The Neo-Liberal NHS: What’s wrong about paying GPs for a diagnosis?

Amir Paz-Fuchs
Amir Paz-Fuchs

The medical community is in uproar since the NHS announced, on 21 October 2014, a new plan to offer GPs £55 each time they diagnose dementia in a patient. Justifying the plan, Dr Martin McShane, NHS England’s clinical lead for long-term conditions, explained that while it is not perfect, the plan was put in place because, at 53%, England’s diagnosis rate of dementia is well below comparable standards. For example, Scotland has a 70% diagnosis rate. NHS England’s plan is to reach a 66% diagnosis rate by April 2015, and the plan was put in place as a means to emphasise the importance of the new target.

Speaking on BBC Breakfast, Dr Brian Hope explained that GPs like himself were already receiving incentive payments, as in the case of diagnosing patients with diabetes or asthma. Therefore, he argued, this incentive scheme would simply be an extension of current practice. He further argued that the additional money received from the government in such cases assists GPs in the extra work needed to offer patients the long term care that they require.

The incentive plan, however, was not well received. On the polite side of the spectrum, Dementia UK queried if GPs ‘really need financial incentives’. One GP accused government  of ‘bullying the doctor-patient relationship’ and ‘crossing a line that has never been crossed before’. The Patients Association acknowledged that GPs receive incentives for some treatments, but found this plan to be ‘a step too far’, ‘a distortion of good medical practice’ and even ‘putting a bounty on the head of certain patients’.

I’m not quite sure how the plan is a bounty on anyone’s head, unless the implication is that GPs will misdiagnose dementia to get an extra £55 (pre-tax) and take on more work and responsibility for the patient. I doubt that this will be the case.

And yet, I align myself with those who think that the scheme is a bad idea and that, indeed, it distorts the doctor-patient relationship. Why is that the case? It is important to distinguish this type of incentive from the existing schemes. As Dr Hope himself explained in the interview, the complex contractual structure of the relations among government-NHS-GPs almost requires some compensation where a diagnosis of high blood pressure, asthma or diabetes is made. The extra work involved may require additional treatment, hiring more nurses, more tests and administrative work, and so on. As most GP practices are, in essence, small businesses compensated by the government for the work, the last thing we would want is under diagnosis of these conditions because treating them properly would lead to a loss. Furthermore, these conditions are assessed and documented objectively, through blood tests and the like. The monetary payment is, therefore, again, strictly compensation for the work, and was never treated as ‘incentives’ to do the work that GPs are expected to do, and indeed do.

In contrast, the dementia plan is billed as an ‘incentive scheme’, designed to achieve government ‘targets’. As such, it is a product of two sad signs of our times: managerial laziness and the infiltration of the neoliberal paradigm into public services.

Money ain't for nothing
Money ain’t for nothing

A good manager decides on policy, aims and, yes, even targets, and knows how to motivate her subordinates to achieve them. She will explain the importance of these aims, offer training sessions, educate, distribute material and, generally, will manage to motivate them to understand the bigger picture, and to accept the goals as their own. The lazy manager will dock pay or give miniscule bonuses.  She will view her subordinates as homo economicus, rational, self-interested actors who can be easily shifted from one life to another simply by changing the financial motivations. Despite being discredited by scholars such as Dan Ariely, and Amos Tversky and (Noble Prize winner) Daniel Kahenman, the ‘rational’ model lives on and serves as the platform on which rests the neoliberal paradigm.

And so, with this new scheme, the neoliberal approach has conquered another stronghold. The NHS, like any public service, always had to take into account monetary concerns. And, as noted, schemes are already in place to compensate doctors for expensive treatment. And yet, inserting money into diagnosis suggests infiltrating a sphere that managed, to date, to exclude monetary concerns. The danger, then, is not in the ‘perverse incentives’ or the fear that GPs will intentionally misdiagnose. It is that, with the introduction of money into an area that was ‘taboo’ in that respect, the general orientation of the profession will change. Fiscal incentives will ‘crowd out morality’ and the ideology of self-interest will be self-fulfilling.

A small example, well-known to some (as it was popularized in Freakonomics), may be helpful to explain this point. A day care centre manager in Israel was frustrated by parents being late to pick up their kids. She decided to fine the tardy parents. After the fine was enacted, the number of late pickups went …up. The explanation: people viewed the ‘fine’ as a cost, and now were happy to pay £2 and stay a while longer at work. Moral condemnation was ‘crowded out’, as parents could respond: I paid my fine, what do you want from me? Moreover, after the fine was withdrawn, the situation remained the same. The parents treated the situation as devoid of moral attributions, but now even without the fine. Morality was crowded out for good.

Back to the NHS and the dementia scheme. To refer to Michael Walzer’s seminal work, the NHS, as social services in general, and public services even more generally, are ‘spheres’ that are different from the commercial one. And as Robin West notes in a brilliant and moving essay, ‘although we are emphatically competent, that can surely change. We can surely become the person posited as the economic man. … We can become incapable of empathy. We can become hardened to others. … But we do not have to.’

Amir Paz-Fuchs is a Senior Lecturer at the University of Sussex School of Law.

Who Wants to be Forgotten?

Andres Guadamuz
Andres Guadamuz

Back when the Court of Justice of the European Union decided the case of Google Spain, one of my first comments was that we needed some time to have a look at the way the decision is going to be applied and implemented. It’s been just under 6 months since the ruling, and we are starting to get a fuller picture of who wants to make use of the right to be forgotten, and what may be the implications for the future.

