Rationality + badly-designed incentives = poor health

In the absence of broad, coherent, long-term goals that are actually meaningful to ordinary people, we end up with Mickey Mouse micro-objectives that, a cynic would believe, are designed to channel society's resources into purely private goals. This can be seen clearly in health care, where there are few incentives to increase well-being as measured by such indicators as longevity, or Quality-Adjusted Life Years, and all sorts of incentives to encourage professionals to prescribe medications regardless of how beneficial they are to the population. Several recent commentaries examplify this point:

Writing about the Number Needed to Treat (NNT) of prescribed drugs, Sebastian Rushworth says:

Doctors have been conditioned by the pharmaceutical industry to think that drugs that provide very low probability of benefit are effective. An NNT of 10 is often considered good, and an NNT of 5 is considered excellent. Even an NNT of over 100 is often considered acceptable! Patients are rarely informed that the odds of them getting any benefit from the new drug they’re being prescribed are far less than 50:50. And they’re rarely informed about what the harms are, and how likely they are to experience them. What defines a good drug?, Sebastian Rushworth, 14 April

Malcolm Kendrick writes about the Quality and Outcomes Framework (QOF) system was being used by doctors in the UK's National Health Service:

Replace it with carefully crafted treatment algorithms, based on the best possible evidence. To explain in a little more detail. QOF itself is a system whereby GPs can earn points for reaching various targets. They are then paid money for each point gained.  Evidence Based Medicine - it was a good idea, Malcolm Kendrick, 25 April

The problem is that these targets have little to do with health, and much to do with the goals of the pharmaceutical companies:  

[Y]ou can gain points for such things as lowering the blood pressure to a ‘target’ level in the approved percentage of patients. Or driving the cholesterol level down below the ‘target level’, or getting the blood sugar (HbA1c) level below the ‘target’ level in the approved percentage of patients.

In short, for QOF to work, the GP needs to create database after database of different diseases. Then carry out audit … after audit. What a great use of clinical time it all is. Appointment after appointment filled with patients called in to have their annual blood pressure check, which just sneaks in just below target level – every single time.

For the pharmaceutical companies this is manna from heaven. Every patient with diabetes logged and audited. Every one driven to reach a ‘target’. A target that will inevitably require medication. Medication that the pharmaceutical company just, ahem, happens to have developed. Medication where they just, ahem, happen to have done all the clinical trials.

Dr Kendrick's skepticism is borne out by his quote from an analysis done by Imperial College London:

A substantial number of English communities experienced a decline in life expectancy from 2010-2019, Imperial College London researchers have found … For such declines to be seen in ‘normal times’ before the pandemic is alarming.

Finally, Guy Hatchard writes about the Wall Street Journal's new-found skepticism about Covid vaccines:

The WSJ article described the effect of boosters as fleeting, mild and short-lived. It sounded a note of alarm saying that neither the CDC [US Centers for Disease Control] nor the US National Institutes of Health (NIH) had made a priority of studying vaccine complications. Moreover their VAERS [Vaccine Adverse Event Reporting System] data collection and analysis process is incomplete and inadequate. In other words, the safety investigation to date of adverse effects of mRNA vaccination is incomplete and potentially misleading. The central question raised by the WSJ opinion piece is, why wouldn’t the US regulators wish to undertake accurate and complete investigation of adverse effects of mRNA vaccination? Have pharmaceutical interests been able to influence decision-making at the FDA [Food and Drug Agency] to their own commercial advantage at the expense of safety considerations? When will these vaccine zealots wake up to the truth?, Guy Hatchard, TCW, 24 April

I share all these authors' skepticism, bordering on cynicism. It's clear that apart from a few outspoken commentators such as these, all players throughout are reacting rationally, if ignobly, to the incentives on offer. My suggestion? In place of indicators and targets designed, in my view, by vested interests, including government agencies to enhance their profits and power, we target for improvement the well-being of all citizens. We need to channel our ingenuity and society's scarce resources into improving the physical and mental well-being of whole populuations and to create incentives to do so. I have written about applying the Social Policy Bond principle to health here and, more extensively, here.