February 2006
GPC
General Practitioners
Committee
Patients presenting with dental
problems: GP responsibilities
Guidance for GPs
link to page 2
Patients presenting with dental problems: GP responsibilities
Introduction
This guidance has been amended (superseding 1998 guidance) to take account of changes to
the General Medical Services regulations.
1 It informs primary medical service contractors in
the UK of their obligations in respect of patients either requesting emergency dental
treatment or asking for an NHS prescription for drugs recommended by private or NHS
dentists.
Emergency dental services
General dental practitioners have an ethical responsibility to provide reasonable access to
advice and emergency treatment for their patients, including those who are seen under a
private contract. This does not however mean that a dentist has to be personally available to
see patients 24 hours a day. From April 2006 NHS dentists in England and Wales will no
longer have a registered list of patients and will lose the continuing care responsibility
together with the obligation to provide emergency dental care. A dentist’s immediate
responsibility will be to patients who are currently undergoing or have recently completed a
course of dental treatment with them. These changes are due to follow in Northern Ireland
from April 2007. In Scotland, however, NHS dentists will continue to hold a list of, and have
continuing care responsibility for, registered patients.
The General Dental Council’s principles are that dental professionals are responsible for
putting patients’ interests first and that they must cooperate with other members of the
dental team and other healthcare colleagues in the interests of patients. A dentist working in
any branch of dentistry would therefore have an ethical responsibility to make appropriate
arrangements to ensure that patients for whom responsibility has been accepted have access
to emergency treatment outside normal working hours and that such arrangements are made
known to patients.
Now that Primary Care Organisations (PCOs) are responsible for the provision of out of hours
care in England and Wales, most will provide emergency out of hours dental treatment for
patients. From April 2006 PCOs may also buy in-hours open access emergency sessions from
dentists.
GPs’ obligations
Because many dentists do not accept NHS patients, and despite the fact that most PCOs now
provide emergency dental services, dental patients often contact their GPs when they require
emergency dental treatment. When this occurs, NHS GPs should be aware of the following
legal and contractual obligations.
1 The National Health Service (General Medical Services Contracts) Regulations 2004
[www.opsi.gov.uk/si/si2004/20040291.htm]
The NHS (General Medical Services Contracts) (Scotland) Regulations 2004
[www.opsi.gov.uk/legislation/scotland/ssi2004/20040115.htm]
The National Health Service (General Medical Services Contracts) (Wales) Regulations 2004
[www.opsi.gov.uk/legislation/wales/wsi2004/20040478e.htm]
The Standard General Medical Services Contract (NI) 2004
[www.dhsspsni.gov.uk/hss/gp_contracts/documents/ni_contract_mar04.pdf]
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Before refusing to treat a patient asking for emergency dental treatment, a GP must ascertain
that the condition requires only dental treatment. As always, GPs must put themselves in a
proper position to judge the nature of the patient's condition by undertaking reasonable
enquiries.
Having established an apparent dental problem, GPs should refer a patient for any further
treatment, if necessary, to a dentist or local emergency service. If the patient has no usual
dentist, or there is no response from the usual dentist, the patient should contact:
• the local Patient Advice and Liaison Service (PALS) in normal hours (England
only)
• NHS Direct (or Scotland NHS 24) out of hours
PCOs may cooperate with each other in some areas to provide emergency out of hours
provision. This service is likely to be similar to those services that PCOs currently provide for
non-registered (dental) patients and may take the form of a fixed OOH clinic, an on-call
service or a combination of the two models.
The GP’s obligation to refer is set out in the GMS and PMS (Section 17C in Scotland)
regulations.
2 This obligation entails making available treatment or further investigation as is
appropriate, including referral of the patient for other services and liaison with other health
care professionals involved in the patient’s treatment and care.
If GPs choose to treat a patient themselves such treatment would be provided under general
medical services and the level of skill and degree of care the GP would be expected to
exercise is that of a general medical practitioner. The determination of a complaint by a PCO
against a GP would take this into account. GPs should not, however, attempt to manage a
condition requiring dental skills unless they have the appropriate training and expertise. Both
the civil courts and the GMC require doctors to have appropriate skills for any treatment they
offer.
Even in cases where the patient is not registered with a dentist, and the GP is unable to
contact a local emergency dental service, the treatment of dental problems is not the
responsibility of GPs. In such circumstances, the patient should be referred to the nearest
accident and emergency department.
2 Regulation 15(4)(b) of the GMS regulations in England and Wales and Scotland, clause 47 of the Standard
General Medical Services Contract in Northern Ireland
Schedule 5, part 1, paragraph 1 of the National Health Service (Personal Medical Services Agreements)
Regulations 2004 in England [www.opsi.gov.uk/si/si2004/20040627.htm]
Schedule 2, part 1. 1(3)(b)(ii) of the National Health Service (Primary Medical Services Section 17C Agreements)
(Scotland) Regulations 2004 in Scotland [www.hmso.gov.uk/legislation/scotland/ssi2004/20040116.htm]
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Prescribing
Dentists treating patients under the NHS are obliged to prescribe from the dental
practitioners’ formulary, which is published as part of the British National Formulary (BNF) and
allows prescription of a limited range of drugs3. Any dentist who refuses to issue an NHS
prescription to an NHS patient or refuses to supply the appropriate drug, having determined a
need, could be found either in breach of his or her NHS terms of service, or guilty of serious
professional misconduct.
If, after seeing a dentist, a patient asks their GP for an NHS prescription, the GP should make
a reasonable investigation into the patient’s condition and accept responsibility for that
aspect of a patient's condition before issuing an NHS prescription. GPs should be cautious
about accepting a patient’s understanding of dental advice and, although they may take a
dentist's advice into consideration, GPs should satisfy themselves that what they prescribe is
appropriate to the patient's condition.
GMC guidance states that if a patient asks a GP to supply an NHS prescription the GP must
refuse unless they are sure they are able to accept responsibility for that prescribing decision.
If a legitimate need for an NHS prescription cannot be established it should not be provided.
This guidance would apply to patients seeking an NHS prescription following the issue of a
private prescription, or recommendation of a drug, by a dentist.
Recommendations for local arrangements
LMCs and Local Dental Committees (LDCs) should establish local links. This could be
achieved by, for example, ensuring effective cross-representation or by arranging for LMC
and LDC officers to meet regularly.
LMCs should liaise with PCOs and local out of hours providers to ascertain local arrangements
for emergency detail treatment. Out of hours providers may have local protocols for dealing
with dental problems.
GPs should ensure that any patients presenting with dental problems know how to obtain
emergency dental care. Arrangements for this care could be publicised in posters and leaflets
at doctors’ and dentists’ surgeries.
Dentists normally prescribe both NHS and private prescriptions from the Dental Formulary and
GPs should not expect to prescribe for dental conditions. Dentists should be encouraged to
tell their patients that a private prescription should be dispensed privately and to advise them
against approaching their NHS GP. GPs should not convert private dental prescriptions into
NHS prescriptions (this is set out in Health Circular EL(91)127 in England]
GPs can raise local problems with their LMC who can liaise with the LDC. If good LMC/LDC
relations are established, the LDC can be apprised of any difficulties with emergency
arrangements.
3 NB - The BNF Dental Formulary is only restrictive for dentists prescribing within the NHS. The whole formulary
is available for dentists prescribing privately.
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Document Outline