9th July 2015

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Lord Darzi
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Health Chat 15th July - King's Fund - London

 Details here.

It's not about the money
News and Comment from Roy Lilley

The Tinker-Man let slip he is not averse to the idea that recalcitrant patients, who miss out on GP appointments, could be fined. No doubt for the privilege of collecting the fines GPs would demand a cut?


The fines would have to be accounted for, audited, paid into a special bank account and be subject to an annual report. Looks like we are talking big-bucks.


Courtesy Dubner and Levitt, let's visit Israel. Haifa. A chain of crèches was having trouble with mums arriving late to pick up their kids. The result; anxious children and staff late going home.


The company looked at the data and discovered, on average, there were eight late-pick-ups a week, at each of the 20+ centres. Their solution was a financial penalty. Any parent, later than ten minutes, got hit with a $3 fine, added to their monthly fee of $350.


The result? Late pickups went up. Yes, up!


Parents thought three dollars was a good price to pay for not rushing off the tennis court, or back from work. Late pickups went from eight a week to over twenty.


This tells me neither the Tinker-Man, nor the crèche company understand economics and incentives.


Incentives are not just economic, they are moral and social.


If economic incentives are to be used the amount has to be worth collecting; factoring in the cost of governance and debt collection.


That means; pretty soon newspapers will be running stories about the "... retired pensioner, war hero, hounded by the Tinker-Man's debt collectors for missing an appointment. Impounding his mobility scooter and selling his budgie..."


To cut the number of primary care DNAs we first have to know how many there are, so we can measure our success in tapering them. As the Tinker-Man has no centrally collected data to go on we are stuffed.


Never mind; the absence of data never stopped a determined politician.


To make the system self-funding the amount of the fine needs careful thought. Enough to be a penalty, enough to cover administration, fees to the GP and the debt collectors.


Punishment, punitive, disincentive, deterrent, hindrance, limiting, discouragement... which? Fifty quid? Thirty quid? A score? A tenner?


High enough to make it worth counting and worth collecting; if the amount is too high it might be a disincentive to make the appointment in the first place... then we are in the realms of unintended consequences.


What else could we do? We still have social and moral to play with.


Moral? How about we list the names and addresses of 'This week's DNAs' in the surgery or local paper; alongside a picture, if available. We could add a caption;


'If you know this person and you see them in the supermarket, in a loud voice, ask why they didn't show. If your nose is broken as a consequence please go straight to A&E.'


We could write a stiff letter to the DNAs; that would add costs to our losses... very NHS. We'd have to hope no letter got intercepted by a nosy partner or parent...


"Why were you going to the doctors?"

"Because I thought I was pregnant..."

"What.... Who...!"


See what I mean?


How about a social incentive.


How about we say;


"... the NHS belongs to us all... don't waste it. If you can't make it, we understand, please; text our free cancellation line, or leave a message on the appointments hotline..."


Making it easy to cancel would require practices investing in decent communications systems. As most of them can't seem to manage an ordinary switchboard... fat chance.


How about we put up a sign;


"...last month 2,500 people had appointments and came to the surgery on time... if you can't be one of them, let us know, please. We can give your place to someone else"


How about we ring DNAs and ask if they are OK? Why didn't they come? They might be struggling and really ill.


Incentives can inspire us, appeal to our better nature and bring out the best in us. That's why we wear a Poppy in November. That's why we don't miss school open-days and parent's evenings.


We do things because we think it matters, we don't want to let ourselves or other people we care about, down.


That's why relationships matter and if we really want to end DNAs we have to understand it's not about the money.


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