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Sir, can there be any justification or moral basis for blaming and penalising general dental practitioners (GDPs) for outcomes beyond their control? The _Dental contract reform: Prototypes

overview document_1 includes a dental quality and outcomes framework carried forward from previous papers. This places up to 10% of NHS remuneration _'at risk'_; 30% of this (3% of

the total contract value) falls into the Clinical Effectiveness (Outcomes) domain where outcomes relate to decayed deciduous and permanent teeth as measured by dt and DT indices, and

periodontal health determined by the BPE score. Virtually all theories of health promotion from the Ottawa Charter of WHO onwards stress the necessity for an overall strategy for health

promotion in order for any action to have the greatest chance of success. Vital areas include building healthy public policy, creating supportive environments, strengthening community

action, developing personal skills, and re-orienting health services. Government inaction has resulted in, amongst other outcomes, failure to construct an effective policy to counter obesity

which would have been consistent with actions to reduce sugar intake and thereby have reduced the likelihood of success of an individual dental practitioner in reducing dental disease. The

new dental contract contains a complex pathway for assessing the risk of a patient to dental disease. The embedded nature of oral health-related lifestyle habits informed NICE2 to conclude

that the most consistent predictor of caries risk is past caries experience (clinical evidence of previous disease), again showing an acceptance of the deeply embedded nature of health

related habits. Under the Care Quality Commission regulation of dental practices programme, one of the fundamental questions relates to services being well led. Inspection reports reveal a

desire for staff to experience a 'no-blame' culture. This characteristic of good leadership facilitates admission of failings by identifying why things may not have gone as desired

and diagnosing actions to take to minimise the risk of recurring events, and continually improve services. A blame culture is overtly evident in the GDC's aggressive approach to GDPs,

but it would have been hoped that good leadership principles in service designers and managers might have been manifest in the construction and values of a new contract. Whilst there may be

no doubt that appropriate intervention by GDPs will help to improve the oral health of their patients, it is singularly inappropriate to blame and penalise them for any failure which is

clearly outside of their control. While 3% may sound a small proportion of dental remuneration it is 3% of gross practice income which translates into roughly 7% of the dentist's

personal income (assuming practice expenses of 55%), or in excess of £5,000 per year. Where is the moral or theoretical justification for this? Are dentists ready to accept a new contract

which is fundamentally flawed or will government push the profession along the same track as junior hospital doctors? 1. By email REFERENCES * _Dental contract reform: Prototypes overview

document_. Finance and NHS Directorate, 2015. * National Institute for Clinical Excellence (2004) Draft for second consultation. Dental recall: recall interval between routine dental

examinations. Available at: https://www.nice.org.uk/guidance/cg19/documents/dental-recall-second-consultation-nice-guideline2 (accessed November 2016). Download references AUTHOR INFORMATION

AUTHORS AND AFFILIATIONS * Seaford J. Aukett Authors * J. Aukett View author publications You can also search for this author inPubMed Google Scholar RIGHTS AND PERMISSIONS Reprints and

permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Aukett, J. Contract reform: Who's to blame?. _Br Dent J_ 221, 686 (2016). https://doi.org/10.1038/sj.bdj.2016.889 Download citation *

Published: 09 December 2016 * Issue Date: 09 December 2016 * DOI: https://doi.org/10.1038/sj.bdj.2016.889 SHARE THIS ARTICLE Anyone you share the following link with will be able to read

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