For the first 40 years of the National Health Service (NHS) there was an implicit notion of quality, with the assumption that providing well-trained staff and developing good facilities and equipment was synonymous with high standards (Halligan & Donaldson, 2001).

The arrival of the Thatcher government in 1979 saw the start of the first major reforms to the NHS. These initially focused on funding, management and organisational reform. From 1982 managers became accountable for output measures, at first concentrating on financial and workload concerns. In 1983 the Griffiths report (Department of Health and Social Security, 1983) described a lack of clarity in accountability at local level, and overturned consensus management, resulting in the appointment of general managers to lead healthcare units.

More service changes followed with the introduction of the internal market in the early 1990s, but these did not specifically look at how to achieve improvements in quality at a structural level. Quality continued to be seen as inherent in the system, sustained by the ethos and skills of the health professionals working in the NHS. Any quality initiatives tended to be insular activities, not integrated across a whole service.

Quality management ideas, which were developed in the Japanese car industry and taken up by business in the USA, crept into the American healthcare system in the 1970s, before arriving in Europe. New concepts included total quality management and continuous quality improvement, but these were not widely accepted. However, the rise of consumerism among the post-war generation was starting to challenge the traditional paternalistic role of healthcare professionals in general, and doctors in particular. Patients wanted more information, choice and involvement in decisions regarding their healthcare. This is illustrated in the rise of the service user movement and with the government'sintroduction of the Patient'sCharter in 1992; shorter waiting lists, and the right to information and to complain were potential vote winners.

There were also questions about variations in practice as clinicians adopted the principles of evidence-based medicine, taking a more rigorous approach to their work. A series of high-profile service failures – an example being paediatric cardiac surgery in Bristol – raised concerns about professional self-regulation and doctors’ accountability. These service failures prompted more urgent demands for change and attempts to address quality in a more systematic and explicit way.