Pay and performance

Many countries have linked the remuneration problem with concerns about quality and performance, focusing new attention on payment for performance programmes. Under these programmes a portion of payment is dependent on performance assessed against one or more defined measures.2 The United States has over 100 private and federal Medicare reward and incentive programmes,3 and Italy and New Zealand are beginning to reward performance in primary care. The UK remains in the vanguard of such schemes, with the quality and outcomes framework paying out around £1000m (€1300m;$2000m) in 2005-6 to general practices4 and being described at its launch as the “boldest such proposal on this scale ever attempted anywhere in the world.”5

Paying for performance is being given increasing attention across many public services, as a means of motivation and drawing attention to local agency.6 Beyond these larger trends, many reasons have been given for linking doctors’ pay to performance (box 1). Taken together, these arguments have contributed to a lessening of ideological debate with much of the deliberation now …