Collini’s article, and the book he reviews are far reaching. A primary take-away are the perverse incentives to cheat, to lie, to engage in what Berwick calls ‘gaming’. It is worth reflecting on the range of examples if only to remind ourselves how easy it is to get sucked in. Collini is mainly interested in education and he talks about:

  • shifting the focus of reward, for example from participation in sports to passing English GCSE, with consequences for say obesity
  • creaming, kicking out the low performing students and reporting on the results of the smart kids
  • straight out cheating. Our epidemiological methods at Dartington caught the imagination of the Superintendent for schools in Atlanta, Georgia. She was arrested for cooking the books before the work could get underway, a narrow escape
  • treat to the test, which maybe explains why the huge advances in treating prostate cancer has not been mirrored in advances in treating the mental health sequelae
  • skewing, taking the easiest cases, bearing in mind the illustration from the input on the ‘third circle’ that shows that the people getting support from high end public systems are not necessarily those in greatest need
  • gatekeeping, taking fewer cases and doing better with those you do take. Actually, this isn’t always a bad idea. At Dartington we experimented with a bunch of local authorities to reduce numbers in care, so as to give those admitted a better chance.

Underpinning all this wrongdoing is a shift from internal motivation to external motivation. In the first era we are driven by ethics, by the ethos of being a good public servant. In the second era we are driven by external targets, knowing we may be punished if we fail.

And in the third era? The example from Jerry Muller’s book dealing with central line catheters may be instructive. The medics involved in the research were driven not by era 2 targets but by old fashioned era 1 ethos of public service. There was no punishment but there was reward, and it was attached to learning. In this context, failure is as valuable as success.


There is no external bad guy. It is the context that matters. The context framed by each of the eras shapes how we behave, encouraging us to go the extra mile, encouraging us to hide and cheat, encouraging us to try and fail.

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