Money - that’s what I want
Zoya Arain examines the growing use of financial incentives to motivate doctors
So, why medicine? the inevitable icebreaker we have all faced in our medical school interviews. The perfectly memorised rhetoric probably involved themes of ‘liking science’ and ‘wanting to help people’.
But are these vague sentiments the sole driving force pushing a medical student through the 5 or 6 subsequent years of medical education and a lifetime of training in the profession? In 1966, in an attempt to prevent the migration of family doctors from the NHS to private practice, the then prime minister Harold Wilson declared that the government would increase the pay of doctors and dentists by 30%, following the recommendations of a pay review body. At present, medical practitioners are thought to be the second highest earners in the country according to the Guardian’s survey of best paid jobs 2010, with an annual salary ranging between £34,272 (10th centile) £141, 662 (90th centile). But how important is financial motivation in a medical career?
This is a relevant question to consider in light of the pending health reforms, where the private sector is looking to hold a larger stake in healthcare in the near future. Andrew Lansley’s shake-up of the NHS will necessitate GP consortiums being responsible for £80bn of the NHS funds to commission healthcare in 2013.
According to one newspaper, a private company, IHP, has suggested a scheme in which they, in partnership with GP consortiums, will generate a profit from the savings on patient care. The company aims to treat patients at 95% of the cost of the NHS, saving approximately £40 per patient. It has been projected by Oliver Bernath, founder of IHP, that if 1000 GPs sign up to the scheme to cover a population of 2 million patients, there is a possible £80 million of profit which could be generated, leading to a windfall of £160,000 for each GP partner.
Lansley’s rationale for delegating this responsibility to GP consortiums is in an effort to save £1 billion in management costs, and will ‘empower’ doctors against the ‘frustrating bureaucracy’ that plagues the health service. Ann Robinson, who has worked in the speciality for 20 years, has said that it is unclear as to why GPs would be better at imposing cuts than primary care trusts: ‘The responsibility involved in commissioning is huge and training non-existent… it is not taught on any medical school curriculum or offered on any course… would anyone want me to be responsible for complex budgetary decisions?’
Financially, the future within this speciality appears increasingly attractive, however this conflicts with some of the current data about job prospects. The number of advertised GP posts has dropped by around 70% in recent years;; the BMA estimate that of the 1000 graduates to enter the speciality this year, approximately a third will struggle to find work. A major part of the problem is that since GPs have become private contractors splitting the profits generated in each practice between them, there is less incentive to recruit more partners and reduce their share of the profits.
Moreover, the BMA found in a national survey of GP opinion 2011, that on average GPs were shouldering an increased workload for less money. Of those who participated in the survey, 88% said that their workload had increased in intensity over the past 5 years. This, says Lawrence Buckman, Chairman of the BMAs General Practitioners Committee, is due to GPs ‘taking on more of the work traditionally done by hospitals’. More than half of those surveyed expected a net decrease in their NHS income between April 2010 and March 2011.
In a healthcare environment that is being increasingly subjected to the phenomenon of profit and saving, perhaps it is necessary to consider the effect that financial incentive has on patient care.
A longitudinal study conducted in 2010, assessing the effect of removing financial incentives from clinical quality indicators by Lester et al, showed that performance declined when the financial incentive was withdrawn. James R. Demming, a Family Physician and Expert Team advisor for the Mayo Health System, comments that ‘This may appear to argue against the withdrawal of financial incentive, but I believe this argues against financial incentives in general…While a secure income is essential, financial rewards for meeting goals actually degrades our work’.
An article entitled ‘Financial incentives for doctors’ by Marc A Rodwin, explores the detrimental effects of this phenomenon. Rodwin argues that financial incentives used to change clinical behaviour implies that ‘doctors should consider their own self-interest when making medical decisions’, however ‘self-interest’ compromises a patient centred ethos which is ‘central to good medical practice’. Rodwin further discusses that many financial incentives ‘create or exacerbate doctor’s conflicts of interest which compromise doctor’s loyalty to patients and exercising independent judgement’.
Another angle from which to explore the extent to which financial factors motivate doctors, is considering reasons for leaving the profession. In a survey conducted on the junior doctors who were considering leaving the medical profession in the UK in 2004 by Moss et al, 75% named ‘working conditions’ as the reason for their decision. ‘Working Conditions’ as defined by the study referred to pay, working hours and job satisfaction. In Australia, it has been reported that doctors have relatively high rates of job satisfaction, which ‘is not surprising’ according to Professor Peter Brooks, director of the Australian Health Work Force at the university of Melbourne, given that Australian doctors are ‘probably better paid than many doctors around the world’. Although financial motivation appears to play a role in the career choices made by those in the profession. Richard Hayward, in an article for the BMJ, discusses why doctors enjoy doing what they do, and elucidating alternative causes for discontent.
He writes that medicine is an ‘individual to individual business: the very concept of a doctor-patient relationship is singular...this attitude takes priority over the community as a whole, which is not to say that doctors aren’t interested in the NHS, but it is too diffuse to warm their blood’. However with the current direction of the NHS reforms, and the more managerial responsibility delegated to doctors within specialities such as General Practice, has the individualistic aspect of healthcare become threatened? Money and the provision of healthcare have become intrinsically linked since the establishment of the NHS. The subsequent focus of health provision has gradually shifted towards the cost-effectiveness of community care. This begs the question to what extent are the simple motives of ‘liking science’ and ‘wanting to help people’ diluted with the increasing burden of financial responsibility and incentive.
Found this article interesting - Tweet or Facebook to share with your friends and followers!