Towards a classification of incentives
OK, incentives. I've hypothesized that incentives are the key to understanding how people inside health systems behave. This is important in the context of seeking to improve or change (let's be cautiously neutral about this) services. I am finding it increasingly important however to define what these incentives actually are, how they work, and what behaviours they incentivize.
This is, of course, really important in measurement and the publication of measurement. We do so in the expectation that this will change the behaviour of the measured, or change the behaviour of those who receive services from the measured.
When I started out on the path of undertaking this work, I was given tremendously kind and helpful advice by Martin Marshall (now the UK's Deputy Chief Medical Officer) and he pointed me towards his earlier work http://jama.highwire.org/cgi/content/abstract/283/14/1866
which emphasized the importance of kudos and censure for healthcare providers, particularly doctors, as a means to incentivize them. As he states with clarity and precision, "publishing the information will increase providers' sensitivity to their performance by reminding, refocusing, or shaming them into action". Certainly this is an important incentive, one which seems more a plausible description of most doctors I have known than "they're only in it for the money".
But it's useful to think about this, I think, as one of range of incentives that may be stimulated by the publication of information .
First are a range of internally generated incentives, ones that are actually immune from stimuli. Typically these could be called "altruistic", seeking to do what the doer considers to be "the right thing"; or, slightly more subtly, seeking to conform to one's self-image that one is the sort of person who does "the right thing". It is worth remembering, of course, that in this context what "the right thing" actually is, is entirely subjective. So the same internal incentive, doing what they believe to be right, exists for both Mother Theresa and Osama Bin-Laden. The point is that external stimuli are not responsible for their actions. Allied to this incentive is the motivation to be a "good professional" whereby acting inside the norms set out by one's peers is critical.
At the other extreme are rewards that are explicitly linked with measurement, these may be financial or non-financial. For example: pay for performance schemes that increase salaries or payments directly according to achieved performance, or through giving market advantages to the better performers; the extra million quid for three star trusts; and the threat of losing your job and salary for 0 star trust chief execs were all examples of financial rewards. Non-financial rewards might have included the opportunity to apply for foundation trust status, or the avoidance of "the terror" of intense managerial/ regulatory oversight.
The "kudos and censure" incentives exist somewhere these two poles. The incentive is an external one, in that the rewards are bestowed by others (as opposed to "being received in heaven") but they are not explicitly, prospectively linked to the measurement. So, for example, the respect of peers and invitations to sit on eminent committees or otherwise advance one's career might be the kudos incentives, while a sense of letting the side down would be a censure avoidance incentive. A more negative expression of this is the sense of pure competition, and clinical colleagues have spoken to me of this. In essence the competition becomes an end in itself, "I want to look better than those cowboys up the road" (and that is a direct quote, well almost, he didn't say cowboys). The reason I say that this is a negative is that when ends start to justify the means, behaviours become less positive, and this will be the subject of a future post.
Four hypotheses follow.
First, most people in any field have a mix of these incentives governing any actions they make, so it is not a simple task to work out which levers to pull. Example - why did I want to do this fellowship. Being absolutely honest a mix of various things: the sense that I would learn things that would be useful for UK health policy, the sense that this would be interesting, the knowledge that having Harkness Fellow on the CV was scarcely a career limiter and the kudos of having an international scholarship. My point is no-one has entirely unselfish motives all the time.
But to leaven that thought, let's consider Maslow. He believed that self-actualisation was the highest point of his "hierarchy of need". This is entirely analogous to the internal incentives I listed above. This would imply that, eventually, these are going to be the most powerful ones. No amount of money, social standing, peer respect or terror is going to work in the long-term if the basic values of the participants are offended. I have been rightly reminded this week about the importance of "calling" in health care.
Second, the best way of publishing performance information will depend upon which of these incentives we want to use. The internally-based incentives can be stimulated simply by sharing an individual's performance data with them with some comparative information. If people purely wish to be the best they can be, evidence of their performance and some sort of comparator (whether theoretical norm, an average level of performance or some description of the distribution of performance), will be enough to "remind, refocus, or shame". Broader publication will not be necessary. To take advantage of kudos and censure, publication of performance information across services is required, with the individual levels of performance being shared with each provider, at a low enough level of granularity to have teeth. This may be individual clinical team or physician, or could be at a practice or specialty level. Explicit, prospective incentives require full publication, either to work at all (market-based approaches) or for reasons of accountability and justification (direct system incentives).
Third, there is a range of responses to these incentives of which not all are positive. There ia also a range of types which will help determine what the response is. This will be the subject of the next post.
Fourth, the wrong measurement, combined with the wrong publication strategy increases the risk of negative responses. This too will be the subject of a future post.
As ever, very much work in progress. More to follow.
This is, of course, really important in measurement and the publication of measurement. We do so in the expectation that this will change the behaviour of the measured, or change the behaviour of those who receive services from the measured.
When I started out on the path of undertaking this work, I was given tremendously kind and helpful advice by Martin Marshall (now the UK's Deputy Chief Medical Officer) and he pointed me towards his earlier work http://jama.highwire.org/cgi/content/abstract/283/14/1866
which emphasized the importance of kudos and censure for healthcare providers, particularly doctors, as a means to incentivize them. As he states with clarity and precision, "publishing the information will increase providers' sensitivity to their performance by reminding, refocusing, or shaming them into action". Certainly this is an important incentive, one which seems more a plausible description of most doctors I have known than "they're only in it for the money".
But it's useful to think about this, I think, as one of range of incentives that may be stimulated by the publication of information .
