A few days ago the British Government published a Review on Antimicrobial Resistance . It described the growing resistance of bacteria to over-prescribed antibiotics and suggested that by 2050 a death from hitherto treatable bacterial infections might occur every three seconds, unless new drugs are discovered. It also urged huge investment in research, including the offering of large prizes (a billion US dollars) to pharmaceutical companies for every new antibiotic they discover. But these vast prizes are insignificant compared to the cost of medicine being thrown back into the dark ages by recalcitrant bacteria.
It is pointless, as some do, to rail against the rapacious selfishness of pharmaceutical companies and expect them to undertake difficult and commercially risky research without incentives.
The report also urged doctors to prescribe fewer antibiotics, and to avoid prescribing antibiotics for infections that are viral. (Here in the Czech Republic there’s a tendency (admittedly now declining) to prescribe antibiotics as a precaution, to prevent a viral cold from turning into a bacterial cough.)
For many years (perhaps even decades) GPs in the UK have been asked to prescribe fewer antibiotics but are understandably upset when patient satisfaction declines. Nevertheless, data from the NHS were published yesterday that showed that doctors had prescribed 7%fewer antibiotics in the last year than during the preceding year.
How was this achieved? Through financial incentives. Some doctors’ practices were awarded 20,000 GBP bonuses, in effect for doing less.
Money talks. Or as the Hungarians say – Money Talks, the Dog Barks.
We don’t like to think that financial incentives play an important role in motivating practitioners of vocational professions. The decisions of doctors, nurses, teachers and priests are not, we like to suppose, influenced by personal financial gain. Decisions must always be made on the merits of each case.
But we know that the priest will do us a better wedding or baptation, the nurse’s hands will be softer and the doctor will see us sooner if we oil the wheels a little.
Here in Eastern Europe from 1948 until 1989 society was inspired by the utopian ideal that each of us would eagerly give ‘according to his ability to each according to his need.’ It didn’t work.
We have to accept that money motivates. If you’re managing a company, you must take account of dozens of factors when deciding how to motivate your staff, but if the money is insufficient, none of the other tricks will work – whether you’re juggling with job title, benefits (such as a company car), training, or responsibility. Even if staff say that the ‘money doesn’t really matter,’ they’ll still agree that money is a kind of recognition, whatever uses it’s put to.
You’ve got to accept that money is an incentive, and when you’re devising your incentives you’ve got to be careful. The NHS in the UK, I believe, will reward doctors for diagnosing and prescribing pills for blood pressure, and reward them for not prescribing antibiotics. The rules of the game have got to be sophisticated enough to achieve the right result but not so complex as to confuse, or be beyond efficient measurement. And there are always the unintended, unanticipated effects of motivation that solve one problem and create another.
But sometimes incentives go too far. My mother is currently being hounded by her young GP (probably recently married with a kid to support), who claims she’s diabetic, and, judging by the frequency with which she tells me this, it has disturbed her peace of mind. She’s used a home-diagnostic kit to prove him wrong. Very likely he’d collect a bonus for adding her to the list of Type-2 diabetics, but he’s not going to get away with it.
Money talks. The dog barks. It will always be so. And if it reduces the risk that antibiotics will fail, who cares?