Pay incentives have always been controversial within the NHS. Only recently, David Oliver argued against their use in boosting numbers in acute specialties, such as emergency medicine, acute medicine, intensive care and geriatrics, which currently struggle to attract trainees and consultants. [1] Doctors attracted to acute specialties, he suggested, were not much motivated by financial gain. And do we really want medical recruitment in the NHS to be motivated by money anyway? That would make it open to gaming by institutions and potentially stir up resentment in a workforce already fragmented and demoralised.

The evidence suggests that financial incentives do work in attracting doctors into less popular specialties. From an academic perspective, the issue of financial incentives and behaviour of doctors generally is riven with methodological problems and I was not able to find a single prospective study of boosting recruitment into specialty. [2,3] Systematic review, however, of studies on decisions around medical careers found future income to be the most consistent factor influencing specialty choice, regardless of country of study, and ranked debt as being the least influential. [4]

In the absence of good academic studies, a number of real-life examples may be illustrative of the ability of money to influence preferences for specialty. The most powerful of these is the rapid growth of hospitalism in the USA. From humble beginnings, the hospitalist workforce, which focuses on general inpatient medical care, now numbers over 50 000 and is the third largest specialty overall (behind general internal medicine and family medicine). This stunning growth has relied not on the recruitment of new graduates into hospitalism, but rather in persuading physicians already in primary care internal medicine to abandon their offices and practise a new and different form of hospital-based medicine. Founders of the new discipline have been clear that financial incentives were a critical factor in its success, with hospitals initially offering recruits salary bumps of up to USD100,000 per year. [5]

As in the USA, hospital-based specialties, especially emergency medicine, were much less popular in Australia than their office-focussed counterparts three decades ago. Recruitment into these specialties was given a major boost in 1986, when charities and (at a later date) not-for-profit hospitals were exempted from the newly introduced fringe benefits tax. This allowed organisations to offer substantially more attractive financial packages to consultant staff, including salary sacrifice, generous study leave and hospital cars. The result has been a major shift of trainees into hospital-based disciples. Australia now has an oversupply of emergency medicine physicians, partly aided by the flight of NHS doctors to sunnier climes. [6] Indeed there are now concerns that the decline in the number of community-based general physicians is contributing to the increasing pressure on hospital inpatient services.

Studies of the use of financial incentives to encourage doctors to move to, and stay in, more rural locations are also instructive. A recent high-quality study of the influence of government-funded schemes to attract and retain GPs in rural and remote locations in Australia found that financial incentives did have a positive effect, although the impact was greatest on new GPs first entering into practice. [7] Closer to home, the Target Enhanced Recruitment Scheme was introduced by NHS England in 2016 and offers a £20,000 salary supplement to GP trainees to work in areas with the most severe recruitment challenges. More than 500 doctors have since signed up. [8]

There are number of important caveats when it comes to doctors and money. Human beings are more sensitive to losses than to gains. [9] The wave of retirements here in the UK in response to the changes to pension and taxation, and the rush of rural GPs back to the cities in Australia following freezes to the Medicare payment scheme, demonstrate that doctors will vote with their feet when existing incomes are threatened. [10,11] So a focus on retention is probably more important, in the longer term, than recruitment.

Secondly, the level of financial stimulus depends on career stage—undergraduates are highly responsive to bonding schemes, which offer financial support during medical school in return for later service, while mid-career doctors require substantial incentives to change either discipline or location of practice.7,10 There are also no quick fixes to the maldistribution of doctors—change in patterns of practice takes decades to achieve.

Finally, financial incentives, while important, are substantially more powerful when bundled with other factors, such as control over hours, flexibility and opportunities for education and research.4,5,12 On this point, Oliver was exactly right.

So financial incentives could work. They might need to be more than £20,000 per year for a few years to effect any lasting change. But given the current recruitment crisis and the pressures on acute hospitals, can the NHS really afford not to try?

Louella Vaughan, Senior clinical fellow, The Nuffield Trust.

Competing interests: None declared.

References:

1. Oliver D. Should we use pay incentives for shortage specialties? BMJ 2019;364:l1398. doi: 10/1136/bmj.l1398.
2. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev. 2015;30;(6):CD005314. doi: 10.1002/14651858.CD005314.pub3.
3. Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev. 2011;(7):CD009255. doi: 10.1002/14651858.CD009255.
4. Yang Y,Li J, Wu X, et al. Factors influencing subspecialty choice among medical students: a systematic review and meta-analysis. BMJ Open 2019;9(3):e022097. doi: 10.1136/bmjopen-2018-022097.
5. Wachter RM, Goldman L. NEJM 2016;375:1009-11. doi: 10.1056/NEJMp1607958,
6. Rosie C. Is Australiasia producing too many emergency physicians? Yes. Emerg Med Australas 2015;27:599-600. doi: 10.1111/1742-6723.12508.
7. Yong J, Scott A, Gravelle H, Sivey P, McGrail M. Do rural incentives payments affect entries and exits of general practitioners? Soc Sci Med 2018;214:197-205. doi: 10.1016/j.socscimed.2018.08.014.
8. NHS England. Targeted Enhanced Recruitment Scheme. https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/recruitment/
9. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 1979;47: 263–291. doi:10.2307/1914185.
10. Armstrong S. Cuts to pension tax relief deepen retention crisis for senior doctors BMJ 2019;364 doi: https://doi.org/10.1136/bmj.l206.

11. Scott A. General practice trends. Melbourne Institute of Applied Economic and Social Research, Melbourne, 2017.
12. Verma P, Ford JA, Stuart A, et al. A systematic review of strategies to recruit and retrain primary care doctors. BMC Health Serv Res 2016;16:126. doi: 10.1186/s12913-016-1370-1.