As more and more payers focus on measuring and rewarding performance, issues arise about how to use that process to motivate continuous quality improvement.

The National Health Services has had the world's largest implementation of pay-for-performance. General practitioners have responded rapidly to the incentives, driving most values rapidly toward their maxima.

This case considers how the U.K. has addressed this "now what" question. This is a political environment, so the pacing and the apparent fairness and rationality of this process of continually raising the bar are very important to continued success.

This case gives insight into the functioning of the National Health Service in the U.K. as well as the role of NICE as a mechanism for forcing quality improvement. It also provides insight into some of the practical issues of implementing, maintaining and improving a pay-for-performance approach to primary care.

Keep in mind that primary care physicians are comparatively better off when compared to the specialists and hospitals than they are in the United States. Each patient is assigned a medical home and electronic medical records are readily available to both physician and payer.