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S. Nicholls: S. Nicholls is a Researcher, National Clinical Governance Support Team.
R. Cullen: R. Cullen is Programme Director, National Clinical Governance Support Team.
S. O'Neill: S. O'Neill is Communications Director, National Clinical Governance Support Team.
A. Halligan: A. Halligan is Head of the National Clinical Governance Support Team.
The history of quality
In 1948 the National Health Service was established with no particular agenda for quality. It was assumed appropriate quality would result from the provision of an infrastructure and the training and education of staff. "Quality was seen as inherent in the system, sustained by the ethos and skills of the health professionals working within it" (Donaldson and Gray, 1998).
There were attempts at quality improvement over the next two decades, but effort during this period was focused on re-arranging tangible components of the service - developing more and better equipment, renewing buildings and facilities, re-training and re-deploying staff.
With responsibility for each of these elements separately apportioned it was inevitable that a lack of "connectedness" revealed itself in inefficiency, duplication, and the generation of complicated processes. (For example, a clinical team (Homa and Bejan, 1995) which reviewed its outpatient process in the early 1990s was able to reduce an eight-step process to one step by reviewing and adjusting clerical support. The resulting service was more efficient, more patient-centred and provided increased staff satisfaction. It also reduced costs by 15 per cent.)
By the 1970s analysts and thinkers were working to define and explain the meaning and relevance of components of quality (criteria, standards, norms, etc.) as the importance of understanding the relationship between structures, processes and outcomes was recognised (Lembcke, 1956, 1959; Donabedian, 1981; Donabedian et al., 1982).
In 1983 the Griffiths Report (1983) described a lack of clarity in accountability at local level, it overturned consensus management and resulted in the appointment of general managers to lead health care units. Medical staff were involved within management teams and this arrangement introduced an element of personal accountability for services provided.
Since 1982 (Honigsbaum, 1994) managers had been accountable for output measures. Targets were revisited in Health of the Nation (Department of Health, 1992) and in Our Healthier Nation (Department of Health, 1998). However, targets remained related to financial and workload concerns, quality...