Incentives for health care professionals

Performance-related pay for health service professionals: the Italian experience

Italy has significant experience of performance-related pay (PRP) for health service professionals: a system which links part of doctors' remuneration to their productivity dates back to 1938. This paper reports on a two-year field research, carried out on the Italian National Health Service, which investigates the objectives, design and implementation of PRP, as well as its operation and effectiveness. First, the evolution of PRP schemes over the latest 25 years is reconstructed, and the range of covert and overt objectives underlying the use of PRP are unravelled. Then, after having highlighted the main structural and cultural factors which negatively affect PRP effectiveness, a critical evaluation of PRP is attempted, drawing on the analysis of both hard performance data and the subjective perceptions of stakeholders. The conclusion is that PRP led to problems and unforeseen consequences in most of the hospitals examined, due to both structural factors, mainly some flaws in PRP design, and cultural constraints, mainly the values of health professionals. However, the case of a Northern Italian hospital proves that, despite the constraining environmental setting, there is still scope for managerial intervention in the implementation process which is sufficient to guarantee PRP effectiveness. This indicates that the implementation process far outweighs the significance of structural and cultural constraints, and that PRP is a powerful tool at management disposal to increase employees' performance and commitment.

Managing medicine: a response to the 'crisis'

A feature of many developed healthcare systems is the attempt to replace provider-driven services by managerially-driven services which are ostensibly more responsive to consumer preferences. Policy-makers anxious over the 'crisis' of escalating costs in healthcare delivery and over the efficiency of some medical treatments and interventions are turning to managerial solutions as a means of holding professionals--primarily the medical profession--to account for their actions. The paper uses developments in the British NHS as a case study to review and explore the issue of managing medicine. Recent and proposed reforms are designed to strengthen the managerial grip on the service. The paper casts some doubt over the likely outcome of these developments. It argues that the success of attempts to shift the frontier between management and clinical work in favour of management is by no means guaranteed. It also points to a major tension which remains to be resolved, namely, the optimum balance to be struck between a doctor's responsibility to each individual patient on the one hand and his/her responsibility to a whole population on the other.