Sir, I was extremely interested to read An analysis of patient expenditure in the GDS in Scotland 1998 to 2007 (BDJ 2011; 211: E3) by Chalkley, Rennie and Tilley. This provided an opportunity to revisit a 'fee for item of service' (FIS) contract and highlighted the tensions which I experienced as a practice owner of a field-site with the Dental Modernisation Agency from 2002-2006.

The objectives of the practice field-site were to adopt a much more preventative philosophy in the delivery of dentistry and to this end change the skill mix within the practice, developing care pathways operating within GDC regulations which involved the therapist, hygienist and oral health educator.1

The FIS contract did not translate readily into our new method of working where two systems were operating contemporaneously: the fee scale from the FIS contract was still in place but the practice was given a global sum without targets attached calculated on the income generated in a six month period of our FIS contract. Those who have worked within the FIS contract will be familiar with the 'widgets' of dental treatment along with the related time bars within which one could raise a charge for certain procedures. Moving away from a delivery system no longer in tune with this method of remuneration led to a drop in patient charge revenue.

Chalkley et al. considered the cost of dental treatment to the patient any shortfall in patient charge revenue results in an increase in state subsidy for dentistry, and hence the taxpayer. I understand that panic, arising from financial information gathered by the Audit Commission which showed a fall in patient charge revenue across early phase field-sites, led to their early demise without proper evaluation and, in turn, to the UDA system. However, when the treatments provided within my field-site, operating to its preventative ethos, were hypothetically converted into UDAs, on my calculations, patient charge revenue was back up to the original level.

Within our site we had several measures related to our activity. From the DPB schedule we maintained the level of patient registration and if people dropped off the list within the two-year period, as they did in a very mobile catchment area, we were able to take on new patients. Together with the Modernisation Agency, a group from the field-sites developed a computer program which measured the number of contacts each patient had with the dentists, therapist, hygienist and oral health educator. At the end of each course of treatment a patient was given a numerical score which linked to the assessment of their periodontal condition and caries activity, proving an excellent oral health motivator. On a weekly basis we monitored the availability of appointments so that we had an ongoing awareness of how easy it was for registered patients to access our services. We also gathered patient feedback and gave particular attention to communicating details to patients of service changes and developments. However, the focus was on our activity and not on the patient charges that were generated.

Although I welcome the recommendations of the Steele Report, my experience does raise the question as to what system of quality measures will be implemented if the patient charge revenue is to be maintained. Clearly, whatever system is in place in the future it is important to have the patient charge revenue reliably maintained so that the contribution of the state remains constant and at a politically acceptable level.