Piecework, that’s what’ll solve the NHS, piecework
Apparently the National Health Service - that Wonder of the World - is not, in fact, very good. In fact, it could be significantly better if it were simply managed better:
Most NHS users in England affected by dysfunctional admin, report finds
Oh, right.
Patients routinely have to chase up test results, receive appointment letters after their appointments and do not know when their treatment will occur because the NHS is so “dysfunctional”.
That is the conclusion of research by two major patients’ organisations and the King’s Fund, which lays bare a host of problems with the way the health service interacts with it users.
Sixty-four percent of people in England who used the NHS or arranged care for someone else over the last year encountered a problem involving its administration or communication.
Patients were left frustrated by test results going missing, being unable to change or cancel appointments or having to pursue the results of a test, scan or X-ray.
It is indeed possible to become too reductionist, too Fordist, about the management of complex organisations. It’s also possible to be not Fordist enough. The incentives of the people within the organisation need to be aligned with the - well, at least the claimed - purpose of the organisation. Which is why salesmen get commission - to incentivise their sales.
Currently in the NHS everyone gets paid whatever happens. So, change those incentives. If the records keeping clerk only gets paid when a record is delivered then we’d all assume that more records will be delivered. If a consultant only when a consultation is done and so on.
So, put the entirety of the NHS on piecework. No salaries, no hourly pay at all. Align those incentives!
Now, true, this does cause problems when taken right to that extreme. There are, for example, jobs where there is no measurable output. Diversity and inclusion departments perhaps. Climate change awareness ones. It’s possible, however lightly, to insinuate that there are jobs where output cannot be measured because there is no output …. diversity, inclusion, climate…..thus we should, in our radical Fordism, decide not to have those jobs done at all. That whole measurement and payment by results idea does allow us to note results and thus decide whether we’d like to pay to not get any.
Aaand, yes, we agree, it is possible to go too far with this. It’s also, as we say, possible to not go far enough with this. Currently GPs are paid for not seeing people, they get a fee for having a list of people they don’t see. It’s not difficult to thus predict that getting in to see a GP is difficult these days - and, Lo!, it is. If we changed those incentives so that a GP gets paid for seeing a patient then we predict that getting in to see a GP will be somewhat easier. Probably worth a try….
Now, if that’s true of that frontline of primary care then where else in that behemoth of a tenth of our entire economy is that also going to be true? We now retreat from our insistence that absolutely everybody be put on piecework and instead make the milder claim that we really ought to go and find out who should be…..
Tim Worstall