tion. The study employs concepts from Giddens’ (1984)
structuration theory and from institutional theory (Seo
and Creed, 2002) to examine implementation of PbR in
three NHS Trusts and implications for objectives of NHS
Trusts, cost and quality of healthcare provision, and power
relations between professional groups including accountants,
clinicians and managers. The paper evaluates change
over time as the spotlight shifted from a traditional focus
on fiscal prudence, to a new emphasis on performance
measurement following introduction of the National Reference
Cost Index (NRCI) (DoH, 1998a), and subsequently to
further refinement under PbR, which facilitated not only
measurement of performance but also its management.
Within this new regime accountants play a key role, as
the accounting data underpinning PbR constitute the backbone
of the changes in this output-focused performance
management approach.