosthodontics??
Please do tell us how it will benefit the patients. This is the third time I have asked the question and non of you can give an answer !
You have to accept that you only deal with OH and periodontitis and do not have the the necessary broader knowledge. A comprehensive treatment plan for patients requires that. This is a political issue and the DOH is behind this in order to increase access to Dental services (with direct access to Therapists) in the UK

Posted by Expat 13/12/11 at 15:28

How wonderfully patronising. Thank you

Posted by shaunhowe 13/12/11 at 16:29

There is a great opportunity on the horizon in Dentistry, unfortunately many dentists and hygienist/therapists are not seeing the wood for the trees.

I am aware there are opinions about the possibility of Direct Access (DA) that vary greatly across the Dental profession. There are objections regarding diagnosis, competence, litigation, and cost. I hope we can see through some of these issues and clarify the benefits of a future in the dental family where DCPs and Dentists work together to improve what we do for our patients and for our Dental Family. I believe DA works to help everyone move into a great way of providing dental healthcare as well as stream lining dental business.

First let's look at the issue of diagnosis. As a hygienist am I qualified to diagnose? I do not carry that qualification regardless of any ability I might feel i have in the light of years of experience, and so, neither do I carry the responsibility. If DA is achieved I will be prepared to carry that responsibility and seek the appropriate training needed to demonstrate competence. I am currently trained and experienced enough in my field to know when there are signs suggesting dental disease is present, and I refer to my dentist if I spot soft or hard tissue lesions, In practice, we can agree working regularly with many patients, I am often better placed to observe changes. It would take little effort to confirm many hygienists have referred patients to the dentist, even after the dental examination, it makes sense this happens and in the event of DA I would anticipate more rigorous training for the hygienist/therapist to reinforce this ability and referral onto dentists for treatment or investigation would continue as always.

Let's look at the question of litigation. There are many issues regarding management of periodontal disease in patients that are not covered by simply referring patients to a hygienist. DA will not open more litigation cracks, it will mean hygienist/therapists will have to be aware of their responsibility in this area, and how can that be a bad thing? The fact is that right now the majority of hygienists walk the litigation plank every time they receive a dentists prescription, how many dentists give their hygienist site specific local prescription or treatment plans with comprehensive periodontal diagnosis. Awareness of litigation regarding periodontal care is not specific to the question of DA, whether it happens or not we all need to brush up on that one.

Continuing professional development covers the competency issue, clarity in the Scope of Practice will need to be achieved, and personal diligence is a matter of individual responsibility, just like it is for GDPs and DCPs alike

Now let's look at the business model regarding hygienist/therapists. DA will enable a clinic run by a hygienist/therapist to be an integrated part of the dental team, inviting patients to enter dental care through another door. A good clinician is a team builder, even if the clinic is not on the same premises as the patients GDP we are all still promoting prevention. Encouraging patients to take better care of their mouths leaves them more likely to invest in their mouths, products and Cosmetic options become more successful in a patient base that is healthy, less invasive dentistry, less cost in provision of basic dental care. If your resident hygienist clinic attracts patients through direct access then you also benefit from product sales and word of mouth enquiries.

The team as a whole will benefit also. In Sweden the hygienist does a full mouth health assessment before the Dentist comes in, they can even take the radiographs, after all a good architect wouldn't start work without a survey! Better educated patients lead to a better working environment for the dental team. Communication has always been a gold standard in surgery, hygienists have historically been recognised as leading lights in this area of patient care. We are all part of the same team who ever gets to see the patient first.

If I work with Direct Access I am under no illusion, I am not an alternative to seeing a dentist and I would NEVER allow a patient to believe seeing me negated the need to see a dentist regularly. Hey guys, we are all on the same team and the patient should be the winner every time.

