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In the olden days, we used to trust public servants to do their best for the people they served. Nowadays things are a little different, especially in the NHS. Policy makers are increasingly resorting to ‘Pay for Performance’ (PfP) in an effort to drive up the quality of care delivered to patients. The Commissioning for Quality and Innovation Payment Framework, or CQUIN as it is known, makes a proportion of income conditional on the achievement of quality improvement and innovation goals. This was increased from 0.5 to 1.5% in the second year of the scheme and this year the percentage was increased to 2.5%. David Nicholson, the NHS Chief Executive said recently that he wants to see this rise to 4 or 5%, presumably due to fears that the 2.5% isn’t having the desired effect.

The question asked by a lot of people is ‘do PfP schemes work’? But this is the wrong question, since it fails to recognise that these initiatives are all different. What we need to do is to look at the features of the individual schemes – how they are designed and implemented and in what context – and assess impact to work out how and to what extent a scheme works.

Our recent evaluation of the Advancing Quality (AQ) scheme in the NHS North West found that it saved almost 900 lives. The bonus payments were a drop in the ocean compared with CQUIN, which suggests that whilst it’s helpful to offer carrots, there are other motives afoot here. Perhaps NHS staff are only too ready, willing and able to improve services, but what they need sometimes is a little help. In this case, help took a number of forms including standardised data definitions and bespoke software. But aside from these technical aspects, collaborative events brought together staff from all 24 participating organisations to share their learning and work through common problems. In addition to shared learning, the development of this AQ ‘community’ appears to have been really important in providing emotional support for what has been (make no bones about it!) a gruelling and often uphill struggle for the staff involved. As our study shows, ‘PfP’ can produce desired results, yet  what motivated the front line NHS staff in our study was not ‘rational’ calculation of efforts versus rewards, but an ability and desire to  work together in a supported way, to do what they all felt was the right thing for patients. AQ has now broadened its scope to include all of the mental health Trusts in the region so we’re watching with interest to see if the initial success can be replicated as the programme expands.

Much of the thinking on incentives has traditionally been dominated by economists who take a rather one dimensional view of human beings. And economic rationality has often been seen as contrary to emotion. But an obsession with finding the magic percentage which proves to be a tipping point is the wrong way to go here (David Nicholson, please take note). What’s needed is for policy makers and evaluators to begin to adopt a less impoverished view of human behaviour - recognising the importance of emotion in improvement initiatives would be a good place to start.

Posted by:
Professor Ruth McDonald
Chair in Health Innovation and Learning
Business School
University of Nottingham

Turner (2002) identifies that recovery has been described as an idea, a movement, a philosophy, a set of values, a policy mantra and also a doctrine for change.  It splits opinion between those who view it as simplistic and obvious and others who see its revolutionary and transformatory potential.  Although increasingly fashionable within current mental health policy and practice, there are precedents for recovery as far back as the seventeenth and eighteenth centuries.  For example Phillippe Pinel appointed ex-service users in a bid for a humane regime at Biceptre in Paris and William Tuke developed moral therapy and self management approaches at the York retreat (Scull, 1981).  However, the roots of recovery are most firmly established in movements of protest intended to improve conditions in asylums and to give equal rights to citizens with disabilities.  Judy Chamberlin articulates these rights based approach when she appeals for recognition of the skills and abilities of people with mental health problems to make their own decisions, run their own lives and provide support for one another (1990, 1978).  While the normative claims of recovery have been adopted within English policy, its implementation in mainstream services is heavily critiqued by service users; the main point being that recovery has come to mean all things to all people (MIND, 2008).  Indeed there is a risk that its increasingly popular status and dominance as a paradigm within policy discourses will lead to it being co-opted and distorted by policy makers and experts in the field.

With colleagues in the School of Nursing we used Noam Chomsky’s critical methodology, as an exemplar of a left libertarian position, (Edgley, 2000; 2005; 2009) to provide a theoretical analysis and test of the coherence of the recovery model (Edgley et al., 2012).  We also used it as a critical mechanism to judge manifestations of recovery in practice settings.  In Chomsky’s political philosophy we find that hope is both a pre-requisite and a pre-condition for a trusting and supportive environment.  Everyone, whether or not they have mental health problems, need these conditions to be able to access and utilise their creativity in dealing with their current reality.  For Chomsky, hope, our innate creativity and a supportive community are the necessary conditions of freedom.  In Chomsky’s view, if our society nurtured our creative potentials, then our human nature would not confine itself to searching for autonomy and independence but would instead generate interdependent arrangements.  This could have direct implications for the implementation of recovery; it suggests that those experiencing mental ill health need to be the co-creators of policy and practice, rather than its passive recipients and they need to be able to build and use their own theoretical structure such as that offered by Chomsky.  This would protect recovery from being ideologically driven and open to political interpretation and potentially more importantly provide the basis to evaluate and present evidence on its own terms.  As we conclude in the article:

“The recovery paradigm has the essential elements in place, but control over its application – and lives- needs to be reclaimed from the state and experts alike before adoption turns to assimilation or perhaps co-option turns to emasculation.”

Posted by: Dr Nicola Wright Research Fellow: Research Delivery and Support Unit Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Nottinghamshire, Derbyshire and Lincolnshire

References Edgley, A (2000) The Social and Political Thought of Noam Chomsky.  London: Routledge.

Edgley A (2005) Chomsky’s political critique: Essentialism and political theory.  Contemporary Political Theory 4: 129-153.

Edgley A (2009) Manufacturing consistency: Social science, rhetoric and Chomsky’s critique special issue: The Herman-Chomsky propaganda model twenty years on.  Westminster Papers in Communication and Culture 6(2): 23-42.

Edgley A, Stickley T, Wright N and Repper J (2012) The politics of recovery in mental health: A left libertarian policy analysis.  Social Theory and Health 10(2): 121-140.

MIND (2008) Life and Times of a Supermodel.  The Recovery Paradigm for Mental Health.  MindThink Report 3.  London: MIND.

Scull A (1981) Madhouses, Mad-Doctors and Mad-Men: The Social History of Psychiatry in the Victorian Era.  Philadelphia: University of Pennsylvania Press.