The permanent revolution within the NHS aims to ensure fiscal balance and the provision of patient centred care while maintaining the support of the medical profession. The fiscal and care aspects have received most attention at the expense of engagement with clinicians, and the policy focus has now moved to the “quality of care” at a time when the word deprofessionalisation captures well the current zeitgeist within the medical profession. Professionalism requires a high level of performance, and so improving standards is fundamental to medical practice; now the issue is how to apply this ethic to the delivery of health care itself. The physician’s primary duty to the patient must be held above other loyalties (institutional, specialist or financial), as this ensures the public’s trust in the profession. However, care in the NHS has to be delivered not only to individuals but also to populations, and this consideration, traditionally confined to public health medicine, must now assume a central position within the wider profession too.

Quality, defined as “the degree to which health services increase the likelihood of desired health outcomes given current knowledge,”1 2 …