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Enough of the sticks, what about some carrots?

Swansea National Health Service Trust, Cefn Coed Hospital, Waunarlwydd Road, Swansea SA2 0GH

Sir: Palmer & Lelliott describe some important aspects of guideline implementation (Psychiatric Bulletin, March 2000, 24, 90-93). Encouraging doctors to change their practice is a difficult task. Examples of published audits confirm this (Duffet & Lelliott, 1998).

As well as considering vigorous strategies for implementing change, we wonder if more emphasis should be placed on provision of reward systems for guideline compliance. Doctors prefer to rely on clinical experience for their decision-making (Dickson-Mulinga, 1998). In contrast, guidelines can be viewed as sinister threats to this professional autonomy. Clinical experience follows an operant learning model. ‘Good’ clinical decisions are rewarded by patient improvement. ‘Poor’ clinical decisions are so labelled because they result in patient deterioration. The perceived reward for following guidelines must be greater than the integral reward predictable from a good ‘clinical experience’-based decision.

General practitioners receive financial incentives for reaching targets for preventative medicine interventions. If a change in practice is perceived as an increased workload, financial compensation can soften the blow. Rewarding high quality practice makes sense. Although this may add to the unit price of change, this system may prove cost effective. Further research evaluation may be indicated, of course. Producing and disseminating guidelines that nobody reads or follows, is surely an ultimate waste of time and money.

References

DICKSON-MULINGA, J. (1998) Rationale behind psychiatrists' choice of drug. Psychiatric Bulletin, 22, 677-680.[Abstract/Free Full Text]

DUFFET, R. & LELLIOTT, P. (1998) Auditing electroconvulsive therapy. The third cycle. British Journal of Psychiatry, 172, 401-405.[Abstract/Free Full Text]

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