First are a range of internally generated incentives, ones that are actually immune from stimuli. Typically these could be called "altruistic", seeking to do what the doer considers to be "the right thing"; or, slightly more subtly, seeking to conform to one's self-image that one is the sort of person who does "the right thing". It is worth remembering, of course, that in this context what "the right thing" actually is, is entirely subjective. So the same internal incentive, doing what they believe to be right, exists for both Mother Theresa and Osama Bin-Laden. The point is that external stimuli are not responsible for their actions. Allied to this incentive is the motivation to be a "good professional" whereby acting inside the norms set out by one's peers is critical.
At the other extreme are rewards that are explicitly linked with measurement, these may be financial or non-financial. For example: pay for performance schemes that increase salaries or payments directly according to achieved performance, or through giving market advantages to the better performers; the extra million quid for three star trusts; and the threat of losing your job and salary for 0 star trust chief execs were all examples of financial rewards. Non-financial rewards might have included the opportunity to apply for foundation trust status, or the avoidance of "the terror" of intense managerial/ regulatory oversight.
The "kudos and censure" incentives exist somewhere these two poles. The incentive is an external one, in that the rewards are bestowed by others (as opposed to "being received in heaven") but they are not explicitly, prospectively linked to the measurement. So, for example, the respect of peers and invitations to sit on eminent committees or otherwise advance one's career might be the kudos incentives, while a sense of letting the side down would be a censure avoidance incentive. A more negative expression of this is the sense of pure competition, and clinical colleagues have spoken to me of this. In essence the competition becomes an end in itself, "I want to look better than those cowboys up the road" (and that is a direct quote, well almost, he didn't say cowboys). The reason I say that this is a negative is that when ends start to justify the means, behaviours become less positive, and this will be the subject of a future post.
Four hypotheses follow.
First, most people in any field have a mix of these incentives governing any actions they make, so it is not a simple task to work out which levers to pull. Example - why did I want to do this fellowship. Being absolutely honest a mix of various things: the sense that I would learn things that would be useful for UK health policy, the sense that this would be interesting, the knowledge that having Harkness Fellow on the CV was scarcely a career limiter and the kudos of having an international scholarship. My point is no-one has entirely unselfish motives all the time.
But to leaven that thought, let's consider Maslow. He believed that self-actualisation was the highest point of his "hierarchy of need". This is entirely analogous to the internal incentives I listed above. This would imply that, eventually, these are going to be the most powerful ones. No amount of money, social standing, peer respect or terror is going to work in the long-term if the basic values of the participants are offended. I have been rightly reminded this week about the importance of "calling" in health care.
Second, the best way of publishing performance information will depend upon which of these incentives we want to use. The internally-based incentives can be stimulated simply by sharing an individual's performance data with them with some comparative information. If people purely wish to be the best they can be, evidence of their performance and some sort of comparator (whether theoretical norm, an average level of performance or some description of the distribution of performance), will be enough to "remind, refocus, or shame". Broader publication will not be necessary. To take advantage of kudos and censure, publication of performance information across services is required, with the individual levels of performance being shared with each provider, at a low enough level of granularity to have teeth. This may be individual clinical team or physician, or could be at a practice or specialty level. Explicit, prospective incentives require full publication, either to work at all (market-based approaches) or for reasons of accountability and justification (direct system incentives).
Third, there is a range of responses to these incentives of which not all are positive. There ia also a range of types which will help determine what the response is. This will be the subject of the next post.
Fourth, the wrong measurement, combined with the wrong publication strategy increases the risk of negative responses. This too will be the subject of a future post.
As ever, very much work in progress. More to follow.
posted by Exiled in mainstream at 4:34 PM
2 Comments:
As I ask around the biggest disincentive to good doctoring that I find is intrusive regulation. There is a tendency to protocolize everything.
It is like painting by numbers. One of the reasons that I have thought that being a doctor was the best job possible was the possibility of 'expressing myself' in the job. It is like saying to Wayne Rooney, "You must never chase a lost ball down the wing. You have to stay within these tramlines. Don't try bicycle kicks. Never cross from the left with the outside of your right foot." or to Freddie Flintoff, "Never hit against the spin and never reverse sweep."
There is a feeling that the authorities are trying to reduce medicine to neat little packages that are easily priced and performable by nurses, rather than by doctors who cost too much to train and talk in jargon that we can't understand.
Regulations on how long a junior doctor is allowed to work have abreviated training and encouraged rote learning. No-one is expected to think.
Clinical research has become a joke. About a quarter of the time available on a PhD is typically spent jumping over the regulatory hurdles introduced by the EU and designed for pharmaceutical corporations not universities.
Clinical time is spent uselessly in meetings of multi-disciplinary teams discussing cases that need no discussion, occupying the time of pathologists and radiologists, and presenting details that are boring and extraneous to many of those attending.
CPD or CME (whichever is the current set of letters) is a bad joke. After several years of reporting 10 times the number of points I actually needed as a demonstration of how facile it is, I have given up filing in the forms. What can they do? Cut my hands off?
If you really want an incentive that would work, offer consultants sabbaticals.
Sunday Times today.
Ministers have announced plans for hernias to be repaired and varicose veins to be stripped by GPs in their own surgeries. I suppose that the logic is that since the European Working Time Directive now restricts surgical training to six weeks with Wednesdays off, patients would be better off with GPs who at least had 6 months as a house surgeon 25 years ago.
Of course, like everything else, the GPs will simply take the money and hire someone from the Indian subcontinent to do the work at one and threepence a day.
It is suggested that nurses go out an give chemotherapy in patients' homes. I'm not quite clear how a nurse going to each patient's home and then traveling on to the next one is going to be cheaper than have all the patients come to a central point where two or three nurses could give the chrmotherapy for 60 patients. We could even call the cental location a ... let me see, how about a hospital?
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