Direct Access is the chance for change that will enhance the promotion of prevention and bring patients into the dental fold in a way that was not otherwise open to them. They can make choice, and if anything brings patients to the door and keeps them coming its knowing they have the choice about how they receive what we have to offer.
Being able to see a hygienist without a referral is going to help anxious patients start receiving treatment when they would otherwise have avoided coming into a practice. it's going to open referrals from coronary or diabetic clinics now that we are acutely aware of the links regarding oral hygiene and other health risks. Direct Access allows time to be spent with families discussing diet at their request. It will enable practices to implement risk assessments for decay and periodontal disease before examinations. Unscheduled advice on product use and methods regarding toothbrush techniques that patients often ask in passing or at the reception desk can be provided without taking the dentist away from his core work. I am sure i have covered only a fraction of the advantages a creative, forward thinking dental team could come up with given the opportunity to work with direct access.

Why would we want to turn down the opportunity to offer direct access to a service patients benefit from. It does make sense if done in the right way. Periodontal disease and a high level of bacteria in the mouth is quickly becoming a focus for concern in more than just dentistry, let's embrace the challenge as a profession and adjust access to relevant services appropriate to what we know now. It's the professional thing to do.

Posted by Bobby Keeling 13/12/11 at 16:30

Well Bobby, beat me to it. What a fine, comprehensive post on the proposal.

I would add that the first couple of ?dentist replies to this article make the fundamental errors made by many on this subject without possession of the full facts of what's being proposed.

These errors are:

Equating DA to independent practice.

Assuming all/many hygienists will want to run off and open their own practices.

Assume these same hygienists all want to be dentists.

Wrong, wrong and, indeed, wrong.

The key phrase that pays is 'within scope'. You also need to realise that hygienists can and have taken up their right to open their own practices. These are referral practices or ones where they employ a dentist. DCPs have been able to do this for years. There's a huge chain in Scotland that is NHS, run by two hygienists and includes a lab I believe.

We are already liable for acts and omissions. We are already required to be registered and carry indemnity insurance. We are already expected to recognise abnormal lesions and conditions and refer them appropriately. We do this daily and not just to dentists. You need to realise that all hygienist/therapists qualifying now are dual qualified and are BSc graduates. We spend much more time on patients training on our specialised skillsets, the education argument is a tad tiresome and insulting. Yes dentists do two more years. They have more to cover. Some also seem to assume that education and training ceases on qualification. Ridiculous in the extreme.

There is so much precedent in the medical world. We have opticians, midwives, nurse practitioners and physiotherapists all seeing patients directly without the need for a doctor. Are GMPs threatened? Nope, they welcome it.

So, with minimal extra training, there's no reason why hygienists shouldn't see new patients directly WITHIN SCOPE. For many of us, this means within a general practice environment. Few will set up on their own, in my opinion and that of many colleagues. Some will but they always could.

The benefit is that a large group of patients who are disenfranchised from dentistry for a variety of reasons have an additional route back into care. It's often quoted that 50% of the population do not go to the dentist. The model has already been proved, both in terms of business and patient demand, rather ironically by a group of dentists who were initially misrepresenting themselves as hygienists until it was pointed out that the use of the reserved term 'dental hygienist' was illegal - Smilepod.

The benefit for a general practice is that their DA hygienists will be free to attract their own patient stream to the practice. Inevitably, some, if not all, of these patients are going to be referred to the dentists. Know any principals who don't want any new patients? No, me neither. The major benefit is that access to treatment of one of the most serious threats to systemic health will be enhanced.

However, through this debate, it's interesting to note that the 'anti' argument is always couched in terms of business concerns dressed up in patient safety and diagnosis non issues, whereas the 'pro' argument stems from the patient care benefits.

At the end of the day, it is for the patient to determine what they want. They shouldn't have to pay a gatekeeper in order to see the professional they wish to.

