NHS England reviews incentives, rewards and sanctions, but misses the point


NHS England has released a discussion document on incentives, rewards and sanctions.  Here’s my open response:

Dear NHS England review,

Two contradictory messages shine through your document.  The first is that the system of incentives, rewards and sanctions is problematic, complicated, causing perverse outcomes and not fit for purpose.  The second is that the system is fundamentally sound and requires a little tinkering here and there, some more complexity perhaps, a little stronger on the rewards and sanctions.
Consider this for a quiet minute.  Because you are not asking the big question:  is the thinking fundamentally flawed?  Perhaps the whole edifice is built on sand?  We need not to be redecorating, but demolishing and rebuilding something quite different.
I went through this personal transformation some years ago, in trying to design bonus and quality schemes in manufacturing.  The work of W Edwards Deming is powerful thinking on the subject.  Peter Drucker, who invented Management By Objectives, realised in later life that he’d been wrong and Deming’s philosophy would prevail in the end.
I don’t know who you are reading this but if you even get these comments on the top level agenda I’ll be impressed.  I now work in the health sector and have a lot of data on the perverse outcomes of targets.  See this on A&E:
See this abstract in BMC on the damage caused by QOF
On the other hand, see the effect of working on a quality service in primary care without targets, incentives, rewards or sanctions:
N82070 Elms v16
There are lots more like this.
Think again.

Yours faithfully,

Harry Longman

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