After protracted negotiations, the BMA and the consultant body voted in favour of a new contract, implemented with effect from April 2004. This contract applies to new practitioners and existing consultants who choose it. During negotiations, the Department of Health sought, but failed to obtain, professional support for a system of fee for service payments, for surgeons in particular. Despite this rejection, professional support among surgeons may now be emerging for the introduction of such a system.

The government's NHS Plan requires considerable increases in medical and surgical activity.1 This can be achieved by changing the size of the medical workforce or by using incentives to stimulate existing doctors to produce more activity. Contracts of NHS hospital consultants include systems of reward and regulation, and both influence activity. Regulation has developed with the evolution of job plans and appraisal, and it will develop further with revalidation and more performance management by trusts. Reward systems and financial incentives, however, have changed little in the …