Knights, knaves and doctors

This paper draws on ideas from Le Grand's (Reference Le Grand2003) book Motivation, agency and public policy. The book was seminal in that its heuristic devices showed the ways in which motivation and agency were implicated in the design and implementation of public policy (Klein, Reference Klein, Marmor and Klein2012). It sought ‘to capture policy-makers’ perceptions of reality and to show how this has affected policy design’ (p.17). Although Titmuss’ earlier work had examined altruism and self-interest (Deakin, Reference Deakin1993; Deakin and Mann, Reference Deakin and Mann1999), Le Grand adopted metaphorical uses of notions of knights and knaves, as well as queens and pawns.

Here, we focus on the way Le Grand addressed motivation, which he defined as ‘the internal desires or preferences that incite action’ (p.2). He argues that both ‘knights’ and ‘knaves’ could be applied to suppliers, users of services and tax-payers. But he uses these terms heuristically, a ‘shorthand for describing individuals’ motivations, not necessarily individuals themselves’ (p.24). His conceptualisation of human agency has, however, been questioned as unrealistic by Greener (Reference Greener2002) who prefers Bourdieu's (Reference Bourdieu1990) notion of ‘habitus’ as it denotes a ‘set of dispositions that incline agents to act and react in certain ways’ (p.691).

According to Le Grand (Reference Le Grand2003), knights are ‘individuals who are motivated to help others for no private reward. . .’ (p.26). These individuals are altruistic and public-spirited, foregoing their own interests in favour of others (at an individual or societal level). In terms of practitioners, knights have traditionally been perceived as occupational groups including ‘professionals such as doctors and teachers’ (p.5). These groups were seen to be motivated by ethics and vocation, heavily influenced by professional norms and socialised into professional values (Exworthy and Halford, Reference Exworthy and Halford1999; Freidson, Reference Freidson1994). Furthermore, social norms have often valued such knightly behaviour through, for example, higher incomes, status or autonomy. Le Grand notes that medicine has traditionally been illustrative of knightly behaviour rather than self-interested knavery. Examples of this include the Hippocratic oath, professional norms of working beyond contracted hours and claims of working ‘in the best interests of the patient.’ By contrast, knaves are ‘self-interested individuals who are motivated to help others only if by doing so they will serve their private interests’ (p.26). Self-interest is multi-faceted but could include financial gain (income), autonomy (freedom from external control), status and power. Given the centrality of senior hospital and academic doctors (‘consultants’) to the NHS, their power lies in their ability to control time (e.g., when patients are seen) and their ability to work in both public (NHS) and private sectors (with the potential to encourage patients to move from the former to the latter, where incomes are invariably higher).

This heuristic distinction between knights and knaves has resonance with debates in the sociology of professions and in human resource management. Shifts in societal attitudes towards providers of welfare have led to a perception of professionals as self-interested. Whilst doctors are still seen by the public as trustworthy (Elston, Reference Elston, Gabe and Calnan2009), such trust has been dented by recent medical scandals (Dixon-Woods et al., Reference Dixon-Woods, Yeung and Bosk2011), some of which have questioned their altruism. Additionally, new public management (NPM), introduced by neo-liberal governments over the past 30 years, has sought to change the balance of power away from medical professionals (Ferlie and Geragthy, Reference Ferlie, Geragthy, Ferlie, Lynn and Pollitt2005; Harrison and Pollitt, Reference Harrison and Pollitt1994). In challenging professional power, the state (and its agents such as managers) has sought to constrain medical autonomy. The state has thus adjusted the social contract between itself and the medical profession (Klein, Reference Klein1990) so that doctors have come to be perceived as ‘largely self-interested’ (Le Grand, Reference Le Grand1997: 158). This shift does not affect professionals alone but all those working in the public sector (Greener, Reference Greener2002).

