Sunday, October 20, 2013

Margaret McCartney writes

Bribing patients is bad medicine

Medics who try to influence patients with cash incentives risk contaminating the relationship

A pen, some Post-it notes, a delicate box of chocolates. As a junior doctor, I am ashamed to admit that I liked the freebies that drug reps offered me, a token of their appreciation for my time while they delivered the latest in their company’s developments. It was only when I read the evidence and realised that these small treats could produce big swings in my prescribing — to more expensive but not better drugs — that I stopped seeing the reps.

Last week, the British Medical Journal published a paper showing that when people with schizophrenia or bipolar disorder are offered £15 to turn up and receive an injection of their antipsychotic treatment, more will do so. The medicines were given every one to four weeks, and the cash immediately afterwards.

Some 71 per cent in the “usual care” group came for their injections, compared with 85 per cent in the intervention group. The researchers pointed out that the costs of the incentives would be offset by the reduction in the need for emergency care for people with untreated mental illness.

Even so, this rings alarm bells. Giving payments to comply with treatment strikes at the heart of medical ethics: as the General Medical Council says, doctors must “maintain effective relationships with patients” and “respect patients’ autonomy”. People have the right to self-determination.

When clinicians try to swing patient choice using cash incentives — £15 may not sound much but to someone living on benefits it is substantial — we decrease the autonomy of the patient and contaminate our relationship with them.

Patients may end up taking the drugs — and enduring the side effects — because they will lose money if they don’t, rather than making a decision based on whether it works for them. In effect, doctors become the new “drug reps”.

Nor is this the only use of financial incentives in the NHS. In Glasgow, a trial is running that offers pregnant women £400 in high-street gift vouchers to stop smoking. Supporters say that we don’t have much help to offer female smokers, and that cutting smoking rates will reduce pre-term births and cot deaths. All this is true. But the patient must have her breath, saliva and urine tested to prove she has not inhaled before she gets the money, a process that assumes the patient may lie, and is potentially degrading.

The relationship between physician and patient is one of trust; the awkward interposition of money places conflicted interests between the two, damaging the assumption that we are each telling the truth.

The issue of inducements is among the most contentious questions in modern medicine, and it’s not just a matter of sweeteners for patients. Under the GP contract, we get “quality points” for showing our skill at prescribing drugs to lower cholesterol and blood pressure, and for demonstrating how often we have asked whether you smoke, and for inviting you to dementia screening. Patients are reduced to sets of tick boxes on the computer; every day I apologise to patients when I feel I have looked longer at the flashing screen than at them.

I am conflicted because I am paid by how well I comply with the contract; not for how clearly I explain the lack of evidence and the problems that may arise from dementia screening, say, or whether I tell you that your statin tablets may bring you more trouble than they prevent.

This causes me enormous professional pain. When people come in to see their doctor, they often have several issues to discuss, often something worrying, and many questions. Patients need time to be listened to. This is what I trained for. Yet the personal consultation has been usurped by the demands of the tick-boxing GP contract. My computer flashes up my failings — the requirements I haven’t satisfied — regardless of whether this is helpful for my patient.

If doctors and patients are to trust each other, we must not only remove those financial incentives that encourage patients to “comply”, but abolish doctors’ inducements, too. Medics ought to be liberated from the shackles of the modern GP’s surgery, so that they practise medicine for patients, not to satisfy targets, not to increase medicine-taking, not to bribe people to do what “doctor thinks best”. In the 21st century, doctors and patients need to be on the same side.

‘The Patient Paradox: Why Sexed-up Medicine is Bad for your Health’, by Margaret McCartney (Pinter & Martin), is available from Telegraph Books at £9.99 + £1.10 p&p. See

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