Patient power payments risk driving defensive medicine in the NHS

By Dr John Holden – first published in the Health Service Journal

The concept of “patient power payments” was recently resurrected by Wes Streeting – but such a policy risks undermining clinical decision-making.

Positioned as part of a wider push to strengthen patient voice, including within the new Women’s Health Strategy, the policy is intended to give patients greater influence over how care is assessed and how resources are allocated.

The strategy, which would allow patients to determine whether providers receive full payment based on their experience of care, is intended to improve standards. These are legitimate and important aims. However, linking financial outcomes to subjective experience risks introducing unintended consequences that could undermine both clinical decision-making and system performance.

New survey data from the Medical and Dental Defence Union of Scotland (MDDUS) indicates that the policy would directly influence clinical behaviour. Most strikingly, 57 per cent of doctors in England say it would make them more likely to practise defensively, including ordering unnecessary tests or avoiding high-risk procedures.

When doctors feel that financial penalties may follow from dissatisfaction, especially where that dissatisfaction reflects circumstances beyond their control, the pressure to avoid complaint competes with the duty to exercise balanced clinical judgement.

That pressure can take two forms. One is over-investigation, including more tests, follow-up and interventions. This is not always because they are clinically necessary, but because they may offer protection against complaint.

The other is risk avoidance, including a reluctance to take on complex cases or to recommend a reasonable but difficult course of treatment. Where outcomes are less predictable, there is a risk that these patients become less attractive to treat. Both outcomes risk harming patients while weakening the effective use of finite resources.

Beyond the quality of an individual clinical encounter is the experience of waiting times, staffing pressures, accessibility problems, fragmented pathways and wider social need. A doctor can communicate well, act appropriately and still be working within a service that leaves a patient deeply frustrated. If payment is then reduced because of that experience, who is really being judged?

Many clinicians question whether patient satisfaction alone can bear the weight being placed on it. Seventy-one per cent of doctors surveyed say it is too subjective a metric on which to base payment, while more than half (55 per cent) believe the policy would worsen NHS care and clinician morale.

Linking financial outcomes to subjective experience risks introducing unintended consequences that could undermine both clinical decision-making and system performance

There is also a real equity concern. Services caring for patients with greater clinical complexity, heavier demand, or more entrenched health inequalities may find it harder to achieve consistently positive satisfaction scores, regardless of the quality of professional care being delivered.

If funding is pulled away from those providers, the result may be to deepen the very inequalities the NHS is meant to reduce. Reflecting this, 73 per cent of clinicians warn that the policy could divert funding away from where it is most needed.

That is why blunt financial levers are so risky. They can appear to reward accountability while in practice penalising pressure points in the system.

Our survey data suggests a further risk. Nearly four in 10 doctors in England say patient power payments would make them consider reducing their NHS commitments, whether through fewer sessions or earlier retirement. At a time when services are already under strain, policymakers should be wary of reforms that may further weaken NHS retention figures.

Feedback from patients can highlight poor communication and expose patterns of care that data alone may miss, and so the patient voice will always be essential to improving care. However, it is most effective when it informs improvement, rather than being used to withhold resources.

If ministers want to strengthen accountability, there are better ways to do it. Patient experience should sit alongside robust clinical outcomes, staffing realities, case mix, safety indicators and local context. Any trial must be carefully designed, transparently evaluated, and protected by safeguards that avoid bias, subjectivity or structural disadvantage from driving funding decisions.

Most importantly, improving care quality depends on getting the conditions right as well as the incentives. Sustained investment, realistic workload planning, meaningful wellbeing support for staff and stronger systems of leadership are more likely to deliver meaningful improvement than policies that risk making clinicians more cautious and less willing to stay.

Get that balance wrong, and we risk weaker services and poorer care for patients.

Download the survey data (PDF)

This article was first published by the Health Service Journal and is reproduced here with permission.

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