When incentives go wrong – £55 for dementia diagnosis is a dead cert.

People argue a lot about whether it’s a good idea to give financial incentives to doctors to provide good care. There’s an argument that you should when it costs more to provide that care. Then there’s the more contentious issue of whether a cash incentive is a useful addition.

The evidence is that incentives do work. At least they work a bit (there are now >20 systematic reviews of pay for performance in health care and one systematic review of systematic reviews). But incentives are far from a magic bullet, and they work best when combined with other quality improvement activities.

Incentives also have unintended consequences. A good example is the incentive to GPs in the Quality and Outcomes Framework to provide appointments for patients within 48 hours. GPs responded to this by opening up appointments ‘on the day’ but limiting (sometimes completely) patients’ ability to book ahead. They’d met their financial target but patients paradoxically found it harder to get appointments.

Incentives go particularly badly wrong when they conflict with professional values. They work best when all the ducks are lined up in a row – financial, organisational and professional incentives. Then the incentives are providing encouragement to do things that doctors believe they should be doing anyway. If financial incentives conflict with professional values, this increases the risk of gaming and damage to internal professional motivation.

This is a risk with the new £55 fee for diagnosing dementia. There are a whole range of professional concerns about this – e.g. see today’s open letter to Simon Stevens from a group of professional leaders. Quite apart from the concerns about whether screening dementia meets conventional criteria for screening, who believes that GPs are really going to be able to get full consent for these really tricky dementia screens during their normal clinical practice? It’s always hard to predict just what untoward consequences will result from ill-advised incentives, but in this case I’d be pretty sure that poorly thought through policy will lead to bad outcomes for some patients.

Screening seems to have lost all connection to evidence in a rush for political soundbites. Last week MPs on the House of Commons Science and Technology Committee called for the National Screening Committee to review the evidence for NHS Health Checks (see the BMJ news item here ). Could they not also review the evidence for screening dementia, including how to do it? In fact they have reviewed it – their current recommendation is “screening is not currently recommended”. Why do we have a National Screening Committee?

Oh, one little PS. I think the idea of paying for dementia diagnosis came in a report from the Social Market Foundation. And who sponsored their report? Eli Lilly. And why am I not surprised that Eli Lilly are active in developing drugs for dementia?

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