--This post was last edited on 13/12/11 at 19:33--

Posted by dbrdh 13/12/11 at 18:44

so many points.Much of what you say is true and much is sheer naivety. There is no doubt hygienists are skilled,no one disputes that,but your knowlege is in a small field. Make no mistake your liability is at present limited. If things go wrong it will be the dentist who is sued. He was responsible for the referral.As for "creeping dilution" The doh/govt is determined to divide and rule and turn dentistry into some kind of "fringe" medical service and thats all to do with money. Direct access will not result in some kind of new referring trend.It barely works at present with implants/endo etc.Those hygienists who set up alone (and I do agree it will be few) will not see an influx of patients from referring dentists nor will the reverse happen either. Ask yourself why would a dentist refer when most will take the attitude I can do it myself.
From the patients point of view gradually patients will skip the check up and just assume the hygienist will pick up any problems.
You say you don't want to be a dentist-bit of a strange comment for some one who spends all of their day looking in mouths and reckons their sufficiently trained to diagnose oral problems.

Posted by gordie 14/12/11 at 08:02

LOL. Troll alert!! You were doing so well until the last line.

Posted by dbrdh 14/12/11 at 11:28

dbrdh you'll have to explain that last comment
if as a dental therapist/hygienist doing fillings,diagnosing decay ,simple extractions isn't dentistry wtf is it

--This post was last edited on 14/12/11 at 12:32--

Posted by gordie 14/12/11 at 12:19

gordie is not a troll.......
As to the eg mentioned by Shaun Howe (GMP not happy as he couldn't access a hygienist directly).... I recently wanted my own antihypertensive meds adjusted, as I've lost 6.5 stone. Original meds prescribed by Prof/physician in one of this countries leading cardiovascular centres. My GP practice offered me an appointment for review - with (wait for it!) a pharmacist. I made it crunchingly clear that I wanted to see someone with at the very least an MB BS first. I very much suspect that the vast majority of my predominantly older upper middle class patients would want to see the 'proper dentist', first. Sorry, folks, that's just the way it is.

Posted by docholliday 14/12/11 at 13:08

Doch. You've not been reading the posts fully, have you? Shaun gave you one patient who wanted DA. I gave the example of Smilepod, who've built a whole business on the demand for hygienist services. You can also read two examples on my blog www.cheesygrin.com of patients for whom life was made very difficult to get a referral to a hygienist. Christina Chatfield has a referral practice with over 4500 patients seen and she can relate examples where patients want to see us but their dentist gets in the way. This all flies in the face of your assertion and we've not even been able to test the 50% who don't come at all…yet. OFT will hopefully look at this as part of their 2nd investigation in <10 years into dentistry.

--This post was last edited on 14/12/11 at 14:28--

Posted by dbrdh 14/12/11 at 14:22

excellent post Doc. It about sums it up.
You have even managed to lambast Pharmacists.

Regarding the GP patient, he has subsequently complained to the GDC that it is pathetic that he cannot access my services directly. He is middle classed and middle aged.

Go on, please, patronise me again. I love it

Posted by shaunhowe 14/12/11 at 14:29

Keep it up, Shaun! They're making our case for us. 8-) Going to submit this and the GDPUK thread to the OFT…

--This post was last edited on 14/12/11 at 14:36--

Posted by dbrdh 14/12/11 at 14:33

'mmmm patronise me, harder, harder.........' As to your GMP, if I was him I wouldn't bother complaining to the GDC about anything being pathetic....... the GDC itself is completely pathetic, a view which seems to be largely shared by the CHRE.

Posted by docholliday 14/12/11 at 14:32

Need a popcorn icon, Julie! 8-)

Posted by dbrdh 14/12/11 at 14:37

I'm sure the OFT will sort it all out ;-) , perhaps they could give Prof Jimmy Steele a call, maybe even Bazza Cockcroft, I'm dead certain they would love somebody to fix it all........LOL.....

Posted by docholliday 14/12/11 at 14:36

Oh, and as to reading postings. One cardinal rule of blogs (esp clinical ones where folks dip in between patients) is - once you go beyond about a dozen lines, nobody bothers. The best eg is 'Igonikon Jack' over at the Torygraph.

