New era for health services will focus on systems and creativity—an essay by Nick Black

In 1988 Arnold Relman, editor of the New England Journal of Medicine, described how attempts to control the costs of the vast array of new diagnostics and treatments that had transformed medical care had had only limited success.1 He recognised how the quest in all countries for “an equitable health care system, of satisfactory quality, at a price we can afford” was having to contend with the countervailing interests of both the medical-industrial complex and unfettered professional autonomy.

Unfettered autonomy was apparent in the geographical variations in clinical practice being revealed, reflecting inconsistency in professional judgments. Relman suggested that a new, and much needed, era of healthcare was dawning, one that would tackle these challenges through rigorous assessment of clinical practice together with greater public accountability of doctors and services.

That era of assessment and accountability dominated the next 30 years. Evidence based medicine, clinical guidelines, clinical audit, surveys, and regulation have achieved much. The gains can be seen not only in improved outcomes and greater adherence to guidelines but also greater productivity.2 Underlying these has been considerable success in challenging medical paternalism and undue professional autonomy.

Yet despite all that has been achieved, health systems are still beset with problems. In England, regulators report the quality of many providers needs to improve, the productivity of services varies widely, administrative complexity bewilders patients and staff alike, lack of integration across sectors persists, staff are dispirited, and progress in developing patient centred care has been disappointing.

Why is this? The widely held view is insufficient funding. Although additional funds …