However, the medical profession has not been passive to such challenges, often adopting a strategy of re-professionalisation. This ‘new professionalism’ (Kuhlmann, Reference Kuhlmann2006) has sought to re-frame the external challenges (such as managerialism or consumerism) and thereby absorb or deflect them (Exworthy and Halford, Reference Exworthy and Halford1999). On occasion, the medical profession has been able to ‘maintain or even enhance its autonomy and control’ (Calnan and Gabe, Reference Calnan, Gabe, Gabe and Calnan2009, p. 58). However, in order to justify this professionalising strategy, the medical profession has re-framed the criteria by which medical performance is measured and managed (Harrison and Checkland, Reference Harrison, Checkland, Gabe and Calnan2009). Traditionally, doctors have been in control of setting the standards of their own work, of monitoring that work (through peer review) and of determining rewards or sanctions (Exworthy, Reference Exworthy1998). Increasingly, doctors’ work is framed in terms of evidence-based medicine (EBM) (Harrison, Reference Harrison2002). Whilst EBM has the appearance of external control, it is the knowledge elite of the profession which shapes the content and format of such evidence. Often, the equivocal nature of evidence lends further ambiguity to this esoteric knowledge, hampering external interpretation, minimising control and thereby preserving autonomy (Suddaby and Viale, Reference Suddaby and Viale2011).

Here, intrinsic and extrinsic motivation can equate largely to the ‘knights and knaves’ distinction used by Le Grand (Reference Le Grand2003). The distinction between intrinsic and extrinsic motivation may, however, be more illusory if they are viewed inter-dependently. Both co-exist in policy and practice and one may have (adverse) consequences upon the other (Taylor-Gooby et al., Reference Taylor-Gooby, Sylvester, Calnan and Manley2000). Disney et al. (Reference Disney, Le Grand, Atkinson and Oliver2013) refer to self-determination theory to explain this inter-relationship (Deci and Ryan, Reference Deci and Ryan2000). Policies which maintain the possibility of autonomy are internalized (thus enabling crowding-in) and, because they are perceived as fair, will enhance intrinsic motivation through extrinsic means.

As Le Grand (Reference Le Grand1997) argues, it is often assumed that there will be no impact from the introduction of, say, a ‘knave strategy on knightly behaviour’. Yet, it cannot be held that knights would continue as before since ‘a knave directed strategy may make the knights behave more knavishly’ (p.162). Le Grand (Reference Le Grand1997) presents a hypothetical argument about the introduction of performance-related pay (PRP), which is germane to the application of his ideas later in this paper. He pre-supposes that doctors are behaving in a knightly way and that they are paid a salary. He refers to a group of knavish doctors who might be ‘spending time on the golf course or managing their investment portfolio’. Even though the latter group are a minority, they are damaging the hospital's reputation. He then considers the impact of PRP.

In this case, doctors as knights will become ‘free-riders’, getting paid additionally for work they would have done anyway. Yet, if financial incentives are (too closely) linked to managerial objectives, it is likely that doctors’ internal motivation will be ‘crowded out’ by extrinsic factors (Frey, Reference Frey1997; Frey and Jegen, Reference Frey and Jegen2001; Marshall and Harrison, Reference Marshall and Harrison2005). Conversely, if doctors ‘feel’ that they ‘own’ the PRP scheme (the process by which pay is determined and allocated), then the effect might be the opposite, a ‘crowding-in’ effect. However, the scale and direction of the effect may be conditional upon three factors. First, doctors may have a ‘reward expectancy’ (Cho and Parry, Reference Cho and Parry2012) which is a ‘target income’ to which they aspire. This may be comparable with others’ professions (such as lawyers or accountants) whom they see as equivalent. Second, there might be a threshold beyond which additional income has a decreasing marginal effect (and, possibly, even negative effect) upon their motivation. Thus, extrinsic motivation might be significant up to a certain threshold but, beyond that, intrinsic motivation becomes more prevalent (Klein, Reference Klein, Marmor and Klein2012). If the profession secures incomes beyond the threshold, it may appear that the members of the profession are solely concerned with intrinsic matters. Third, it may be that the financial amounts per se matter less than the prestige and social reputation associated with the status of a senior doctor (Frey, Reference Frey and Oliver2013). If so, non-financial recognition could be more applicable. This already happens somewhat in medicine, with its propensity for awards, honours and medals (Frey and Neckermann, Reference Frey, Neckermann, Brennan and Eusepi2009).

