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J R Soc Med. 2006 October; 99(10): 483.
PMCID: PMC1592069

An NHS at the mercy of freakonomics

Should doctors be rewarded for their performance? If so, what should the reward look like? The medical profession has enjoyed many forms of rewards, some performance-related and others a simple perk of the job.

Steven Levitt and Stephen Dubner in their best-selling book Freakonomics claim that incentives are the cornerstone of modern life, although they observe that incentives can be economic, social and moral. Indeed, substituting an economic incentive for a social or moral one can achieve the opposite effect to the one desired.

Every consultant, as part of professional status, expects to receive professional and study leave. Many doctors have used this leave wisely; a minority of course have used these professional benefits to enjoy a round of golf, develop business interests or indulge mistresses.

The conclusion of investigators of the culture of hospitals is that clinicians do not feel part of the organization. They do not identify with the mission of the hospital, trust, or strategic health authority. Instead they view themselves as ‘consultants’ who contract out their services to an employer without having to embrace the corporate enterprise.

The complaint from anthropologists and managers is that it is precisely this disloyal thinking that is a major barrier to effecting change and improving the quality of patient care. Ironically, consultants and other senior doctors spend most of their free-thinking careers with one employer, unlike hospital managers who invariably avow their allegiance to their current employer's objectives.

The NHS consultant contract—a contract that has increased the income of consultants—and the subsequently poor financial performance of the NHS have embedded the view that doctors negotiated an incredible deal at the expense of the financial integrity of the NHS.

Consultant appraisal and job planning have delivered to management a stick with which to beat doctors into submission, cut back on their study and professional leave—time spent away from trust activities is no longer tolerable—and make them corporate beasts.

The fly in this management ointment, however, is that while management might well be slobbering at the prospect of reining in doctors, those same doctors are feeling bruised, angry, and rebellious. The view on the shop floor is that doctors are being turned into factory workers, clock watchers stripped of their professionalism and their opportunity to develop and contribute something meaningful to the profession more broadly than the big-fish small-pond world of hospital medicine.

This difference in world views between management—including doctors turned managers—and clinicians is a recipe for an almighty row. Some hospital doctors are even considering strike action. What to do? Clearly accountability is essential and to be welcomed, but some of the fascist managerial empires that are in bloom are heading for a blooming disaster.

The best approach I have come across is one where a medical director painstakingly negotiated a mutually acceptable job plan with every consultant, the effectiveness of which would be reviewed at the yearly appraisal meeting. Another option, of course, is to use economic incentives more overtly but Pete Abel and Aneez Esmail (p. 487) remind us just how problematic distinction and merit awards can be—and the new job-planned NHS does not automatically end discrimination in the awarding of these incentives.

In any case, what is the appropriateness of using economic incentives for delivering clinical productivity? It is a question that any self-respecting freakonomicist would be asking. Perhaps it is a question that Philip D'Arcy Hart, the distinguished medical researcher who died earlier this year, might have asked? Tilli Tansey's biography of his life describes a man motivated by social and moral incentives (p. 537).

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press