The aim of this article is to report the results of a study examining salaried payment for general practitioners (GPs) in Scotland. The study examines ‘paragraph 52’ salaried payment, where GPs can employ a GP as a member of practice staff and claim reimbursement from the health board. The paper reports results of 18 semi-structured interviews with managers at two health boards, and at seven general practices who have a salaried GP. The paper also presents quantitative data about the nature of the salaried contracts and presents a comparison of practices with a salaried GP with other practices in Scotland. Seventeen practices employed a salaried GP 18 months after the scheme began. Ex-fundholders and training practices were more likely to have been selected by health boards to employ a salaried GP. The two health boards took different approaches to the scheme. The first selected those practices that were more likely to have identified specific service developments as part of their bid for a salaried GP. This approach might reward those practices that were already innovative, thus potentially increasing inequality in service provision between practices. The second health board used the scheme to maintain and support practices in rural areas, and was less concerned with service development, thus potentially reducing inequalities in access. Salaried GPs were ex-GP registrars and ex-locums who wanted more stability and less responsibility, and administration. Some were happy in their post, while others saw it as a stepping stone to a partnership. Most practices used the salaried GP to release the time of partners to engage in practice development. Some practices mentioned the financial benefits of the scheme and benefits in terms of enabling service development. Compared to using locums, it was suggested that referral rates of salaried GPs may be lower, and continuity of care higher. Participants felt strongly that the scheme should continue. The paragraph 52 scheme was used little, but was potentially valuable in introducing stability and experience for younger GPs who do not want a partnership. Health boards had different interpretations of the objectives and use of the scheme reflecting different local circumstances. The potential of the scheme to address inequalities in the distribution of GPs is uncertain.

In an effort to control ambulatory care costs, regulatory practice guidelines (références médicales opposables or RMOs) were introduced by law in France in 1993. RMOs are short sentences, negatively formulated (“it is inappropriate to \ldots”), covering medical and surgical topics, diagnosis, and treatment. Since their introduction, physicians who do not comply with RMOs can be fined. The fine is determined by a weighted combination of indices of harm, cost, and the number of violations.

The impact of the RMO policy on physician practice has been questioned, but so far few evaluations had been performed. At the end of 1997, only 121 physicians had been fined (0.1% of French private physicians). The difficulty of controlling physicians, the large number of RMOs, and the lack of a relevant information system limit the credibility of this policy.

The simultaneous development of a clinical guideline program to improve the quality of care and of a program to control medical practice can lead to a misunderstanding among clinicians and health policy makers. Financial incentives or disincentives could be used to change physician behavior, in addition to other measures such as education and organizational changes, if they are simple, well explained, and do not raise any ethical conflict. But these measures are dependent on the structure and financing of the healthcare system and on the socioeconomic and cultural context. More research is needed to assess the impact of interventions using financial incentives and disincentives on physician behavior.