Membership FAQs

A. Over the years we’ve had many enquiries from members regarding working with or without a nurse - even more so since publication of the GDC Standards for the Dental Team which came into effect on 30th September 2013.

Our view is that it’s in the best interest of patients that our members work with the support of an appropriately qualified member of staff. But of course, working as a clinician, this isn’t always easy to enforce - financial constraints being cited as the most common barrier to providing a nurse.

The new guidance makes it very clear that every clinician needs to have another member of the team in the room with them and includes great emphasis on the definition of the terms “should” and “must” in order to clear up any ambiguity.

The issue of lone working has been raised with the GDC and  it was explained that many of our members find difficulty in complying with this requirement. Appointment times are being shortened, and wages are being cut in order to afford to have nursing support.

The GDC responded by saying that they are aware of this situation and have published the following new guidance:-

  • Standard 6.2 states that you must be appropriately supported when treating patients.
  • In 6.2.1 we make clear that you must not provide treatment if you feel that the circumstances make it unsafe for patients and this is our primary concern.
  • 6.2.2 states that you should work with another appropriately trained member of the dental team at all times when treating patients, except in the particular circumstances outlined in the Standards for the Dental Team.
  • It is not acceptable for dental professionals to be working alone on the premises when they are treating patients. Ideally, we would want all members of the dental team to have another member of the dental team with them in the same room, when they are treating patients.
  • However, if in their professional judgement, they decide that having another member of the dental team on the premises who is able to offer them support if needed, complies with the requirement to ‘work with’ an appropriately trained team member and does not put patients at risk, and they therefore choose to work under this arrangement, they must be able to justify their decision.
  • BSDHT still recommend that you speak with your indemnity provider before making a decision.

A. Please see the link for the Medical Emergencies guidelines from the resuscitation council which advises that every member of staff in a dental surgery should be trained in medical emergencies. This is also the advice of the GDC.

The GDC have also said that the minimum number of trained staff in medical emergencies treating a patient in the surgery at any time should be two. This would be the person treating the patient and another appropriately trained staff member working with them. In exceptional circumstances one clinician can work on a patient if there is another person with them in case of an emergency to phone for help etc. This is only in exceptional circumstances. For example if a dentist has to open the surgery at the weekend because a patient is in pain and then can’t get another member of staff to help, then it would be acceptable to bring an extra person who is not trained.

The new CPD guidance recommends that all registered members, as part of the minimum verifiable CPD requirement undertake Medical Emergencies: at least 10 hours in every CPD cycle ­ at least two hours of CPD in this every year.

Anaphylaxis kit Route Dose Quant
Buccal Midazolam (Epistatus)10mg/ml Buccal Buccal Midazolam (Epistatus)10mg/ml 1 bottle
Adrenaline pre filled syringes *I.M use only Injection 1mg/ml x3
Oral Glucose e.g dextrosol, Hypostop Tablets/ powders According to manufacturer's instructions 2 tubes/ packs
Glucagon I.M Injection 1mg kit x2
Aspirin tables Soluble orally 150-300mg 1 box
GTN spray Sub-lingually 400ug per dose x1
Salbutamol inhaler Inhalation 100ug per dose x2

A. In medicines legislation (The Human Medicines Regulation 2012, The Misuse of Drugs Regulations 2001) PGDs are required for:

  • the administration of all parenteral Prescription only Medicines (PoMs)
  • the administration of midazolam (a controlled drug)
  • the supply directly to patients of all PoM and Pharmacy (P) medicines

Medicines legislation does not require PGDs for:

  • administration of non-parenteral PoMs
  • administration of P or General Sales List (GSL) medicines
  • supply of GSL meds directly to a patient.

Medicines legislation exempts certain parenteral PoMs from the requirements if used in an emergency to save a life. These medicines do not require a prescription and may be administered by anyone.

