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However, previous quality initiatives have been seen as 'bolt-on' extras rather than as fundamental to the way treatment and care are provided. Also, definitive evidence of the value derived from the one to two billion pounds of public money spent on NHS and allied quality programmes since the end of the 1980s has proved difficult to gather. Against this background, this report aims to clarify the concepts and issues underlying national debate on health care quality. It offers a critical look at the claims made by proponents of quality management techniques. 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