When the National Health Service (NHS) was born in 1948, there was no specific agenda for clinical quality, which was assumed to be inherent in the system. The received wisdom was that good professional training with self-regulation and appropriate opportunities for ongoing professional development all inevitably added up to high-quality health care. Unfortunately, as we now know, this was not and is not true. What quality initiatives there were tended to be disconnected, with duplication, inefficiency and complicated processes all too often the result. Understanding of the relationships between structures, processes and outcomes improved in the 1970s, but in the 1980s, effort was arguably constrained by a prominent emphasis on organisational performance and cost containment.