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Rapid Responses: Rapid Responses published:
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Payments and other incentives can help vulnerable patients stay well
- Sue Collinson (9 August 2007)
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Primary Prevention and use of Incentives
- Nitin Gupta (13 August 2007)
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Sue Collinson, TB Case worker Homerton University Hospital, Homerton Row, London E9 6SR
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Joanne Shaw states that to pay patients to take medication would create perverse incentives (Head to Head, 7th August 2007), but in her discussion she dismisses a particularly complex group of patients, with TB, despite the public health issues involved. This is a group of patients for whom payment, or other forms of incentive are of critical importance, both at the individual and the public health level. They are patients for whom health is very low on their list of priorities. Although this is a minority of patients, 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 (Story, 2007). 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 type of incentives they will offer these patients, and although research suggests that money is the incentive proven to be most effective for adherence (Volmink, 1997), 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 within 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 (Craig, 2007). Sue Collinson
References: Story A, Murad S, Verheyen M, Roberts W, Hayward AC. Tuberculosis in London - the importance of homelessness, problem drug use and prison. Thorax 2007 Published Online First: 8 February 2007. doi:10.1136/thx.2006.065409 Volmink J, Garner P. Systematic review of randomized controlled trials of strategies to promote adherence to tuberculosis treatment. BMJ 1997;315:1403-6 Craig GM, Booth H, Story A, Hayward A, Hall J, Goodburn A, Zumla A. The impact of social factors on tuberculosis management. Journal of Advanced Nursing. 2007 Jun;58(5):418-24. Epub 2007 Apr 17 Competing interests: None declared |
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Nitin Gupta, Consultant Psychiatrist-South Staffordshire and Shropshire Healthcare NHS Foundation Trust Margaret Stanhope Centre, Belvedere Road, Burton upon Trent, DE13 0RB.
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Burns [1] and Shaw [2] debate on the issue of incentives for drug users. In their discussion, they take up examples from wider mental health and physical health aspects. In principle, I would agree with part of arguments put forward by both authors. However, in my opinion, a much wider issue of primary (rather than secondary) prevention has somehow not received appropriate attention and emphasis and I would like to draw attention and focus on another major area related to adherence that come to my mind. Compliance to treatment, especially medications, is an important issue. But in today’s scenario where community based medicine, public health and prevention of development of illnesses is of prime importance, I think that using the concept of ‘incentives’ can be productive and help policy makers and health professionals alike. It is a reasonably well known fact that compliance of general public for preventative measures is not extremely high- whether it is related to preventing development of physical or mental illnesses or other issues like sexual health etc. Using incentives may be more cost-effective, practical, adherence enhancing and contributing significantly to appropriate recourse utilisation. To illustrate, I would quote the example of using Quality Outcome Framework (QOF) points given to General Practitioners (GPs) for meeting targets related to BP monitoring, Physical Health Check-ups, maintaining SMI registers etc. GPs are being given ‘incentives’ in terms of QOF points to ensure both aspects of primary and secondary prevention. One needs to question why? Why have incentives in place for professionals only? Why not apply them for the public, and even patients’ [1] then? Though, for patient groups, in general, I agree that the concerns expressed by Shaw [2] may come to the forefront during such situations. But- I would like to put forward the case for using ‘incentives’ more in aspects of public health and primary prevention. By offering ‘incentives’ (e.g. ‘minor’ monetary incentives) for ensuring proper health check-up of people who are not by definition ‘ill’ and ensuring both ‘prevention of development’ and ‘early detection’ of illnesses is, in the balance of things and the wider picture, a small price to pay with minimal risks attached to it. It may also help to appropriately mitigate, in a manner of speaking, the onus of responsibility (as it currently stands in the NHS) on healthcare professionals for ensuring appropriate monitoring of health of non- compliant‘healthy’ people. I would probably suggest a pilot of this concept of ‘incentives for adherence’ in the general public domain before implementing it for patients who are seeking treatment for an already present (and/or long- standing) illness. Every new concept has its potential advantages and disadvantages. It is up to health professionals and policy makers to maximise its benefits and help develop innovative methods/approaches to promoting good health. REFERENCES: [1] Burns T. Is it acceptable for people to be paid to adhere to medication: Yes. BMJ 2007; 335: 232. [2] Shaw J. Is it acceptable for people to be paid to adhere to medication: No. BMJ 2007; 335: 233. Competing interests: None declared |
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