Doing a Good Job – Doctors

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It wasn’t new, but Margaret Thatcher gave it a huge boost.  What is it?  The idea that “Every man for himself and the Devil take the hindmost” is the only way things can be. The idea has been growing, and it’s done an awful lot of damage. An implication is that people won’t do what you want them to do unless you give them an incentive. Or you have to threaten to punish them for not doing what you want.

The idea has been especially damaging in professions such as medicine and teaching. Once you’ve decided people can’t be trusted unless you’ve arranged sticks and carrots for them, you have to interfere more and more. So governments have, for the last thirty five years, progressively interfered in more and more detail. Every sector where government takes a hand has to have targets. Incentives have to be provided to help to meet the targets.

But this is a very crude view of life, and it quite evidently doesn’t work. Let’s look at a very recent example to see what goes wrong. The government decided that family doctors were not diagnosing people with dementia properly. It was deemed that there should be more dementia diagnoses. The logic of every man for himself then led to the introduction of extra cash for doctors who diagnosed their patients with dementia.

Now, can you guess what happened next? Of course you can, with a cash incentive the number of diagnoses went up sharply. But you can probably guess what went wrong too. Once family doctors have decided a patient has dementia, there is normally a referral to a specialist. The specialists are reporting that a lot of the people referred with dementia are actually suffering from something else. In fact, since the payments for diagnosing dementia were introduced, the rate of misdiagnosis has doubled.

There ought to be a lesson here, but governments are slow learners. If you treat people with crude sticks and carrots, you get results, but you don’t necessarily get the results you wanted. People are adept at claiming the carrots and evading the sticks, but they may not use the route you intended.

The fact is that there is no easy way to manage the professions. Their work is complex and cannot easily be broken down into simple elements. Drawing back from detailed interference means you have to pose the problem of supervision in a more subtle way. It isn’t possible to achieve perfection, and any system will have its failures. Some doctors will be better than others.

But the only way to effectively supervise complex professional occupations is to do everything you can to encourage people to live up to the expectations placed upon them. To celebrate the successes and treat them as exemplars. There also have to be procedures for dealing with bad behaviour and excluding people who fall seriously short of the professions standards. Most professionals take a genuine interest in their work and the quality of what is being achieved.  What is needed is a society where we place more trust in one another, and encourage everyone to live up to the trust placed in them. Sticks and carrots don’t work.

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