Views & Reviews From the Frontline

Hold the carrots

BMJ 2008; 337 doi: (Published 11 November 2008) Cite this as: BMJ 2008;337:a2511
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}

    In less politically correct days behavioural therapy was called “sticks and carrots.” Now carrots are called “incentives.” Financial incentives, such as the quality and outcomes framework (QOF) system of payments, are widely used in medicine to deliver change. But even well intentioned financial incentives have many unintended and far reaching effects that can distort health care. The traditional strength of the NHS has been the absence of incentives: staff do not expect kickbacks, and the only gift is genuine, impartial advice.

    Now general practitioners are being offered incentives to reduce the rate of referrals. This is a bad thing. It is not that reducing referrals isn’t a good thing, but this is not the way to do it. I have a winged gatekeeper riding a Harley Davidson tattooed on my chest—holding the line is my job. I am proud of not referring. And in these healthy and educated days my surgeries are full of ill informed and well patients. Health anxiety is the scourge of modern medicine. Referral to hospital often serves only to compound health introspection and misery. Consequently I need to protect my patients from hospital colleagues who rightly seek a medical explanation when all too often no such explanation exists. The most important intervention by general practitioners is to do nothing—but to do nothing with style.

    Why do referral rates keep rising? The Labour government hosed money into the NHS, destabilising what was an impoverished but essentially sound system. It misguidedly promoted “choice.” This set free the devil of consumerism, driving up unrealistic and unreasonable expectations. Stupid disease awareness campaigns just sparked bush fires of health anxiety. At the same time the government sought to break the perceived stranglehold that doctors had on the NHS, just at the point when the profession’s strong sense of hierarchy was beginning to crumble. New policies shifted medical powers to other professional groups in the false belief that care can be broken down into easily definable units (it can’t). Thus clinical responsibility was terminally fractured, destroying that bedrock of general practice, continuity. Doctors are pilloried in the media for making supposed mistakes, resulting in a paranoid and increasingly risk averse profession. Today doctors feel like employees, not independent professionals.

    To reduce referral rates we need to re-establish and enforce channels of communication between primary and secondary care, not blunt incentives. More importantly we need to return to the founding values of continuity in general practice: generalism, localness, ordinariness, confident reassurance, and pride in holding that gate, whatever the cost.


    Cite this as: BMJ 2008;337:a2511


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