A news item that caught my eye the other day was a UK survey by Doctors.net.uk, which found one in three GPs support the idea of charging for accident and emergency services to deter the 'entitlement culture' that has led to it being 'free at the point of abuse'. Many A&E services are claimed to be not far from breaking point and 'radical action’ is needed to ease the strain. Hence charging patients - only logical, no?
Statements like radical action is needed are usually seen to mean that, even if there are drawbacks, the pros are too important and outweigh the cons. But behind this, I suspect it's often an admission that we don't know if the proposed solution will work, but hey, better to do 'something' rather than 'nothing'.
Having had a spuddle around, I’ve decided the discussion surrounding this A&E survey is indeed interesting for what it omits. Along with a 'slippery slope' to privatisation (or indeed 'Americanisation') that contradicts the principles of the NHS, the arguments against have mainly focused on the unintended impacts charges could have on genuine and vulnerable patients who may be deterred from using A&E when they should do. Then there's some discussion of whether or not 32% is a large proportion of GPs to agree with A&E charges, and some too on whether the revenue generated from £5 or £10 charges would be financially worthwhile.
As far as I can see, entirely missing is any discussion of whether charges would actually deter the 'abusers' that they targeted. These are the people who should be waiting until they can see their GP, popping down to their pharmacy, using a stickling plaster or wrapping up with a hot toddy, instead of taking up valuable A&E capacity. The assumption is that a £10 fee would deter them, but what evidence is there?
I’m minded of Dan Ariely’s book Predictably Irrational, which discusses research on a nursery that started imposing fines for parents who picked up their children late. Surprisingly, following this move they saw not a decline but a rise in lateness. Why? The researchers argued that many parents switched from seeing lateness as a social ill that caused inconvenience and embarassment, to viewing it as an additional service they legitimately paid for. The fines shifted perceptions of the value of lateness and the cultural norms that follow.
Without evidence, we don't know that a similar impact wouldn't follow with A&E charges. Introducing payment could well serve to commoditise A&E, legitimising its use by patients with minor cuts, parents whose children have earache, or whatever it is that should wait until the morning. It could encourage a consumer mentality and the sense of entitlement that underlies abuse of the service.
In fact, the healthcare profession has led the way in adopting evidence-based practice and the world of people management is way behind, as the Center for Evidence-Based Management and authors Pfeffer and Sutton have argued for several years. Still, while I wouldn't want to start slinging mud, it's almost encouraging to see that healthcare isn't infallible to flimsy assumptions about what actually affects change.
The Cabinet Office's 'Nudge Unit' has made great inroads into the more effective application of policy, based on research evidence of what actually works. A similar shift is overdue in people management. We should develop the 'science of HR', drawing on practically applicable insights from neuroscience and social sciences to strengthen the activities of HR, leaders and line managers alike.
Over the last 18 months, we’ve been drawing out social science insights for learning and development (research published here and more forthcoming). We now plan to build on this, drawing lessons more broadly for people management.
Less a question of what policies we should have, more a question of how to make them stick.
Have you seen policies or practices work in unexpected or interesting ways? What niggling questions do you have that undermine assumptions often made in leadership and people management?
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All the points discussed above are economic in nature, which means that they deal with the incentives and constraints created within the system. No system is perfect. The point is about finding a better system. Undeniably, more will be demanded at low prices and, without any prices at all or personal consequence for excessive use, a 'tragedy of the commons' scenario will befall the free 24/7 A&E service: the incentives for such use are high and the constraints, such as guilty feelings, are low. A price point that will deter A&E use for trivial maladies needs to be set above the level perceived as fair compensation for both the treatment and the avoidance of a bad conscience.
The statement, 'Less a question of what policies we should have, more a question of how to make them stick" is problematic to begin with. As there are no 'solutions' and only 'trade-offs', the question would be more usefully framed around the likely short, medium and longer term consequences and effects associated with and caused by the incentives and constraints by the system as it is practiced or will be practiced.
15 Jan, 2014 20:43
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