Posted by docholliday 14/12/11 at 14:56

Because the guy is a GMP doesn't necessary mean that he knows anything about OH. I used to have a few GP's in the UK whos mouths were dreadfully affected by gingivitis and periodontitis. The amount of time I saw patients who had been to their GP's and got AB for carious teeth and pulpitis + 2 cases of Torus Maxillaris (Anything that is hard and looks like a "lump" should be treated with AB) ! Bobby has mentioned Dental hyg. in Sweden and direct access to them. Let me tell you how it works there:
They always work in a practice with a Dentist and or specialists. They do only see recall patients not new patients. The ones who do take radiographs and do fillings (They can only do 1 surface occlusal fillings after appropriate training) have 3 years of training + extra courses in diagnosis and cariology.
The overall responsibility for intrepretation of the radiographs taken by them is with the Dentist that they work with. (I do not have a problem with a similar system in the UK)
The patients over there do not moan when they have to pay £75- £90 (30 min. app.) to see the hyg. first and then if a ref. for Exam + consultation with the Dentist needed the appropriate fee to the Dentist which is up to £90 - £100 (In the UK you will be accused of ripping them off for something like that)
The level of knowledge about OH and OH levels in general in Sweden is not comparable to the UK .
They see and treat well maintained patients.
This is a politically motivated move by the DOH to increase access. They don't have the money for a system that offers high quality dentistry , therefore trying to con the electorate with access to cheaper Dental services (Being seen by a therapist).

Posted by Expat 14/12/11 at 14:55

It's great to see such a healthy debate from all sides.

I am certainly getting alot of information about the assumptions and attitudes that run through the profession. It is interesting how we view our fellow dental health care professionals. I admire and respect the majority of work I see my patients sporting when I am guiding them through some of the intense periodontal therapy they require.

My posts are my opinion, and they are considered, with a fair chunk of experience and a good topping of reflection. I would thank you for affording me a little respect when it comes to your replies. I have run clinics on referral basis extremely successfully, I have seen patients who commit to extensive treatment when it is explained to them thoroughly, you would be amazed at the value of a smile. And I have the utmost faith that given the right information in the most effective way any patient will choose a treatment plan that is in their best interests. Most of all I have worked with dentists and team members who have supported this way of working. Often patients are told the reason for seeing me is because I will achieve a better result than the dentist, why? Because I claim only to be master of one trade not Jack of all.

For me the model of dentistry I choose to practice today is an ever changing model that aims to be even better tomorrow. High quality dentistry is what I aim to achieve. That means I deliver what a patient needs, that means listening and planning accordingly, seeing the patients needs in a holistic manor and learning from their perspective.

We are evolving, like any good profession excellence is about aspiration and leadership about inspiration. I know a few incredible leaders, people who really do excellence in dentistry. If you want to believe that you are being manipulated by the political card ask yourself if it will ever change. My answer is only if you change your perspective.

Direct Access is a different perspective for our patients and us, It is not about egos and territory. It is an opportunity to regroup as a highly effective dental healthcare team. I for one am going to work towards a change that I believe is for the better, not whine about my lot now. And I am looking for leadership, aspirations and inspiration so if you can step up to the mark lets hear it. I am looking to share problems so i can find solutions. Let me share this, periodontal disease is the most common cause for tooth loss, no surprise? So we keep doing the same thing? Easier access to hygienists is doing something different, why wouldnt we want to make this an option?

--This post was last edited on 14/12/11 at 17:45--

Posted by Bobby Keeling 14/12/11 at 15:46

Typo corrected :)

--This post was last edited on 14/12/11 at 17:46--

Posted by Bobby Keeling 14/12/11 at 16:34

Very entertaing discussion. I think the dentists win this one. Docholiday, Expat & Gordie consistently raise interesting & valid points in a clever & witty way, while dbrdh & Shaun have said nothing other that 'stop patronising me' :,(& 'I'm telling the OFT' :'(. Know your role.

