ÐÏà¡±á>þÿ <Fþÿÿÿ;sÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Á5@ ø¿“+bjbjÏ2Ï2 +eXX[#ÿÿÿÿÿÿˆÒÒÒÒ"""6ººº8òdV<6%~žž"ÀÀÖµ4é$ %%%%%%%$'R])~2%"!W^µ!!2%ÒÒÀÖG%ooo!LÒ8À"Ö%o!%oVoÅVø"@ "¼#Ö’ Ã¬ÞûÆºm|8# $l]%0%D#xÛ)éjÛ)¼#66ÒÒÒÒÛ)"¼#ä!!o!!!!!2%2%66„ºS66ºDecember 2005 GPC General Practitioners Committee Patients presenting with dental problems: GP responsibilities Guidance for GPs Patients presenting with dental problems: GP responsibilities Introduction This guidance has been amended (superseding 1998 guidance) to take account of the changes in The National Health Service (General Medical Services Contracts) Regulations 2004. It informs primary medical service contractors 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 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. 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, 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. 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 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 PCTs 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 regulation 15(4)(b) [Essential services] of the GMS Regulations and in schedule 5, part 1, paragraph 1 of the National Health Service (Personal Medical Services Agreements) Regulations 2004. Regulation 15(4)(b) Essential services ‘Management’ includes the making available of such treatment or further investigation as is necessary and appropriate, including the referral of the patient for other services under the Act 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. 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 and allows prescription of a limited range of drugs. 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 [see paragraph 39 of the NHS (GMS Contracts) Regulations 2004 below]. 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. If a patient asks a GP to supply an NHS prescription the GP must refuse unless they are sure they are able to accept sole responsibility for that prescribing decision (see health circular EL(91)127). If a legitimate need for an NHS prescription cannot be established, under paragraph 39(1) of contractual terms, 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. Paragraph 39 (1) [PMS paragraph 38 (1)] – Prescribing Subject to paragraphs 42 and 43 [PMS paragraph 39 and 40], a prescriber shall order any drugs, medicines or appliances which are needed for the treatment of any patient who is receiving treatment under the contract [PMS agreement] by issuing to that patient a prescription form or a repeatable prescription and such a prescription form or repeatable prescription shall not be used in any other circumstances. Paragraph 42 (1) [PMS paragraph 41(1)] – Restrictions on prescribing by medical practitioners In the course of treating a patient to whom he is providing treatment under the contract, a medical practitioner shall not order on a prescription form or repeatable prescription a drug, medicine or other substance specified in any directions given by the Secretary of State under section 28U of the Act (GMS contracts: prescription of drugs etc) (a) as being drugs, medicines or other substances which may not be ordered for patients in the provision of medical services under the contract but may, subject to regulation 24(2)(b), [PMS 15(2)(b)] prescribe such a drug, medicine or other substance for that patient in the course of that treatment under a private arrangement. 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. [See prescribing responsibilities and refer to EL(91)127] 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. 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