Nigel Jones offers an overview of the dental landscape in Northern Ireland as it navigates a period of systemic strain, shifting workforce dynamics, and a growing divergence between NHS and private practice models.
Although NHS dentists in each of the four home nations strive towards the common goal of providing patient care, since devolution in 1998, the systems under which they work can be markedly different from each other.
NHS dentistry: a system under pressure
At the heart of the current crisis is the erosion of NHS dentistry’s financial and structural integrity. Although the dental budget in Northern Ireland was loosely ring-fenced, that appears no longer to be the case, as over the last year or two it has been reallocated for other expenses, such as covering the nurses’ pay increases. Consequently, funds for dentistry are insufficient to be able to offer dentists a pay and expenses uplift sufficient to cover the ever-increasing costs of running a dental practice.
Despite a long-running pilot scheme involving a limited number of practices which aims to improve access for unregistered and migrant patients, the drift towards private dentistry continues. Participating practices receive a lump sum per patient and are expected to operate within the constraints of the NHS system. However, the antiquated Statement of Dental Remuneration (SDR) system, similar to the Scottish system, allows for a mix of NHS and private treatments. Meaning dentists can benefit from the NHS fee for seeing the patient but are still free to offer private treatment.
The cost crisis and workforce imbalance
Rising costs are crippling practices across the board. Dental nurses, who pre-COVID may have been earning £10-11 per hour, now command £18 or more per hour. With the additional costs of pensions and the hike in national insurance contributions, the real costs for a nurse are much higher.
In addition, as the minimum wage increases for the lowest paid employees, to be able to maintain the differential between them and more senior staff members, all wages need to increase as well. So, an increase in the minimum wage could affect a practice’s whole salary structure.
Another problem for practices is that hygienists are also in short supply. With no local training school in Northern Ireland for over a decade, the result is an ageing, part-time workforce earning £40 to £45 per hour, which puts a further strain on practice resources.
However, associates are the real winners at the moment and they are thriving. Many earn upwards of £15,000 per month without having the overheads and burdens of practice ownership. This has created a scenario where principals are left grappling with rising costs and diminishing returns, while associates enjoy high earnings and flexible schedules. In these circumstances, associates prefer the status quo to practice ownership, which has a negative effect upon the practice sales market.
The private shift: a new norm
The post-COVID era brought about a cultural shift in the profession. Young dentists, often just 18 months out of university, are opting to move into private practice, working three days a week and earning substantial incomes. Rather than being purely about money this trend’s focus is on lifestyle and wellbeing. They have no desire to subject themselves to the stress of high-volume NHS work with its accompanying constraints and bureaucracy. Consequently, they are choosing the slower pace and profitability of private care.
Conversions from NHS to private practice are also becoming increasingly common. Anecdotally, most practices that make the switch see a 20-30% increase in profit while treating fewer, more appreciative patients. The SDR system in Northern Ireland facilitates this transition by allowing practices to zone their appointment books – registering patients under the NHS while delivering much of the care privately.
Patient access and public perception
As with many other parts of the UK access to NHS dentistry remains a significant issue, particularly in rural and underserved urban areas. Dentists are reluctant to work in the NHS in these regions when private practice offers better pay and work-life balance. This has created dental deserts where patients struggle to find care, exacerbating health inequalities.
Another downside of NHS dentistry is public perception. Practitioners are reporting a growing attitude among some patients that NHS dentists are obliged to fix problems without any need for them, the patient, to take any personal responsibility for the state of their teeth. This entitled attitude, coupled with low patient charges and high expectations, contributes to professional burnout and disillusionment with the service.
The education and workforce pipeline
A critical bottleneck in the system is the limited supply of locally trained dentists. While Queen’s University Belfast has increased its intake, the majority of new students are international and unlikely to remain in Northern Ireland post-graduation. Of the 60 students admitted annually, only 20 to 25 come from Northern Ireland.
Dentistry is a profession that is female-dominated and offers a great opportunity for women to combine a career with family, if that’s what they want. However, that often includes part-time working. The net result is that of those 60 students, only 12 to 15 full-time equivalent dentists will be added to the local workforce annually.
To overcome this, a solution similar to the one successfully implemented in parts of Scotland during the oil boom of offering student debt forgiveness in exchange for a five-year NHS commitment could help address the access crisis and ensure a steady supply of NHS dentists.
The exit dilemma and practice valuation
For principal dentists nearing retirement, the future looks uncertain. Practices with high NHS commitments are increasingly unattractive to buyers, whether associates or corporates. As already mentioned, associates enjoy high earnings with minimal stress and so see little incentive to take on ownership responsibilities. Corporates, once aggressive acquirers, are now more cautious, especially given the inflated valuations and operational challenges of recent times.
This leaves us with a looming crisis of succession. Sadly, many principals may find themselves unable to sell and could be forced instead to scale back and manage their practices part-time into their sixties.
Looking ahead: reform or retreat?
Despite the bleak outlook, Northern Ireland’s dental system is not beyond repair. Compared to England, where clawbacks and UDA targets create a draconian environment, Northern Ireland still offers relative flexibility. Rather than having to take a ‘big bang’ approach like their colleagues in England, practices can make a gradual transition to private dentistry and although the SDR system may be antiquated it offers scope for creative adaptation.
However, without strategic intervention in education, workforce planning, and funding the system is at risk. NHS dentistry in Northern Ireland has reached a critical point. The current model, while not as punitive as England’s, is increasingly unfit for purpose. Rising costs, workforce shortages, and dentists’ shifting personal and professional values are driving a quiet exodus from NHS dentistry. Without bold, co-ordinated action, the region risks losing not just its dentists – but the very foundation of equitable oral healthcare.
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This article is sponsored by Practice Plan.