Taking each of the medicines on the dental emergency drugs list:

  • Glyceryl trinitrate (GTN) spray (400micrograms / dose): P medicine
  • Salbutamol aerosol inhaler (100micrograms / actuation) non-parenteral : PoM
  • Adrenaline injection (1:1000, 1mg/ml) Parenteral: PoM allowed for use in an emergency
  • Aspirin dispersible (300mg): P medicine
  • Glucagon injection 1mg Parenteral : PoM allowed for use in an emergency
  • Oral glucose solution /tablets /gel/powder: Not a medicine
  • Midazolam 10mg (buccal) (see Appendix (viii)): Controlled Drug
  • Oxygen: Not a PoM

That means that except for midazolam for which a PGD is required, all other medicines may be administered without a PGD. If you follow the algorithm in To PGD or not to PGD on the PGD website where the medicines involved are P(Pharmacy) or GSL(General Sales List) medicines for administration (not supply): ‘PGD not required.

A protocol can be implemented to administer medicines that are P or GSL. This may also apply for medical gases, none of which are POM.'

In conclusion, although there is nothing to stop an organisation opting to use PGDs for all emergency drugs they are not a legal requirement except for the administration of midazolam. However, use of robust protocols would be good practice. If PGDs are used they must comply with medicines legislation.

When it comes to injecting or administering drugs in a medical emergency the GDC believe you should act in the best interest of your patient. That would mean that if they needed a drug to save their life you would be acting in their best interest to administer it.

A. A Patient Group Direction (PGD) is a legal document and therefore must be completed as set out by law. This means that regardless of POM’s being used or sold the document must adhere to the strictures of the law. To get a good general understanding of the issues involved in setting up a PGD you should be familiar with the Good Practice Guide on PGDs issued by NICE in August (available at nice.org.uk ). However, the NICE GPG is aimed at the NHS setting and not the private setting although most basic concepts are guided by the law (Human Medicines Regulations 2012).

We have quite a comprehensive advice sheet on our website.

You do need a pharmacist to sign this document. It won’t be recognised otherwise.

The advice sheet we have on the website (above the template sheet) states it needs to be signed by

  • a dentist who should have been involved in developing the direction AND
  • a pharmacist who should have been involved in developing the direction AND
  • a representative of the NHS body e.g. the local primary care organisation for NHS patients (often the Clinical Governance lead) OR
  • a representative of the registered provider (dental business registered with the Care Quality Commission) for private dental practices/clinics.

The last two are “or” and this would depend on the type of practice (NHS or private), but the first 2 are compulsory to make it a legal document.

PGD’s are quite common in the health service but you do need to use a Pharmacist who has competency in PGD’s. this may mean commissioning one if working in a Private practice.

A. The answer is yes. This is the very crux of their existence. PGDs are used extensively in NHS Walk-in centres where a large number of patients have not been seen by the service before.

Any template PGD that has been prepared cannot be used though without the involvement and signature of a local pharmacist and dentist. This is set out in the legislation.

Each PGD should be prepared specifically for the setting within which it is to be used.

A. We have an advice sheet on our website just above the PGD template which should have all the relevant information on necessary signatures and I have attached the NICE good practice guidance and a Q&A sheet which should also help.

The advice sheet we have on the website states it needs to be signed by:

  • a dentist who should have been involved in developing the direction AND
  • a pharmacist who should have been involved in developing the direction AND
  • a representative of the NHS body e.g. the local primary care organisation for NHS patients (often the Clinical Governance lead) OR
  • a representative of the registered provider (dental business registered with the Care Quality Commission) for private dental practices/clinics.

The last 2 are “or” and this would depend on the type of practice (NHS or private), but the first two are compulsory to make it a legal document.

I have to agree that getting a PGD signed is proving very difficult. In fact we have passed on quite a few enquiries to the former Chief Dental Officer for England to look into.

What I can tell you is that you will need a pharmacist who is competent in working with PGDs. This is proving quite difficult now with the demise of the PCT. There should be more suitable pharmacists than the 27 found in the CCGs though as each PCT would have had a suitable contact prior to the changes.

The dental contract is managed by the Area teams so they will have the responsibility of signing a PGD if it is an NHS PGD but not if its for private patients.

