This paper presents the findings of a study on the impact of ‘Payment by Results’ (PbR) on performance measurement and management in three National Health Service (NHS) Trusts in the East of England. The study employs concepts from structuration theory and institutional theory to provide a holistic analysis of change in these organisations. Structuration theory is shown to be valuable in understanding the context of change and in highlighting the emergent contradictions that resulted from new approaches to performance management, as new conceptions of organisational activity premised on ‘cost’ and ‘income’ were introduced. Institutional theory was employed to analyse the process of change in specific organisational contexts, given its emphasis on the importance of contradiction for praxis, as organisational members enact the change process. Significant findings include the importance of financial performance, adoption of a business-focused attitude and co-operative relationships between clinicians, managers and accountants in achieving change.