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The political reforms of the public sector, termed “new public management” (NPM), now have a 20-year history. This paper looks at local differences between England and Scotland over a particular dimension of NPM — performance management in health care. In the context of the dynamic reform agenda in the UK, it is expected that these “local” lessons will have some global relevance. This paper elaborates on these inter-country differences and proposes how the approaches in England and Scotland may affect productivity and innovation in health care delivery. It does this by exploring research into the behaviour of the most powerful of health care providers, the senior clinicians in hospitals.