Posted by Amar1001 14/12/11 at 17:44

Amar,
If it were X-factor we know who you would be voting for, and some passion in the debate has lead to a little regression perhaps. I do however believe I know and admire your role as a dentist, and I am very aware and well practiced in my role. I am just not sure that Gordie, Expat and doc share a sense of how valuable it is to the patients access to dental healthcare. Neither have presented a valid reason for not gaining DA other than pointing out we do not have their training.

In a witty and clever way? Well, they have made me smile, creeping dilution and middle class expectations are ailments I too would demand to see some one with full credentials for too.

Its not about competition, its about working the best way possible as a team for the patient.

Am I making sense? Maybe only to a some, but everyone has the right to challenge.

Posted by Bobby Keeling 14/12/11 at 18:12

--This post was last edited on 14/12/11 at 19:30--

Posted by Bobby Keeling 14/12/11 at 18:12

Bobby,
If you read my comments, you will notice that I do have the highest respect for your role as a dental hyg. I also believe in Team work, but that doesn't change the fact about the different training and roles that Dentists / Dental hyg and Dental therapists have. I am not going to be politically correct here just for the sake of it, nor am I worried about any competition from our Dental hyg. or therapist colleagues. Please enlighten us how DA will lead to an increase in attendance of that 50% of the population that do not see a Dentist?
The two main reasons for patients not attending is the cost and fear of Dental treatment. Lets look at them and your role as a hyg since you guys keep mentioning it as a very important reason for DA :
Are you going to see them on a private basis or on the NHS system?
The current UDA ("Nectar point") system charge is £17 for an Exam, radiographs, S+P by a Dentist !! (Hillarious) Are you going to compete with that price? Less than £17 ? How viable will that bussiness be?
I assume that your charges will be much higher in the region of £35 - £70 depending on location and overheads. Now that will not improve access for the people who claim they can not afford Dentistry (But easily can afford their booze and fags etc..)
The ones with a real fear for Dental treatment will not be standing in line jumping of joy to see you with your sharp instruments for scaling and debriding and suddenly come to realise, what the heck this is not so bad, what was I affraid of all these years and now I can go ( on a ref. by you to a dentist) and have a few fillings and a few more extractions (for £47 hey it is a bargain by the way).
Beside these 2 groupes of people, I can only think of a third one, the ones who simply don't give a s... about their OH and their teeth and I can not see DA doing anything, so that they will start to see you or a Dentist.

Posted by Expat 14/12/11 at 20:15

Amar1001 wrote:
Very entertaing discussion. I think the dentists win this one. Docholiday, Expat & Gordie consistently raise interesting & valid points in a clever & witty way, while dbrdh & Shaun have said nothing other that 'stop patronising me' :,(& 'I'm telling the OFT' :'(. Know your role.

Another who hasn't really read the posts fully. All the DCPs in this discussion gave full, comprehensive arguments for DA. The respondents have chosen to ignore the detail of these and concentrate on 'you're not as qualified as a dentist'. No-one arguing about that at all. What we are arguing is that we are able to work autonomously within our scope with direct access.

They keep arguing about dentistry on the cheap yet much, if not most, hygienist care is provided on a private basis within NHS practices (still not sure how that conversation goes!). None of the DCP's here have made any allusion to less expensive treatment. I'm sure Chris will tell you it costs nearly as much to run a hygienist practice as a general practice.

It's about increasing access to the circle of care - it's just another access point. Of course patients will be signposted to a dentist. Why wouldn't they? Even if I saw or found nothing, I would still have a date of last dentist visit in my history taking and would strongly advise a patient to have a full examination by a dentist if they hadn't been because they need to! However patients are not subject to direct orders and assume responsibility for their own health and if they do not take advice then it's their choice. That said, perio is a serious systemic risk and if we can improve the chances of treating this then we should do it. It can't be a check up on the cheap because it won't be a check up in that sense. We will assume responsibility for acts and omissions within scope. We won't need to assume responsibility for dental/medical problems outside of scope because we will have referred these patients to dentists and/or other professionals. By way of example, I have recently referred two men of around 50 to their GMP as they presented with erosion and complained, on close questioning, of reflux. Before they went, I told them about Barretts syndrome and the associated risks for guys of their age. As previously posted, education doesn't stop on initial qualification.