For private practice you may consider commissioning a chief pharmacist but I do not know the costs this might incur.

We are starting down the path of lobbying for limited prescribing rights for hygienists and therapists. It’s a long journey though, probably about five years. This will be a better solution for us but in the meantime a PGD can bridge this gap.

A. Patient Group Directions (PGDs) are written instructions allowing the sale, supply or administration of specified medicines by named, authorised, registered health professionals, to a pre-defined group of patients needing treatment in an identified clinical situation. Using a PGD is not a form of prescribing. it is a legal document which needs to be drawn up according with the law.

Dental therapists and dental hygienists (not dental nurses) have been recognised ‘registered healthcare professionals’ able to work under a PGD since 2010. The Human Medicines Regulations 2012 details the individuals allowed to work under a PGD in Part 4 of Schedule 16.

In private dental practices/dental organisations when PGDs are written by a non-NHS body and are being used outside the NHS, the practice/organisation is not required to inform local NHS bodies. NHS funding is not available for their implementation (e.g. writing, training, auditing). The private practice/dental organisation is responsible for ensuring that their PGDs are clinically sound, comply with legislation and professional standards, and that governance and audit procedures are in place.

Legislation requires that each dental PGD is approved and signed by :

  • A dentist* who should have been involved in developing the direction AND
  • A pharmacist* who should have been involved in developing the direction AND
  • A representative* of a local NHS body# for NHS patients OR
  • A representative* of the dental business registered with the Care Quality Commission for private patients AND
  • The manager of the dental clinic/practice

* Advice on experience and competencies that are expected of PGD signatories can be found in the PGD website Q&As. What experience and competencies are expected of PGD signatories? and responsibilities of signatories of PGDs and also in the NICE PGD guidance, Section 3.7 and Table 2

# From April 2013 Clinical Commissioning Groups, local authorities and the NHS Commissioning Board Area Teams were given the powers required to authorise PGDs. Legislation also put in place transitional arrangements allowing PGDs to remain legal after their original authorising body was abolished.

A. Yes, mandatory CPD began on 1 August 2008. Further details can be found in Continuing Professional Development (CPD).

A. Unfortunately we don’t have a template for treating patients under direct access, we can only offer guidance. The main reason we don’t have a template is that we as a profession will not be treating patients any differently because of Direct Access (DA). We will follow the same procedures we always did. Each patient will have medical history updated, consent given, etc. just the same as we would have prior to 1/5/13.

Our former President Julie Rosse wrote and published some guidance. It was sent out with Dental Health. There have been a few minor changes since then which are discussed on the website documents - see Guidance Notes section of the website to download a copy.

These are essentially the same regulations that we had to adhere to prior to DA. The only real differences between now and before DA are that you:

  1. Need to let the patient know that you are working under direct access and that you can only work within your scope of practice. (i.e. you can't do a full dental examination, etc.)
  2. That they can phone and make an appointment with you without the need to be seen by a dentist first
  3. You have discussed and developed a referral protocol between yourself and the patients dentist. (Normally this is easy if you and the dentist are in the same practice, but for hygienists and hygienist therapists that work independently this needs to be in place.)

The GDC have recommended that patients are made aware of your scope of practice and how to book appointments via your practice literature, website, Facebook... but it is also an idea to clarify this with your patients again before getting consent.

The key points to remember are:

  • Only to carry out treatment that you are competent and qualified to do.
  • Work only within your scope of practice, except for tooth whitening, taking radiographs and giving POM’s (except where a PGD is in place) which need a PSD and therefore can only be undertaken out-with direct access.
  • Abide with the all GDC guidance documents with special focus on:
    • Patient consent chapter 3 in Standards
    • Standards
    • New scope of practice

The anomalies in the NHS contract do not allow for direct access use in the NHS. For the time being direct access is only available in a private capacity.

  • I have attached some documents for you and you can also access 2 documents on our website guidance notes found under the research and resources tab.
  • The GDC document was updated in December 2013 (even though it says April 2013) so it includes the changes to diagnosis. The other documents show where we are at the minute with the anomalies of DA.