There are times when you do not know whether to laugh or to cry, and this is one of them. The Imperial College Healthcare Trust has announced it will run a pilot programme to reward surgeons with bonuses for "excellence". Even for a professional group – medics – known for their gallows humour, this seems to be taking things a bit far. How, after all, do you judge "excellence" in surgery? Points for style? Theatre manner? Minimalism of wound or stitching? The speed with which a hip replacee picks up his bed and walks? Oh yes, and survival rates, too.
To be fair to the Trust, they say they are looking at awarding bonuses for specific procedures for which patient "outcomes" can be measured. But this only poses a whole new set of questions: what about those surgeons who specialise in procedures where outcomes are less measurable, at least by what are presumably supposed to be objective criteria? Are patients going to be expected to grade their surgeon post-operatively, knowing that their assessment will affect his – or much more rarely, her – already quite substantial remuneration?
Even more seriously, if there are to be bonuses for outcomes – put crudely, payment by results – then what about those surgeons working at the pioneering edge of their speciality? Are they to be penalised for failure rates that are likely to be higher than the average, or are there to be "points" for difficulty? The recent publication of mortality rates for particular operations, while welcome as a step towards transparency and accountability, might also have the unintended consequence of discouraging – necessary – risk-taking.
In essence, the Trust's proposal seems to mirror a much wider misconception that is current in government and management circles: that money alone spurs performance, and that more money will automatically improve results. It is probably true that, over a single generation, money has increasingly become a gauge of status. But we do not think that most professional people – whether nurses, teachers, lawyers or doctors – do what they do only, or mainly, for the money.
Most professionals are trained to do the best job they could do and find their work interesting and rewarding. More money is always welcome. But for the comparatively well-paid, such as doctors, money as a performance incentive has its limits. Two years ago many GPs took only a portion of the higher pay on offer, choosing instead shorter, more regular hours.
The bonus culture has spread like a plague through the public sector, where already well-paid people are paid even more simply for doing their job. It does not belong here, and it belongs in the operating theatre least of all.Reuse content