Some patients are finding it difficult to get a referral. Others know they have a gum problem and want to see a hygienist directly. Chris has told you of this as have I. There's precious little reason why this shouldn't be the case.

I would ask you to carefully read our posts in their entirety, 12 lines or more - it's too big a subject for sound bite debates, and think about them. I have certainly put a lot of thought, time and care into mine.

Posted by dbrdh 14/12/11 at 19:38

dbrdh,
I have been direct in my comments here about the different training for dentists and hygienist/ therapists. I would have respected you guys even more if you had mentioned that one of the reasons (Probably the main one) for DA is for you guys to increase your income (which is understandable and I do not have any problem with) by as someone had mentioned eliminating the "gatekeeper" role of the Dentists. Stop disguising it behind the arguments like the patient'st choice and those 50% of the patients who do not attend regularly. It is more honest and I personally would support it.

Posted by Expat 14/12/11 at 20:56

Enough, already! I know that my patients will see me first. Others can do as they want. I know my (non NHS) model works, it's busier than I now want as I'm really wanting to go part-time in a year or two. As far as patients 'knowing they have a gum problem' - well, I'm no fan of self-diagnosis, so a 'gum problem' could be anything from a chronic sinus tract to an urgent oral medicine problem needing immediate referral to the consultant in the nearby DH.
Direct access is merely a cost-cutting exercise for the DoH. As I've little interest in the hopeless machinations of the NHS any more, I actually feel a certain sorrow for those hygienists who fondly image that some sort of new nirvana will open up before them. Dream on!

Posted by docholliday 14/12/11 at 20:56

Expat,

Sheesh,there you go again!
You know absolutely nothing about me, that's clear. It wouldn't take much effort to find out. You have a similar level of knowledge of the other DCP's here.

Your mercenary accusation shows a complete ignorance of what makes me tick.

None of us here has made income a factor for the simple reason it isnt. I, for one, am more than happy with my remuneration. I've also made it clear that I want DA for my role within the practice I've been with for nearly 18 years. If DA works as we think it will, the whole practice will benefit. I accept you may find it difficult to believe but I really do want to get at the 50% and I do want to see the patients who are being actively denied our services. I do want to make it easier for patients to see all within the circle of care. I'd like to see wider cross-referral - from GMPs, cardiac departments, diabetic clinics, midwives into dental professionals of all persuasions: a full embrace of the holistic philosophy.

And the 'gatekeeper' term? That came from the BDA, I believe. It's how they see their members' role apparently.

--This post was last edited on 14/12/11 at 21:43--

Posted by dbrdh 14/12/11 at 21:12

Sheesh , that is a very interesting way to debate and I was not referring to you personally.
I have made my points and have not received a proper answer to my questions about the benefits with DA and I will stop now.

Posted by Expat 14/12/11 at 21:50

My sincere apologies. My mistake. It's just when a post is addressed to me personally and contains the word 'you', I usually assume the correspondent means me.

Even if you meant the wider collective rather than the three of us who have posted here, myself included, my post still stands as regards my motives for seeking DA.

--This post was last edited on 14/12/11 at 23:02--

Posted by dbrdh 14/12/11 at 22:11

Browser double post deleted

--This post was last edited on 14/12/11 at 22:15--

Posted by dbrdh 14/12/11 at 22:11

I think there are 2 seperate issues here, and that is whether you have direct access for dental hygiene services or whether a dually qualified hygienist/therapist who train for 3 years have direct access for hygiene and restorative treatments.

I fully support direct access for hygiene services and challenge any dentist to say that we are not trained to treatment plan, recognise and treat periodontal disease. Honestly, you need to look at the undergraduate curriculum for the first 5 yrs and map it across the DCP training - its changed as the scope of practice has changed. For perio we have BPE; a tool dentists should be using at every exam prior to referral to a hygienist. Ian Chapple speaks, and so do many specialists, of referrals with BPEs of 5 - I have certainly seen them - why should I have to take my lead from that?

