Intended for healthcare professionals


Improving pay and working conditions is better than merely rewarding healthcare teams

BMJ 1998; 317 doi: (Published 29 August 1998) Cite this as: BMJ 1998;317:602
  1. K G M M Alberti, President.
  1. Royal College of Physicians, London NW1 4LE

    EDITOR —I read with admiration, interest, amusement, and some sadness the editorial on rewarding healthcare teams by Bloor and Maynard.1 My admiration is for Maynard's persistence. He has for many years advocated the replacement of doctors by other healthcare professionals and the abolition of distinction awards. He manages to mount a range of interesting alternative methods to justify this. The only thing that he forgot to introduce in this editorial was his recent (and equally damaging and superficial) suggestion that not only should we replace doctors with nurse practitioners but that we should make up for any remaining shortage of doctors by using other countries' unemployed or rejected doctors.

    The present thesis is important. How can we reward healthcare teams?Yesterday's solutions of competitive tendering by healthcare teams are mounted. Many of the changes suggested are already in place. Many of us in chronic disease management and primary care already work in teams, and skill mix has inevitably changed. I would indeed advocate totally new forms of healthcare professionals trained specifically for new tasks rather than using nurses and doctors who have acquired different skills. But should we reward teams —and should we reward them at all? Is there no satisfaction in doing a job well and making people feel better without extra financial reward? One major problem is imprecision of measurement. What outcomes would be checked? Even to get clear evidence of improved medical outcome is time consuming and difficult, and such evidence is extremely difficult to interpret due to variable starting points, socioeconomic backgrounds, and facilities. If other variables are added in, such as patient satisfaction, cost effectiveness, and adherence to protocols, then the cost of making decisions about “success” far outweigh the resources available for “rewards.”

    I would propose that rather than pursue this unrealistic and divisive suggestion we improve pay and flexibility of working for all nurses and other healthcare professionals. This will lead to much better care across the board at lower bureaucratic costs than would be the case if small numbers of teams were judged according to idiosyncratic criteria proposed by armchair health economists.


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