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.
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.