The first development worthy of mention is that a national court has used Google Spain to answer a request to remove links to potentially damaging information. A court in the Netherlands has denied a request by the owner of an escort agency who was convicted for attempted incitement of arranging a contract killing, a matter which is currently under appeal (excellent report of the ruling here). The subject wanted links to the reports of the crime removed from search results, but the Dutch court refused the request with a very interesting analysis of the interaction between privacy and freedom of expression . The court commented:

“The [Google Spain] judgment does not intend to protect individuals against all negative communications on the Internet, but only against ‘being pursued’ for a long time by ‘irrelevant’, ‘excessive’ or ‘unnecessarily defamatory’ expressions.”

I thoroughly agree with this interpretation of Google Spain. The intention was always to remove links which may cause an excessive invasion of privacy. The court concluded:

“The claimant now has to bear the consequences of his own actions. One of the consequences of committing a crime is that a person can be in the news in a very negative way and this will also leave its tracks on the Internet, maybe even for a very long time.”

It is difficult to tell, but I would not be surprised if national courts take this approach in future cases, and the fear expressed time and time again by many commentators that Google Spain will be misused by criminals and other undeserving recipients may very well be unfounded.

The second big development has been that Google has released its transparency report for European privacy requests for search removals, which makes for some very interesting reading. Google received 146,938 requests and google-right-to-be-forgottenevaluated 498,830 URLs for removal, of which 58% were not removed.

Unsurprisingly, it received more requests from the largest countries in the EU (France, Germany, UK and Spain), with the UK accounting for 18,597 alone. What is interesting is the type of requests being received. These are some of the examples cited by Google:

  • “A victim of rape asked us to remove a link to a newspaper article about the crime. The page has been removed from search results for the individual’s name.”
  • “We received multiple requests from a single individual who asked us to remove 20 links to recent articles about his arrest for financial crimes committed in a professional capacity. We did not remove the pages from search results.”
  • “We received a request from a crime victim to remove 3 links that discuss the crime, which occurred decades ago. The pages have been removed from search results for her name.”
  • “An individual asked us to remove links to articles on the internet that reference his dismissal for sexual crimes committed on the job. We did not remove the pages from search results.”

google-rtbfJust from this quick snapshot we could argue that the Right to be Forgotten (RtbF) is being used by two types of people. First there are the criminals who would like to have links to references of their offfences removed from search engine result; these requests seem to be usually denied. Then there are requests to more serious privacy threats, such as the aforementioned rape victim; those requests are usually granted, and we could argue that in this regard the right to be forgotten is working as intended.

Google also released a list of most links removed by recipient website. I found it surprising that the main site which has links removed is Facebook, with over 3,000 links. This is logical when you think about it, these are links to embarrassing pictures and comments made on Facebook which are probably available in the open  web. The second website is Profile Engine, a site that I was not familiar with, which gathers information held about you online (apparently I still work at Edinburgh, and have an IQ of 120 according to that site).

It is still too early to conclude categorically one way or the other, but based on both developments highlighted above, it would seem that the fears from US freedom of speech advocates about the potential damage caused by the RtbF were unfounded. In my view the right is working exactly as it is supposed to, and it will give a tool to gain a bit more privacy wherever a serious breach may occur.

However, Google will probably continue to fight against the right to be forgotten. There is always a possibility that users will realise that they are not getting the full Internet, and will move to another search engine.

Dr Andres Guadamuz is Senior Lecturer in Intellectual Property Law at the University of Sussex

Another Step towards Gay Marriage across the US

Philip Bremner
Philip Bremner

Same-Sex marriage is a more politicised issue in the United States than in the United Kingdom. Legislative support for civil partnerships and now gay marriage has been more forthcoming in the UK than has been the case across the Atlantic. This is partly because of the diversity of approaches to same-sex marriage amongst the different state legislatures in the US. As a consequence of this diversity, same-sex couples who are married in one state are in a precarious position if they move to another state where these rights are no longer recognised.

 

Until recently, 19 states in the US, plus the District of Columbia, recognised same-sex marriage. However, on Monday, this number rose to 24 when the United States Supreme Court refused to review decisions striking down bans on same-sex marriage enacted by the state legislatures in 5 states (Indiana, Oklahoma, Utah, Wisconsin and Virginia). It is likely that courts in a further 6 states (Colorado, Kansas, North Carolina, south Carolina, West Virginia and Wyoming), all of which currently ban same-sex marriage, would follow suit if challenges were brought.

 

Opponents of same-sex marriage have criticised these decisions as usurping the democratic process as expressed through the state legislatures. However, by allowing the courts to scrutinise legislation for downloadcompliance with principles enshrined in the US Constitution, this is precisely what the US political and legal system allows for. Furthermore, public opinion in the United States does seem to be shifting in favour of same-sex marriage. Legal reform can even influence social attitudes in a particular direction. For example in the United Kingdom, the creation of civil partnerships encouraged support for formalised same-sex unions, rather than social attitudes necessarily being strongly in support of them beforehand.

 

In the rapidly changing landscape of formal recognition of same-sex unions in the US (and internationally), this is a progressive step towards eliminating disparities in the legal rights and recognition afforded these couples depending on their geographical location. Charlotte Paterson, a psychology professor at the University of Virginia, who has conducted extensive research on gay and lesbian families, recently presented on this issue at the Leverhulme International Network on New Families; New Governance conference at the University of Notre Dame in London. She considered not only the US position but also the global same-sex marriage debate. Her conclusion was that both in the United States and elsewhere, ‘the achievement of true marriage equality anywhere requires marriage equality everywhere’. Monday’s United States Supreme Court decision was a step closer to this.

 

Philip Bremner is a Lecturer in Law at the University of Sussex