At the annual conference of Local Dental Committees (LDCs) earlier this month, delegates were updated on what’s going on in the devolved nations. Here’s what Ciara Gallagher, chair of Northern Ireland Dental Practice Committee, had to say.
In Northern Ireland, we are on a fee-per-item contract with some patient-based background allowances. The combined fees and allowances are nowhere near enough to run a modern dental business.
We were well supported during COVID, but when COVID support ended in March 2023, and we returned to the normal statement of dental remuneration (SDR), the business realities and the financial squeeze returned with it. At that point, we had no functioning government and no realistic route to reform.
So, practices responded in the only way available to them. They reduced NHS time, they increased private provision, extended recall intervals, and allowed registrations to lapse, whilst restricting new NHS activity. The result was predictable - registrations fell sharply, access deteriorated, and the dental budget began to underspend.
To tackle the crisis, the Government introduced a series of selected fee enhancements and an emergency dental access scheme.
No stability
The measures themselves made for relatively positive headlines. But when you look underneath, most of them are either too small to move the dial, targeted away from core practice sustainability, or just layered on top of fundamentally uneconomic fees.
We're training additional dentists, but it's a leaking bucket. And rather than continually topping up the bucket, as the BDA messaging says, plug the leaks - make health service dentistry a career destination rather than a stepping stone to private practice.
Schemes were designed to stabilise the system – for example, selective fee enhancements and enhanced child examination fees - but far from stabilising it, the decline continued at an alarming pace, with every output measure decreased year on year.
Needless to say, the lack of availability of care has led to complaints from patients to their elected representatives, resulting in our MLAs, who are equivalent to your MPs, asking multiple Northern Ireland Assembly questions and holding the Minister and officials to account for the crisis.
Since 2024, we've had three iterations of these in-year enhancement schemes. The BDA has appeared twice in front of the health committee, and twice there have been two full Assembly debates on dentistry, with the latest debate as recent as last month.
Messaging
The motion for debate highlighted the alarming shrinkage of the service and called for urgent action from the Minister. It was a real testament to BDA Northern Ireland team that most of the language used throughout the debate echoed our MLA briefings and media communications.
‘It is a crisis that the minister and successive governments have allowed to fester year on year without getting a grip’; ‘The crisis was not created by dentists’; ‘Dentists have been sounding the alarm for action’ and ‘There's no time to waste’.
Our messaging was written all over the debate and the response from the Minister was unequivocal: it’s a deep structural problem that requires a serious strategic response.
A serious and strategic response would be to set your health priorities, decide your budget, measure the cost of care, and figure out what you can buy according to your budget and your priorities.
But not only is there no more money, in Northern Ireland, there's no actual money, we are starting the financial year £800M in deficit so it was time for an honest conversation about what the Department of Health can actually afford.
Priorities
With that in mind, we had a meeting with our Health Minister to start that conversation. We presented the registration figures and invited an honest conversation. Health service dentistry is in free fall, and without intervention, it will disappear. We acknowledged the reality of no new money and we acknowledged the state of the health service in general. Our waiting lists are enormous, and patients are lying on trolleys in A&E.
So, dentistry is not at the front of the funding queue, but the status quo is not an option.
Our proposition was straightforward: if the government can’t fund everything, it should decide what it can fund. We should work towards a smaller, clearly defined service with a reduced treatment menu, but one where every item is properly costed and properly paid. We called this an Essential Dental Care Service.
The decision about what remains publicly funded should be made by health economists and public health experts, not by the BDA. Our position is not that we advocate the model, but rather that we wouldn't object to it if that's the only viable route to preserving access and sustainability.
Our Minister was interested and he invited further discussions with his officials at that stage. When I presented that to GDPC in February, Eddie Crouch expressed his doubts about follow-through. He had seen these conversations started and then allowed to melt away for fear of populist revolt.
And Eddie may be right because in the end, the department did not invite discussions around an essential core service. Instead, they commissioned a short-term working group called the GDS Reform Advisory Group. And the remit of the group turned out not to be pay reform. It's much more wooly than that. And there's no definitive time-based or fee-based output.
Cost-of-service review
The key to contract failure, as we've all heard, is the mismatch between costs and fees, and so the first stage in addressing this must be to measure the actual costs.
BDA Northern Ireland, as well as BDA UK, have repeatedly called for a cost-of-service review, and our minister finally commissioned it from Professor Ciaran O'Neill, who's a health economist at Queen's University in Belfast.
He used as his sources HMRC earnings and expenses data, BSO (payment organisation) data, DDRB evidence and NASDAL accountants’ figures - and also, uniquely, he’s taking into consideration the cost of opportunity. What would dentists be doing if they weren't doing health service dentistry? And how much do we have to pay them to stay?
The first draft was submitted on the 31st of March this year, and it was considered too data-heavy, too raw, inconclusive and difficult to understand.
Next steps
So, there's a new summary to be written. It should be made available to BDA and the Dental Advisory Group at the beginning of summer.
We have asked for sight of the full review as well as the summary report, because anybody who has put anything into AI and asked for a summary will know that mistakes can be made, you can input the right data and come to the wrong conclusion. So, we have asked for the raw data.
A lot is resting on the cost-of-service review. It should confirm for us what we already know and it should provide evidence for the Minister to get more money for dentistry from the Executive.
So, what happens next, and when?
In Northern Ireland, we have a short window of opportunity to translate the cost-of-service review into a rebasing of fees. Our elections are due in May next year, and political caution by ministers will likely begin in February - that's just eight months away - and I worry that although we are at the pivotal stage, with crucial evidence just around the corner, time may run out.
At the BDA AGM meeting, Martin Woodrow described Northern Ireland as having made the least progress of the four nations. That was difficult to hear, but it is also difficult to argue with, because despite extensive lobbying, repeated assembly debates, cross-party support, and sustained media attention, we have seen very little tangible improvement in terms and conditions in NHS dentistry.
But I remain cautiously optimistic. Registration numbers continue to fall, activity continues to fall, and the access crisis continues to worsen.
Now, none of those are positive developments, but what they have done is they have created a level of urgency that can no longer be ignored. So, if the cost-of-service review provides the evidence that we expect, it should become the foundation for meaningful reform.
We're at a pivotal moment, and my hope is that when I return next year, I will be reporting progress rather than potential.
This is part of a series on the devolved nations. Read the updates on Wales and Scotland.