Sir, as in photography where cameras can be aperture priority, or, speed priority, I have come to the conclusion that Dental Practice within the NHS, can be 'patient priority' or 'business priority'. Patient priority practitioners will always put the interests of the patient first, business priority practitioners will always consider their bank balance first. I accept that there will be 'average' practitioners who endeavour to practice ethically whilst avoiding an overdraft at the bank, but, most practitioners will have an inclination towards one priority or the other.

Until now, this has been difficult to quantify. Recent publications from the Dept. of Health1 inform us that after joining a PDS pilot, practitioners' restorative treatment patterns decreased by about 10%. In other words, when the pressure to practice in a 'business priority' mode was removed, and practitioners were free to practice in a 'patient priority' mode, their prescribing habits changed by 10%. Thus, the new draft contract for the General Dental Services2, (Clause 13 g) concludes: “In the period from 1st October 2005 to 30th September 2006 practices will be able to free up capacity of a minimum of 10% of weighted courses of treatment”. Clauses 13 i & 13j go on to state: “NHS commitment will be measured as 95% of weighted courses of treatment in the base year”, “within that 95 % of courses of treatment, practices will see at least 5% more patients by 30th September 2006”.

Some of us have always endeavoured to practice in a 'patient priority' mode. Our practice introduced a reserved one hour emergency period 20 years ago! We have always offered advice on diet, oral hygiene and preventive methods. We have always had a system of watching and reviewing early enamel lesions. We have always had a flexible patient recall system based on a risk assessment of the patient. We did not wait until there was no financial penalty for doing these!

It is now clear that the NHS has been penalising 'patient priority' practitioners by a minimum of 10% of gross income (or a minimum of £10,000 per annum of net income). By adopting historical financial data as the basis for the new contract, the Department of Health is ensuring that this penalty continues in the future. In addition, it would appear that facilities are being placed in the new contract to further penalise these practitioners when they are unable to achieve further savings and take on more patients, because they are already treating patients in a 'patient priority' mode and have limited or no ability to alter their prescribing patterns further.

This contract is intended to be a 'fresh start'. The draft however, contains basic mistakes and false assumptions which will almost certainly ensure that practitioners, who have become disillusioned with the NHS and reduced their commitment to it, are certain never to return again.

Professor Raman Bedi, Chief Dental Officer for England responds: Mr Byrne's letter raises some interesting misunderstandings with regard to the dental reforms. It is rather unfortunate that I have to disagree with the primary point your correspondent makes about dentists' priorities when treating patients. I believe that the vast majority of practitioners put the needs of the patients first, providing good patient care while at the same time wishing to maintain a reasonable level of earnings, consistent with their training and personal investment in their practices. The current item of service system does tend to focus the mind on individual fees, which is the reason that we wish to get away from it in our current reforms. Our PDS pilots and Modernisation Agency field sites confirm our belief that when the subconscious drivers of the item of service system are removed, the numbers of items of treatment provided fall by at least 10%.

The new contractual arrangements and the Heads of Agreement document published on the BDA website in September 2004 showed that the government expected savings to be made in terms of time spent on intervention type treatment and intended to share those savings with practitioners.

I do not understand how we are “penalising practitioners by a minimum of 10% gross income”, especially as we have given a very clear guarantee that gross income will be protected for a period of three years in return for a maintained NHS commitment. The sort of data contained within the Heads of Agreement document is to be provided to PCTs and dentists alike.

The document also says that if your NHS commitment – as measured by weighted courses of treatment – fell outside the agreed parameters then this would not trigger a reduction in contract value, but would trigger a discussion between the PCT and the contract-holder. If you were able to show that you were adopting these new ways of working prior to the introduction of the new contractual arrangements, then that could be agreed between you and the PCT and both sides would obviously be benefitting. The intention of this legislation is to make the NHS a more attractive place for dentists to work and to ensure that taxpayers get a better return on the major investment they make in NHS dentistry by delivering the most appropriate patient-led service.

The current demand from dentists to move into early PDS is enormous. We expect to have 25% of practices in pilot arrangements by early April 2005, and more applications are coming in daily.

It seems that the profession as a whole does see the advantages of the new ways of working, appreciates the benefit that working in the NHS can bring – for example, the NHS pensions scheme, maternity pay, free Continuing Professional Development and, as the service develops, closer integration with the rest of the NHS and involvement with NHS-funded capital developments.