“A Questionable Bonus”

Generally, as I have commented on in my “Submission to the Dilnot Commission” dated 6 February 2011, I am strongly in favour of a radical change in NHS care of the elderly.  I am less sure about the changeover from PCT’s to GP Commissioning.  In principle, it seems sensible to put clinicians in control, particularly if they are closer to the customer which GP’s are.  However, the changeover is very rapid and GP’s are not best known for their management skills, nor are they immune to the influences of drug companies and the private health care sector.

Controlling the multi-billion pound budget will be a massive challenge for GP’s but the Government has a crude answer to this.  The Health Minister, Paul Burstow, is considering incentivising GP’s to “spend NHS funds effectively” by linking their salary to a “quality premium”. 

I have never been keen on bonus pay, I believe people should be paid the right rate for the job and then motivated to deliver good quality.  Even the best targeted bonus systems can lead to people becoming overly competitive and inclined to take short-cuts to secure higher pay.  Often at the expense of teamwork and resulting in distorted outcomes.

The key questions are who defines “spending effectively” – this could be just code for keeping within budget; and what is meant by a “quality premium” – this should surely be about outcomes, but that might lead to GP’s being selective about the patients they take on their list.  In both cases GP’s might be inclined to avoid  elderly people  who will certainly have higher drug costs and more frequent and longer  hospital admissions.

There is already concern from the British Medical Association that this system might mean GP’s deny treatments in order to maximise their salaries.  This is a justifiable fear since past experience shows that NHS managers had to do this all the time.

Carrot and stick pay structures like this have no surgical precision and potentiallycould lead to very unhealthy outcomes.


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6 Responses to “A Questionable Bonus”

  1. Jon Cleaver says:

    It does seem to me the NHS has always been the ‘cake’ in which to push the knife by whichever administration rules. Every change of government brings new ideas on what should happen to the NHS. I believe there must be an across the board approach free of dogma, only then can we have a more stable approach to the NHS.
    In 1989 the NHS underwent dramatic change which led to a major escalation in bureaucratic complication and high administration costs, no where in any changes has the wellbeing of the patient been considered. The transferring of billions of pounds over to family practitioners to control is a worry. From my own experience GPs are mostly at the start of what can be a long process to the consultant at the end of the chain and recovery, surely these are the people who should decide where the finances should go.
    Some GPs may have the qualities required to handle such vast sums but many don’t and profess not to, all this without even considering a policy for the care of an ever increasing older populace.
    Fourteen months ago I experienced the workings of the NHS at its finest. I received the best treatment from a well trained team of doctors specialising in Chemotherapy, Radiotherapy, Dietary requirements and a top Consultant Surgeon. The down side of this of course is at what cost? And frankly until this particular nut is cracked it does not matter who controls the purse strings, it is a matter of forward planning. What is it going to cost year on year, how to include a decisive policy of care for the elderly, once a basic figure can be agreed upon then maybe the budget can be placed into safe hands. But, maybe all that is too simple?

    Jon C

    • John Graham says:

      It’s great that you had a fantastic experience of NHS health care and I am sure thousands of other people, including myself, could give similar testimonials to excellent NHS staff. Sadly that is not everyone’s experience.

      In an organisation the size of the NHS, there is always going to be good and bad practice and it’s always going to be the case that the general public has ever increasing expectations of better health care. What is not so clear is how, as a society, we are prepared to pay for it. A starting point must be to look for greater efficiency in NHS practices. There is huge variation between the best and the worst and this must be improved to the benefit of everyone.

  2. david freeman says:

    Dear John, I have brought up the subject of Bus passes and Bonus pay in this one response.
    As one looks at the wider picture of today’s political and economic affairs within the UKplc. then something has to give. We all have to learn to live within our means. This implies some will gain and some will lose maybe a bit more than others in the same society/community. We all have to be patient and understanding and tolerant towards one and other.
    An interesting aspect that was put to me was that maybe the schooling and educational programme of previous years was somewhat to blame? As a society we need to review the altruistic objectives of upbringing and have more of a footprint in education at a younger age, as to what makes a good citizen, such as tolerance; compassion and respect for ones’ fellow citizen who may not be as fortunate in life as one’s self? I.e. working towards a goal of a better and selfless society.
    Going back to the Blogs. I have no comment other than that to note the one on bus passes, may be more of a grumble!
    However when one considers the broader picture of economics facing the UKplc. A moan for bus passes does pale while one considers the plight of the NHS, maybe?
    The idea of Bonus pay for medical practioners invoking the schemes for budgetary control within the NHS. The medical profession under the labour years negotiated handsome returns in monetary value for themselves personally according to the media and antidotal evidence. We now enter the realms of the Coalition Government, and something has to be done: We cannot spend more than is proportionate on health care, however one may wish it> If we do not earn the money we cannot spend the monies irresponsibly. We need a review on how and why and to whom the service of the NHS serves? This includes the patients of all sections of society, clinical practioners/nurses/administrative and support staff.
    I believe we have to review the objectives of the NHS and its policy very rigoursly, and while with emotions, but also with the head, and a reality of what we can afford as a nation.
    I note your comments that the case may arise when the older patient is left to their own devices, and gently ignored by the majority. I would expect dignity, respect and courtesy from all the people in my society, and especially those in the NHS, from whom I may seek help as I become frailer and more dependent on societies services, I do not expect to be pigeon holed or put on a shelf and told quietly to go away? As with all things there is a price on life itself, all though to our families we are maybe priceless! So I would like compassion in my future treatment, and understanding
    One last though for you to digest: ‘As a society do we need to be more candid about old age and the eventuality of death and the grim reaper’. Here I do not mean fire and brimstone, blood and thunder, but a realistic view of how we discuss personally and as a society with dignity and honesty as one in an aging society how one grows old comfortably within one’s own skin and with a total peace of mind.

    • John Graham says:

      You’ve linked some of my thoughts together in your reply to this post.

      My earlier post on the demise of bus passes, was an illustration of how elderly people may be significantly disadvantaged by the current round of cuts in public expenditure. I acknowledge that in itself, free bus passes might appear to be a luxury our society can longer afford. However, looking at the bigger picture, if this leads to greater social isolation of older people, that in turn leads to higher levels of lonliness, depression and ill health. So saving on bus passes may lead to greater costs in free health care.

      Now link this to bonus incentives for GPs to cut costs on health careand you wonder where all this will leave old people. Could they be stranded without buses or GP services – then where will we be ?

  3. Maureen O'Neill says:

    Like you, John, I am not an advocate of a bonus system for anything but your article reminded me of an incident which happened a good few years ago.
    My brother was a senior plaster technician in a well known hospital in Britain and he became concerned about the ordering for his department. He asked to be allowed to do the ordering himself. This was not received well by the consultants but he stuck to his guns and finally was given the all clear to do this.
    He ordered some things that were considerably cheaper because they were more effective and was told “We have always used ….” Some of the things he ordered were more expensive and again the same remrk was made. He justified his ordering and he remained in charge of this until he retired.
    He said that he began to think that some of the consultants received ‘backhanders’ although of course he had no proof of this
    As you say GP’s are not immune to the influence of drug companies or indeed might penny pinch.
    I found this article very interesting.

    • John Graham says:

      Thanks Maureen. Your example shows how difficult it is to make changes in a big monolithic organisation like the NHS. It also shows how distorted things can become when there are perverse incentives added into the system. I am sure this is why there is so much consternation about the current changes that the Secretary of State is trying to make.

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