Yet, claims of intrinsic motivation among professionals, notably doctors, may be reliant upon a more implicit (yet powerful) expression of extrinsic motivation. Le Grand (Reference Le Grand2003) suggests that, rather than just being intrinsically motivated, public sector professions are also driven by extrinsic ideas of self-preservation, power retention and financial concerns. This has implications for conceptualising professional motivation. For example, it may be argued that the existing stratification of the profession between knowledge elite, administrative elite, and the rank-and-file (Freidson, Reference Freidson1994), can be aligned with intrinsic and extrinsic motivation. Whilst individual rank-and-file professionals are able to claim an on-going commitment to altruism, public-spiritedness and thus intrinsic motivation, they are equally able to eschew extrinsic motivation. Yet, the administrative elite (locally or nationally) can, at the same time, act to defend (or enhance) their members’ financial interests. Similarly, Klein (Reference Klein, Marmor and Klein2012) argues that doctors may act as knights towards their patients but as knaves towards the state. This approach helps resolve the paradox whereby doctors, whilst claiming to be focused solely on intrinsic concerns, are well rewarded extrinsically (financially and otherwise). Moreover, unlike the sociology of professions, much of the literature on motivation does not adequately distinguish between individual (micro) and collective (macro) levels. (Le Grand (Reference Le Grand1997: 167) does, however, recognise this in an endnote.)

Despite such theoretical arguments, empirical evidence on professionals is less plentiful. This dearth might be explained by three factors. First, expressed claims about motivation may not reveal a ‘true’ picture given the ‘halo effect’ whereby respondents would be expected to display outward signs of intrinsic motivation and reject extrinsic concerns (Le Grand, Reference Le Grand2003: 34). Extrinsic factors thus remain hidden from the researcher's gaze. Second, many empirical studies provide little corroborative evidence of motivation claims: specifically, there is very limited evidence about actual decision-making. Third, most studies are experimental in design, focusing on manual workers in manufacturing organisations (where PRP may be easier to measure and implement) or on lab-based tests with students (Frey and Jegen, Reference Frey and Jegen2001). Less evident in studies are public sector professionals or the deliberations behind pay-based decisions. In health-care, studies of the Quality and Outcomes Framework (QOF; the scheme for incentivising primary care doctors) are exceptions (e.g., Grant et al., Reference Grant, Guthrie, Huby, Watkins, Checkland, McDonald and Davies2009). Senior hospital doctors are often overlooked in studies (Bloor et al., Reference Bloor, Freemantle and Maynard2008; Le Grand, Reference Le Grand2003; Crilly and Le Grand, Reference Crilly and Le Grand2004; Klein, Reference Klein, Marmor and Klein2012). Moreover, the literature of public service ethos does not usually address financial matters (Needham, Reference Needham2006).

The evidence presented here points to a number of research questions: Do CEAs offer an insight into the motivation and behaviour of the medical profession and doctors? How does the medical profession seek to control the distribution of CEAs? Do CEAs (as extrinsic rewards) ‘crowd out’ any knightly behaviour? Is there evidence of knavish behaviour as a result of CEAs? These questions (drawing on Le Grand's thesis) frame the empirical study relating to the medical profession, motivation and financial incentives.

Clinical Excellence Awards–a knightly or knavish strategy?

A case-study of ‘clinical excellence awards’ was conducted to explore how and in what ways members of the medical profession act as knights and/or knaves with regard to their pay. These awards require some description since they are not commonly discussed in UK health policy and no other country has an equivalent scheme (Capita, 2011).

CEAs were established in 1948 (under a different name – merit and distinction awards) to secure the participation of the medical profession in the fledgling NHS, whose members might otherwise be tempted to work in the private medical sector. The then health minister explained that he had to provide doctors with additional money (‘stuff their mouths with gold’) to secure their involvement in the NHS (Timmins, Reference Timmins1995, p. 115). CEAs were also designed to encourage individual doctors to practise in all geographical areas and in all specialities.

