The ethics of pay-for-performance.

Pay-for-performance (P4P) is a popular means of incentivising behaviour change. As a result, P4P or contingent rewards are ubiquitously applied by people in a variety of settings, from parents rewarding their children for examination success, to employee remuneration packages in the workplace, to payments for healthcare or other organisations achieving quality targets. The issue of P4P in healthcare is hotly and widely debated. Recent and increasing evidence from behavioural economics and from research on the effect of contingent rewards on healthcare organisations has led to a wider and deeper exploration of the ethical considerations of P4P. The basic rationale for P4P from behavioural psychology is that rewarding performance with contingent incentives will heighten motivation and increase effort, leading to better performance. There has been a widespread assumption that the underlying reasoning is true. This leads us to ask a number of questions including the following: