Intended for healthcare professionals


Payment for performance in health care

BMJ 2008; 336 doi: (Published 07 February 2008) Cite this as: BMJ 2008;336:306
  1. Russell Mannion, director 1,
  2. Huw T O Davies, director 2
  1. 1Centre for Health and Public Services Management, University of York, York YO10 5DD
  2. 2Social Dimensions of Health Institute, Universities of Dundee and St Andrews
  1. Correspondence to: R Mannion rm15{at}
  • Accepted 14 November 2007

Debates about performance related pay seem to have moved on from whether it is desirable to how to make it work. But Russell Mannion and Huw Davies cautionthat we still don’t know enough about the potential problems

Health service pay is top of the political and media agenda in many countries. In the UK, moral outrage over doctors’ pay - fuelled by the lay media - has contributed to a widespread belief that pay rises have soaked up much of the recent investment in the NHS.1 Doctors’ representatives respond that rising pay reflects rising quality and performance, but doubts remain and even the government has expressed alarm, threatening to cap future rises. Other countries are also grappling with how to pay healthcare professionals, particularly doctors.

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 …

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