Against a backdrop of immense pressures in Health Service dentistry, a shift in the dental landscape following the COVID-19 pandemic and a cost-of-living crisis, it's only natural to consider your options - including the amount of private work you offer. A decision to move away from Health Service provisions is never easy, but it may be the only viable option available to protect your future.

BDJ In Practice spoke to Ciara Gallagher, Chair, BDA NI Dental Practice Committee, about the dento-political landscape as she sees it, as well as why now is the right time to be assessing your own landscape within the profession.

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Why is it important for practitioners to consider all of their options at this moment in time given the dento-political landscape?

CG At the best of times, as Dan Kennedy once wisely said, one is the most dangerous number in business. One client, one supplier and one source of income. Relying on one source of revenue makes your business brittle and changes in this source that are out of your control, can have a devastating effect.

So when that one primary source of income is the NHS, a primary source of income where sequential and unilateral changes to terms and conditions have resulted in significant reductions in real-term take home pay in the last ten years. Then Dan Kennedy's words can be heard as knelling the end for NHS focussed dental practices.

The Department of Health acknowledges that additional funding is needed, but there is no minister in place to action this. In the face of spiralling costs of care and in the absence of any foreseeable change, it is essential that practitioners consider all their options - and in doing so, consider the stark fact that NHS committed associates in Northern Ireland have the lowest incomes of all dentists in the UK.

Providing a proportion of private dentistry - an area where what is paid for care is much more reflective of the cost to provide this care - is becoming increasingly essential to ensure business viability.

What has led to the number of practitioners increasing their provision of private dentistry?

CG The NHS business model, with its bureaucracy, high workload and low or no margin has created a stressful working environment, where providing proper patient care, which is what we all aspire to do, strikes at the heart of our business.

The disconnect between what is paid by the NHS for care and the actual cost of this care, means it is nigh on impossible to run a viable dental business providing solely NHS dentistry. There is a poor return on time and financial investment, little scope to apply enhanced skills and little or no money for modernisation.

It is a relentlessly downward spiral and the absence of any sign of this changing is driving dentists away at an alarming rate.

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© Peter Dazeley/Photodisc/Getty Images Plus

How do you see the future model of the dental workforce in Northern Ireland?

CG Quite frankly, the future model of the dental workforce in Northern Ireland depends on how much the government are prepared to invest in the NHS.

According to a recent BBC commissioned survey, last year 90% of patients who wanted to could not register as an NHS patient because we do not have enough dentists willing to work in NHS dentistry.

Expanding capacity to meet this need requires two things: NHS dentistry must receive sufficient funding to be viable and be attractive as a career option, and we must train more people who can deliver all aspects of dentistry, including preventative, restorative, endodontic, periodontic, prosthodontic, orthodontic and surgical.

Not every aspect of these branches of dentistry will require the direct input of a dentist. Dental therapists, hygienists, clinical dental technicians and nurses working to the full scope of their practice can provide many procedures independently or under the prescription of a dentist. Furthermore, digital dentistry, milling and printing of prosthetic devices is likely to reduce reliance on dental technicians.

Ideally, practices of the future would have all of these professionals working to the top of their scope of practice.

Is there an existential threat to Heath Service dentistry, or is that an exaggeration?

CG There is an existential threat to Health Service dentistry.

The very existence of NHS dentistry is under threat through the failure of the Department of Health to quantify and address the cost of care and reflect it in the fees allocated for NHS treatments.

We are in the business of patient care. The purpose of NHS dentistry is to provide dental care for patients. Under the current level of NHS funding it is nigh impossible to do this. Until and unless there is significant action taken on dental payment reform, Health Service dentistry is on a worryingly steep downward trajectory. DDRB have made that crystal clear, along with what actions are required of all governments. Despite this, things have got worse in Northern Ireland through recent cuts to the much-needed RSS and there is no end in sight. Lack of government and budget are undoubtedly constraining factors, but it is no less true what businesses in Northern Ireland need to survive, compared with elsewhere. Scotland have acknowledged and acted upon this, we need the same big steps here.

Thus there is an existential threat to Health Service dentistry.

What will happen if the balance dramatically shifts to private dentistry provisions? Would that theoretically be beneficial for patients?

CG Yes, if a patient can afford to pay for private dentistry. No, if a patient cannot afford to pay.

In private dentistry what is charged reflects the cost of care, there is a budget to invest in the most up to date technology, use the highest quality materials and create comfortable modern surroundings. The patient experience and the clinical outcomes are optimised. This is very beneficial for patients and highly satisfying for dentists.

On the other hand, many cannot afford to pay, so a whole cohort of the population will not be able to access dental care because they cannot afford it and health inequalities will widen. There will inevitably be an increased burden on other areas of healthcare such as GP surgeries and A+E, as patients in pain who can no longer access NHS dentistry seek help in ever increasing numbers.

The truth is that the balance is already shifting. How far it continues to shift will be directly related to government decisions on funding and contracts for NHS dentistry. It is often said that you can judge a society by how it cares for its most vulnerable. Those who have presided over the demise of NHS dentistry will be judged to have failed those who need it most.

For anyone starting out their career, what advice would you give to them to safeguard their future?

CG Build strong general clinical skills, find a mentor, ask for feedback and take it how it is intended. Become a really great general dentist first and foremost, and everything else will follow. It is natural to want to narrow your focus to your preferred sphere of practice, but it is important to spend a decent amount of time on general dentistry first. Narrowing too early can create blind spots. If there is a treatment you don't like, figure out why, and address that through additional training.

Buy loupes and take photographs, develop a critical but not harsh eye for your own work and strive every day to do even better dentistry than the day before. Learn from your mistakes but don't beat yourself up over them.

Invest in training and practice evidence-based dentistry - this will pay dividends, not only through increased clinical confidence but also improved clinical outcomes and better patient satisfaction. Stay in touch with the latest developments in digital workflow.

And finally, on a human level, make sure you leave work behind when you leave the surgery. Dentistry is a stressful profession and having strategies to decompress after a hard day is essential.