Are you in it for the money?

People try lots of ways to get other people to work harder: bonuses, performance-related pay, incentive schemes, targets, QOF, profit shares, fee for service, commission, piece work, payment by results, stock options . . . all are carrots to extract more work from staff. But how effective are they?

The evidence is, not very. As I found out for myself.

Twenty years ago I was a partner in a practice which had a staff bonus system. I was commissioned to write an article for a general practice magazine. They expected me to say how motivating it was for staff to share in the practice’s profits. I described how we were abandoning it because it had proved so demotivating.

A difficult year had put strains on the team and on the practice finances. Everyone deserved a bonus but there wasn’t any money. “Yes, we know,” they said, “but where is my bonus?” They had come to take the share-out for granted. Perhaps they had already spent it.

Even in a good year distributing the pot was an uncomfortable process. Were we rewarding effort or achievement? How do you rate a valuable member of staff who has underperformed this year because she has been nursing her sick mother versus the loyal employee who tries her best, but whose best is not, in all honesty, much good? How to handle the delicate problem that a partner’s wife works part-time in the practice and her husband values her contribution much more highly than his partners do? And the less there is in the pot, the more agonizing it is deciding how to share it out.

How else can you show staff that they are appreciated? A bottle of booze at Christmas? No good for non-drinkers. Knick-knacks? Embarrassing to find them recycled at the local bring-and-buy. A weekend in Paris (after a very good year)? Some people don’t want to go to Paris, others don’t want to go without their spouses, the youngest partner drinks too much and behaves inappropriately – very inappropriately – at the celebratory dinner. And it rains. Bonding? No.

I have discovered that there is a whole industry trying to design incentives that provide maximum motivation with minimum opportunity for abuse. All such schemes involve changing the goal posts frequently to keep staff on their toes, but none is effective in the long term; in fact the reverse. In the real world, you can’t eliminate the possibilities for gaming, and gaming is what humans do. If there is a bounty on rats’ tails, people will breed rats.

But those in charge continue to believe in financial incentives. Successive governments have attempted to squeeze more out of general practice. They have tried to combine the carrot of better pay with the reward of better care of patients, but there seems to be little evidence that patients are healthier as a result. If a higher level of QOF payment can be reached by eliminating more patients from the denominator, few practices will resist the temptation to search their list for exceptions to report. They may then reach the target, but it won’t be a joyful experience.

Whatever they say, governments and big organisations like top-down solutions. Providing extrinsic rewards enables them to tick their boxes. And if million-pound bonuses are necessary to reward bankers for doing their job, they feel that a few crumbs will screw more productivity – as defined by them – out of the NHS’s huge workforce. But few people work in the NHS solely for the money. They value the opportunity to exercise their skills. They value teamwork. They value solving problems. They value the feeling that they are helping people.

Teams will strive to meet goals they have set for themselves. In the past many GPs felt that, however desirable it might be to check every patient’s blood pressure, it was unrealistic. In 1974 Dr Julian Tudor Hart’s Welsh mining town practice set itself a challenge: to measure the blood pressure of every patient in the practice. They showed that it could be done, and that patients whose hypertension was identified and managed lived longer.

Being part of a team with a shared purpose is a big motivator. Soldiers will lay their down their lives for their mates. On the front line of the NHS, your contribution doesn’t have to be heroic. For months everyone has seen the stained chair in the waiting room that no patient ever wants to sit on. If you have the courage to take it away, your colleagues cheer. And the best thing the boss can give is not monetary reward, but acknowledgement. Although the US government has only one vice-president, American companies have platoons of them. Why? Because recognition is an effective cheap way of fostering motivation. It doesn’t have to be a title; in the NHS, a smile and a word of appreciation go a long way, but they are often forgotten.

NHS staff have been flocking to make Change Day pledges. It’s exhilarating to see your pledge earning dozens of ‘likes’. Wherever you are, through the web and social media you can feel part of something big.

I don’t know how many of the half a million Change Day pledges come from sessional GPs, but a good few locums will have made New Year resolutions. Good-enough practice may be good enough to make a capable doctor, but exercising your own imagination and meeting your own challenges is what professional satisfaction is all about.

Judith Harvey

Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.

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