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In the head to head debate, Shaw says that to pay patients to take medication would create perverse incentives, but in her discussion she dismisses a particularly complex group of patients, with tuberculosis, despite the public health issues involved.1 2 This is a group of patients for whom payment, or other forms of incentive, are of critical importance, at both the individual and the public health level. For these patients, health is very low on their list of priorities—they tend to be those suffering from social exclusion, often with histories of offending, substance abuse, mental health problems, and homelessness. They require the most complex care and are least likely to complete treatment, particularly when the course of treatment is lengthy.3
It is common practice in tuberculosis teams to carry out a standard risk assessment with each patient and to offer incentives to those who would be at high risk of non-completion of treatment. Shaw asserts that even in the case of infectious tuberculosis, the disadvantages of financial incentives outweigh the benefits. However, the reasons she cites for non-compliance with TB medication do not correspond to the attitudes that we find in our high risk patients, for whom the daily business of finding a place to sleep, eat, inject, or sell their bodies comes well before whether to take their medication. Different teams vary in the types of incentive they will offer these patients, and although research shows that money is the incentive proved to be most effective for adherence,4 other interventions, such as social support, free meals, bus passes, and food tokens, are effective. Unlike in New York, where direct payments of $10.00 are made, financial incentives are not permitted in the NHS. However, through the use of social care incentives, completion rates for TB treatment in this at-risk group of patients are far better than would otherwise be the case.5
Competing interests: None declared.