The awards are given to senior doctors who meet criteria across five domains, indicative of a quality of work ‘over and above’ contractual obligations, as determined by a system of local and national committees. (These domains include: delivering a high quality service, developing a high quality service, leadership and managing a high quality service, research and innovation, and teaching and training). Criteria for allocating awards have changed over time but since 2001, greater emphasis has been placed on ‘delivering and improving local and health services.’ This emphasis has been complemented by rising managerial and lay representation on award committees. However, doctors still account for 50 per cent or more of the representation of these committees; the remainder comprises managers and lay members.

The value of individual awards ranges from £3,000 (€4,065) to £75,000 (€101,000) per annum across 12 levels, which are paid in addition to basic salary (exchange rates as of May 2015). Together with CEAs, the median annual total earnings of a consultant (from the NHS) are, for 2011–12, £109,000 (€147,000) (National Audit Office, 2013). (Income from private medical practice would be additional). The awards are pensionable. They are reviewed every five years but are rarely withdrawn.

In 2013, 61 per cent of the 40,000 NHS consultants were in receipt of an award (NAO, 2013). The estimated cost to the NHS is over £500 million (€677M) per annum (National Audit Office, 2013), equivalent to the annual revenue of two medium-sized hospitals. If CEAs were to be shared equally among all consultants, this would imply an additional £12,848 (€17,409) per consultant, representing 11.8 per cent of a consultant's salary. This proportion is much higher than the usual value of PRP schemes in the public sector which tend to be no more than 5 per cent of salary (OECD, 2005).

The economic recession since 2008 has prompted the UK government to curtail public sector pay through a freeze in pay increase of those earning over £21,000 (€28,500) per annum (up to April 2013). Earlier in 2004, primary care and hospital doctors negotiated a new employment contract with the government, which led to significant ‘basic’ pay increases (of 24 per cent for lower grades, rising to 28 per cent for higher grades)(NAO 2013). These did not, however, lead to commensurate rises in NHS productivity (National Audit Office, 2010). In 2013, CEAs were under review in England and Wales, were withdrawn in Scotland, and were withdrawn and then re-instated in Northern Ireland (following judicial review by the doctors’ union, the British Medical Association (BMA)). Reforms to the awards have so far tended to be marginal, removing anomalies or clarifying criteria; there has been no attempt to remove CEAs.

Findings: medical pay, income and the new professionalism

Submissions from professional bodies and individual doctors were overwhelmingly supportive of CEAs. Some sought to remove anomalies, others favoured greater transparency but all sought to ensure the continuation of the scheme. Very few suggested specific reforms. It is significant that critical voices within the profession did not use this opportunity to express their concerns. One group did, however, disagree with the term ‘clinical excellence’:

Often, the claims made in the submissions were normative, without much empirical justification. When sources were cited, it was invariably partial, drawing on a limited range of evidence. For example, evidence from economics and psychology were occasionally cited (in the form of one or two articles) but without much critical insight.

We confine our findings to two major themes (pay and income, and the new professionalism) which emerged from the analysis.

Doctors as knights and knaves: a re-assessment

In this paper, we examined the motivation of the medical profession with regard to CEAs. We used the lens of ‘knights’ and ‘knaves’ to interpret the profession's attitude towards financial awards.

Written submissions to the DDRB consultation illustrated the range of medical opinion, from major professional bodies (such as the RCP) and the doctors’ union (BMA) to individual doctors. Such extensive and detailed data are usually unavailable elsewhere. However, in responding to the consultation, preferences and interests were revealed. Yet, the submissions were partial and sought to defend a position. As the quality of medicine has hitherto largely been defined, measured and rewarded by the profession itself, it is hard to judge (from these data) how far CEAs motivate members of the medical profession beyond what they would have done anyway. The longevity of the CEA scheme might also denote a further sense in which it has become socialised into medical politics and, with the majority of consultants getting an award, is seen as an entitlement for senior doctors and an incentive to junior doctors.

