This is the second part of the BMJ Leader new blog series written anonymously by “Magical Meander”, a medical manager working in the NHS, to help align perspectives and build understanding of medical management across these two professions.

Coronavirus has made us all think about antiviral vaccination. Yet in a good year we struggle to get influenza vaccination rates at above 80% in healthcare workers. True the efficacy of the vaccine may change from year to year (although even a minor benefit at ultra-low cost should be worth it). But surely the potential risk to ourselves should encourage uptake. Or maybe if the risk to self is not a strong enough driver, then the benefit of not needing sick leave, of not risking patients directly through infection or indirectly by not being able to work should drive uptake in the healthcare environment. Yet it does not. It doesn’t even seem that the challenge is access – for peer vaccinators seek out times that suit those that need the vaccine, they travel to wards or labs or clinics. They try and make it easy. So what would shift this?

The Prospect Theory that won Kahneman and Twersky the Nobel prize for economics identified a crucial feature of what supports people to do things. A small negative incentive is actually as powerful if not more so than a positive one. Yet played out in particular situations the effect is confusing. A behavioural economics study carried out in Israeli nurseries split parents with children at nursery into two groups. In group 1 the nurseries charged the families a small amount if they collected their children late. In the second group the nursery carried on with the status quo: gentle reminders to pick up children on time. The research team monitored the pickup times of families in the two groups pre and post the intervention. Perhaps surprisingly, the risk of financial penalty did not improve the pickup times – in fact the pickups were later in this group. The tricky thing to work out is the why? Was it that the penalty was set to low to have an effect? If so, why did the pickup times actually get worse? The conventional wisdom seems to be that by putting a financial price on the action, the nurseries changed the heuristic of the families. Instead of all being aligned by a desire and a moral commitment to timely pickups, the interaction became transactional and to these families this price was small enough to be paid.

This is a crucial area for healthcare. When we try to amend inherent quirks or failings of the current system, policy makers or managers or indeed researchers, think about how to effect the change. If we want more people to take up flu vaccines what should we do?  All too often the response has been to pay people to do things: Quality outcome framework for GPs, Clinical Excellence Awards for consultants and in a more roundabout way job planning which itemised, and perhaps without intent commoditised, the time of clinicians. Sometimes the incentives are not positive but negative e.g. penalties for 4 hour ED breaches, fines for 52 week waiters. Some of these are directly attached to individual performance, sometimes the repercussions are felt at a team or service or indeed organisational level.

The risk of such routes is the inherent conundrum of the nursery case. If you put a price on something – do you increase its value? Or do you risk taking something that is profoundly important to people but has a less tangible benefit: not financial but rather moral or of shared purpose. Is it a financial incentive that actually drives desire to improve, in healthcare? Or is there something deeper: is the reason that clinicians choose to be clinicians (active altruism), not a more powerful driver? The desire to help others – intangible maybe, but for anyone who has felt the effect of a clinical decision that has led to a successful outcome, it feels good and it can be addictive, or at least incentivising of its own accord.

So how to juggle all of this into something useful for managing a situation like flu vaccination. This year might be an easier year to convince people to have the vaccination. But generally should we be draconian and penalise annual leave for those who get sick and haven’t had the flu vaccine (using the prospect theory approach but with the risk of a nursery type outcome) or should we reward those who did receive the vaccination, with anything from badges to coffee vouchers? My thinking evolves constantly. Having spent a few hours on the entrance of our hospital encouraging flu vaccine uptake, with a peer vaccinator standing next to me ready to leap into action, I don’t think draconian approaches will work. The feedback surprised me: too many people felt cornered and uncomfortable and were more resistant to the offer.

So if this were a normal year I think the approach would be multilevel. For early adopters there will be limited number of highly coveted badges that hopefully develop a “pull” of their own, and at very least are a very visible reminder of the vaccination campaign. For the middle group, those who aren’t averse but aren’t quick to leap to action – chocolates or some other instant reward upon vaccination, to give people that instant sense of virtuousness (or at least sweet satisfaction). For the final push to pull in the laggards – coffee vouchers. Of course this year if the feared second wave of corona comes – all this may contribute less to the change in behaviour than fear.

With thanks to a wonderful podcast The Hidden Brain – which stimulated my thinking and reminded me of the perverse and challenging findings of the nursery study.

Magical Meander

Magical meander is an anonymous blog written by a medical manager working in the NHS and published every six weeks on BMJ Leader Blog.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.