Quality: link with effectiveness.

In summary, though the notion of "quality of care" has become fashionable, most of the focus has been on initiatives such as the patient's charter, waiting times, quality of the physical environment, patient centredness in outcomes measurement, etc. Nevertheless, at the heart of quality must be the effectiveness and cost effectiveness of interventions. Without ensuring that health technologies are effective and are delivered appropriately then many of the other dimensions of quality may simply be window dressing. Substantial variations in the rates of procedures, the way in which similar patients are treated, and the degree to which professionals often ignore the best scientific evidence have all been well documented. The NHS needs methods for ensuring that the effectiveness dimension of quality is brought to the fore and becomes a routine part of quality assessment and activity. Clinical autonomy can no longer be an excuse for inappropriate care. The challenge for the future is twofold: to increase the amount of health technology assessment carried out and to develop methods of ensuring that health care converges with this best practice--that is, the promotion of evidence based practice. By introducing evidence based clinical guidelines and associated utilisation review and persuading purchasers to "purchase protocols" rather than just procedures the effectiveness dimension may become more routine, but it will require a radical rethink of the type of data collected and the way in which the purchaser provider split is managed.