- This paper is intended as a contribution to the Prime Minister's Review of the NHS. It argues that the use of incentives, competition and better management has already led to significant progress in improving efficiency, effectiveness and consumer responsiveness within the NHS. The key challenge now is to build on these beginnings in order to accelerate this process. A key premise of the paper is that it is not possible to specify now, in advance, in any useful degree of detail, what the NHS should look like in four, five to ten year's time. Purposeful and beneficial change will not be achieved by prospective detailed prescription from government. Rather, it will be far better and far more effective to: a) concentrate government attention on a small number of key strategic themes; b) translate these themes into a change agenda; c) create conditions within which local initiatives consistent with this are encouraged; d) create a surveillance function.