You are right, referrals for services from dentists will be low, even if they dont have the facilitiies to treat, I can vouch for that. But I am seeing their patients and their patients are continuing to see them. Its called service and consumer wants. Less than 4 % of my base of 4500 have come from dental referrals, although that number is increasing because of the quality and access of service that we provide.

The benefit for a patient to see a hygienist directly, a patient that has not been for years and perhaps is too frightened to go to a dentist, is surely obvious; a healthy mouth, oral cancer screening, smoking cessation advice and the health benefits for the rest of the body, in turn building up confidence and empowerment. The next stage is then about the patient being able to trust the dental profession to then go on and have dental treatment done with a dentist if need be. This has frequently been the route back in for many of my patients.

People should be given choices - they have a legal right to that choice, but are they given it at the moment, in house or not at all?. How would you feel if your patient said they did not want to see your hygienist, would you give them a copy of their treatment plan or offer another choice elsewhere? Hopefully you would do, because it is their legal right. One of my patients was referred for implants. He was quoted £15,000. He said it was the cost of a new car and although he wanted it, could not afford it. He was not given a choice of a second option. He did go elsewhere to get a 2nd opinion and was quoted £8000. He is very happy with his work. How can the costs be so different between people with the same qualifications?

Now I do whitening under the prescription of a dentist. I am cheaper. Does that mean the quality of what I do is substandard? With regards to direct access to a dental hygienist/therapist for restorative treatment, I'm launching a 2 tier system in January offering restorative treatment with a therapist under the prescription of a dentist, and cheaper than a dentist. They will take longer to do it, but will use the same materials and produce the same result. However they will be cheaper to pay and therefore the cost benefit to the patient that chooses her/him is passed on. And you are right, not everyone will want to see a therapist, but it is about valuing your team and understanding what they are capable of delivering. It's all about giving quality care/treatment, information and choice.

Of course I can see access to therapy to be benefical to a whole generation, in fact our children and our elderly. How are we going to manage their care? Supervised contracts might be an answer here - I do not believe that the majority of therapists want direct access, but the majority of hygienists do and there in lies the difference - FOR HYGIENE SERVICES.

I have a meeting with OFT tomorrow in London and will share the information to date..

I am not playing at my business- I know the costs- I have been running for nearly 5 years.

Direct access is not about working alone or in independent practice - it is about a a dental hygeinist/or dually qualified dental hygienist /therapist working like an assocaite seeing patients for hygiene services directly- a great practice builder.

The market is changing either accept change and grow with it or be left behind-

--This post was last edited on 15/12/11 at 08:31--

Posted by chrischat 15/12/11 at 07:03

Chrischat

Good points well presented and evidence based. I believe that answers the questions asked comprehensively.

There are those I will have to agree to disagree with, but I know many practices and patients as well as prospective patients who will benefit from this way of accessing our services directly.

It's not a dream, and any one who feels sorrow about this opinion need not worry because I am looking forward and moving on, and I shan't pretend to feel sorrow for there apparent short sighted attitude either.

It's going to happen, change is coming, take the opportunity for patients sake :)

Posted by Bobby Keeling 15/12/11 at 07:53

...... opinion, not 'evidence based'. If a patient didn't wish to see my excellent hygienist, BTW, I would suggest to them that as they didn't want to see my valued colleague as recommended, then our relationship would be coming to an end - ie they should find themselves another dentist as well as hygienist....

Posted by docholliday 15/12/11 at 08:31

And do you know what, Stephen? If I was a DA hygienist in your practice, I'd say the same to any patient of mine who needed to see you. It'd be exactly the same if, and it's a big if for me, I was in independent practice.

Posted by dbrdh 15/12/11 at 08:51

Indeed, Dave. Actually, most patients much prefer to see Donna than me. She's much too nice to them.........