The medical profession showed a remarkable degree of consistency in the content, tone and scope of its arguments. Such consistency might be evidence of a logic which sought to forge a new professionalism, accommodating traditional forms of medical power with external imperatives. Submissions thus sought to secure cohesion of/within the profession in the face of further stratification. Such a strategy is significant since the authors of the submissions (from representative medical bodies) comprise the administrative elite (Freidson, Reference Freidson1994). Their views may not thus coincide with those of the rank-and-file. Submissions from individual doctors were analysed although it is hard to gauge whether this small number represented wider opinion amongst doctors. Equally, the individual submissions tended to reflect existing award holders rather than, say, those without CEAs or junior doctors. Their opinions would be worth investigating.

Whilst traits of both knightly and knavish behaviour were visibly apparent (Disney et al., Reference Disney, Le Grand, Atkinson and Oliver2013), many of their arguments relied on an inter-dependence between them (Frey, Reference Frey1997; Frey, Reference Frey and Oliver2013; Klein, Reference Klein, Marmor and Klein2012; Le Grand, Reference Le Grand2003). Thus, extrinsic rewards were required, they argued, to secure their intrinsic motivation. However, whilst doctors displayed strong ‘knightly’ characteristics (of working ‘over and above’ contractual requirements, working beyond contracted hours, etc), they also argued that the CEAs were an essential part of the financial recompense that doctors deserved. Doctors’ claims that removal of CEAs would threaten knightly behaviour thus appear a knavish strategy.

The ‘crowding out’ effect of intrinsic motivation of CEAs was not apparent in this evidence. As the profession has continued to control the criteria by which CEAs are allocated and the decision-making processes which distribute the awards, it could be argued that intrinsic motivation has been ‘crowded-in’ by the continued ‘ownership’ of CEAs (Frey and Jegen, Reference Frey and Jegen2001). Knavish doctors would also still benefit since they may be more adept at completing CEA application forms and relying on clinical networks to influence local CEA committees. Clearly, some senior doctors may receive a CEA but may not be motivated further by it (Le Grand, Reference Le Grand1997: 162; Reference Le Grand2003: 105). These ‘free riders’ may be contrasted with those doctors who do not apply (perhaps for moral reasons), whose applications are not successful but who still work ‘over and above’ contractual requirements (e.g., long hours) and who are subject to discrimination in their CEA application. Such views are moderated by the growing sense of entitlement to CEAs now that over 60 per cent of consultants get an award. Indeed, some submissions recognised that CEAs had become a de facto career ladder. Intrinsic and extrinsic motivation are thus inter-twined.

As the profession has continued to ‘own’ CEAs, managerial reforms (e.g., ‘organisational’ criteria or managerial representation on CEA committees) have not significantly undermined medical power. So, rather than the medical profession being co-opted into state apparatus and its managerial discourses, the profession has been able to articulate a reconciliation between external challenges and medical professionalism. As a result, the profession can deflect and absorb such challenges through a subtle and on-going re-definition of what it means to be an ‘excellent’ doctor. This absorption has rested upon a judicious mix of managerial arguments (as shown by acceptance of PRP) and a new professionalism (which signifies the traits of what being an ‘excellent’ doctor is supposed to entail). This is redolent of ‘soft bureaucracy’ (Courpasson, Reference Courpasson2000) whereby external ‘control’ (here, the prospect of CEA reform) needs to be vague enough to reflect local (here, professional) circumstances but sufficiently testing to prompt professions’ reactions (in the accounts we examined).

The traditional norm of the medical profession has been avowedly knightly rather than knavish. Yet, the paradox that members who display such altruism might also be well rewarded financially requires explanation. So long as the administrative elite of the medical profession is able to defend the extrinsic benefit of CEAs on the grounds of altruism and self-interest, its (rank-and-file) members can legitimately claim to (only) be motivated by intrinsic factors (Klein, Reference Klein, Marmor and Klein2012).

Although the prospects for CEA reform now seem stronger than in recent years, it is not certain that wholesale change is imminent. Judging by the submissions to the DDRB consultation, CEAs symbolise a strong characteristic of the medical profession's extrinsic motivation. Its ability to deflect and absorb external challenges through re-framing the criteria and through maintaining control of CEA allocation suggests that CEAs will remain a feature on the NHS landscape for the immediate future.