Although not always recognised by clinicians and the public, the principal aim of most of the reforms of the NHS in England over the past decade has been not only to increase efficiency and productivity but also to improve the quality of care—that is, its effectiveness, humanity, and equity. For example, establishing the National Institute for Health and Clinical Excellence and national service frameworks was meant to enhance effectiveness; introducing competition and choice was partly intended to improve the patient’s experience of care; and adjusting resource allocation to commissioners sought to achieve greater equity.

The multiplicity of changes to the governance, organisation, and financing of services has made it difficult to judge the effects of any single reform on the quality of health care. Despite this, there has been no shortage of people ready to express authoritative opinions, from members of the public and patients’ organisations, through royal colleges and trades unions, to the private sector and parliamentarians. Inevitably, such views tend to be partial and to reflect particular interests. An attempt to provide a …