Posted by docholliday 15/12/11 at 09:06

I can see why you would feel like that- let me re phrase - what if your patient could not see your hygienist because it was not convenient and you had another service to use.

You patient can legally ask for a copy of their treatment plan and take it elsewhere- so therefor you would stop them coming to your practice because they chose a different service to compliment what you do eslewhere.

How many dentists/ hygienists do you have working for you? Not every patients gets on with every clinician- clashes on both sides- however good we are or think we are.

Anyway this is not about your practice this is about access to hygiene services across the UK- you already have a good hygienist. My friend has a practice in Worthing - he has 4 hygienists working there but refers some of his patients to see me in Brighton - it is more convenient for them to see a hygienist here and he is happy with the service provided.

As I said I do see now a number of patients from local practices some with hygienists and some without.

How many patients do you have, how long are your appointments with the hygienist and how many hours a week does she work?

Posted by chrischat 15/12/11 at 09:09

'Legally ask for a copy of their treatment plan' - yes. But what if a new patient came to us bearing a treatment plan done by someone else? They might as well wear a dayglo vest with 'Potentially Big Trouble' written in 46-point type front and back. Virtually certain referral to the great big Ivory Tower just down the road. I suppose that's the difference, really. I don't work to anyone else's treatment plan. Just mine.

Posted by docholliday 15/12/11 at 09:53

Excellent comments Doch.
I thought I would stop but I have read a couple of silly comments that I have to write this.
"£15000 vs £8000 for implant treatment "with the same qualification" !!
If as a dental hyg , you do not know this, then this is another good reason for my argument about the difference in the level of knowledge between Dentists and hyg. and therapists. The difference can very well be justified depending on the kind of training, experience and skills + material used. There are people out there who are doing implants after a week-end course or a 10 day course in the caribean (which the GDC should put a stop to btw) and the people who have an Msc in implantology or a prosthodontist or some one who has been on lots of different courses and has maybe 10 - 15 years of experience. You can also use the well proven implant systems or the ones that you buy for £40 - £50 hence the difference in price and certainly quality.
There are very specific criterias for something to be "evidence based" I am not going to get into it but do not throw these words around (just to try to make your comments sound better) when you don't know what they mean and when and how to use them.
The patients can legally ask for a treatment plan. Yes. Does the next Dentist / hyg / therapist they see have to follow that TP NO
I will not treat any patients according to someone elses treatment plan. They want to see me , I do my own treatment plan or they can go somewhere else.

Posted by Expat 15/12/11 at 11:08

Quite frankly I have had enough- Forgive me for not knowing my role in the dental team.

That second quote came from a recommendation made by me- I gave him a couple of well respected qualified implantogists- please do not make assumptions on my knowledge in such a public manner it is bullish and shows you up more than me- I know what I am talking about, the systems used and the research behind them.

Regarding treatment plans- I know what you mean about working to someone elses treatment plan - hygienists have to do it all the time - the majority change it though- that is the current GDC guidelines- makes a mockery for patients dont you think? Direct access will resolve that and make it much clearer for patients.

Posted by chrischat 15/12/11 at 14:42

Chrischat let's just agree that we disagree with da . You see only the positive and we don't . As I said I think this is the thin end of the wedge. It opens yet more fractionalisation of the profession and will lead to confusion in the minds of the patient. All organisations and professions need a hierarchy for clarity with someone at the top who is ultimately responsible . That exists now and I see no advantage in changing what if everyone does their job well a successful arrangement for patient care.

Posted by gordie 15/12/11 at 15:13

A lot of patronising, misguided and destructive comments here...

Posted by Young_EU_NHS_GDP..aka..Satan 19/12/11 at 08:39

Can I remind all that the the OFT have asked for comments re direct access by today - 19th
Nows the chance to have your say.

Posted by chrischat 19/12/11 at 13:18

Here is the link
http://www.oft.gov.uk/OFTwork/markets-work/market-studies-further-info/current/dentistry/dentistry-survey

Posted by chrischat 19/12/11 at 13:23

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