“So why did you become a dentist then Mr Thain?” was how the conversation started. My practice takes work experience placements from the local school and this was our first since the fateful day in March 2020 when Covid closed us.

That question about “why dentistry” really got me thinking. I’ve been a practice owner for almost 20 years now and a second generation dentist, having followed in my father’s footsteps.

What would he think of where we are now and where we are headed? I think more than anything else he’d be disappointed by the fact that it is now a near insurmountable challenge to provide many of our patients with the care they deserve.

The NHS model has relied on “contractor” dentists (like me) in independent businesses providing services in return for payments and with an expectation of professional competency – but also some professional autonomy.

For a multitude of reasons that model appears damaged if not outright broken and urgent change in our sector is needed if NHS dentistry is to survive.

Dentists don’t want the NHS to just survive – we want it to thrive. As chair of the Scottish Dental Association (SDA) we have sought to turn the challenges of Covid into a springboard for reform and our members have myriad suggestions as to what the Scottish Government should do next.

Currently, the Scottish Government has committed to a “New Model of Care” for dentistry and for a consultation process to begin later this year. As part of this we believe Scottish Government should hold a “Dental Services Summit” at the Scottish Parliament. A similar event took place at the Welsh Parliament and they are now embarking on a new dental contract and wider reforms.

Part of the consultation process must involve a repaired relationship between dentists and the NHS/ Scottish Government. Unfortunately, as of April, we have been returned to a funding model we were assured – in writing – would not return post Covid. This is just one instance of our profession either being told one thing for another to happen or just simply not being listened to at all by the Scottish Government.

It’s critical that dentists and their representatives are taken seriously in negotiations with NHS and Scottish Government leaders and, as a matter of urgency, work towards a more sustainable funding model; this is especially true given the significant increase in overheads over the past two years which increasingly makes NHS dentistry simply unaffordable to deliver on current funding.

Dentistry also faces a severe recruitment and retention crisis. New graduates and those from overseas are no longer attracted to the service and there are no easy answers to solving this. NHS dentistry needs to become attractive and fulfilling again; that goes much wider and deeper than merely what and how dentists are paid. We need to look at career development, facilitating training while remaining part-time in practice, and keeping more care delivery locally to benefit patients and dentists.

NHS dental services have a missing “middle” layer of intermediate level care: patients currently either see a general dentist or are referred to a specialist in a dental hospital. “Dentists with Special Interests” already exist in England and could provide a level of care between the practice and hospital, through the NHS, and both improve services and cost efficiencies.

The Scottish Dental Association is affiliated with the Royal College of Surgeons, Edinburgh, who have proposals to develop career pathways like this in Scotland and we hope this will make a difference in the future.

For the present, dentists could be supported and incentivised to offer as much locally as possible but this will take changes to our funding model – again, the lack of meaningful engagement from the Government with the profession has not helped to develop a potentially new way of working and I return to my point about us having to work better together for the benefit of our patients.

The impact of changing demographics is enormous in dentistry and we haven’t yet worked out how to deal with this. The population’s care needs change and while we now have ever increasing numbers of older people with teeth, age comes with co-morbidities, and often complex treatment requirements.

We also have to ensure that prevention is at the core of what we do to ensure our children get the best possible start and, if they remain engaged, can expect a life largely free of dental problems.

When I qualified most dentists still worked full time (normally long hours) in the same practice for years and so looked after the same patients for years. In line with other careers, there are now far more dentists working part-time and taking careers breaks than ever before. This trend will only accelerate with around 80% of our dental schools’ undergraduates being female.

With planning this could have been accommodated however there hasn’t been any planning for this and unfortunately Government quotes of “more dentists working in Scotland than ever before” doesn’t tell the whole story.

Contract reform must take account of this and a suitable model could be the General Medical Services contract of 2018. The trend towards a more flexible workforce and need for staff flexibility already exist in General Medical Practice and dental services could learn how to do better from our medical colleagues.

It seems like a missed opportunity not to develop the funding model, effectively a salary model, adopted over the past two years, if only as an interim measure. Such a model would allow dentists to focus on patient outcomes rather than focusing on providing items of treatment.

Ultimately the goal should be to have engaged and motivated patients requiring little active treatment, so a payment model based on provision of items of treatment is fundamentally flawed. Improving dental services also means focusing dental services on what the NHS should provide – and excluding what it shouldn’t provide.

This already happens in Orthodontic services, where cases judged mostly cosmetic - not functional - are unlikely to be funded, but it needs to happen across all dental services. Scottish Government has committed to remove any patient charge from dental treatment in the next few years, incidentally something I would welcome and applaud if implemented appropriately as part of a truly New Model of Care.

However, removing patient charges will remove 20% of the budget. Another 20% of the current budget is actually paid to high street Orthodontists who typically gross far higher fees than general dentists. What’s left is not going to cover the current range of dental options we are expected to offer on the NHS.

Something called the “Scottish Needs Assessment Program” (a bit like NICE but for dental services) already exists and has issued several reports over the last 15 years. This body needs rebooted and should be working now to establish exactly what dentists in the NHS should and shouldn’t offer our patients.

The SDA view is that primary care dentistry should be focused on prevention and good quality basic care for life. At the same time the system needs to fairly fund dentists and our practices and the model needs to be sustainable.

Many of us are being forced to move to private dentistry to keep our practices viable and ensure our staff are still employed. It’s not what we want to do but what we are having to do given the ongoing inertia of NHS reform.

I hope Scottish Government now make good on their promise to consult and introduce a new dental contract over this year – the clock is ticking.

Douglas Thain is a dentist, chair of the Scottish Dental Association and a partner at Central Dental Care in Cumbernauld