- The 1997 white paper 'The New NHS: modern, dependable' promised to put quality at the heart of the health service, announcing the formation of a National Institute of Clinical Excellence, a Commission for Health Improvement, evidence based National Service Frameworks, a new system of clinical governance in NHS trusts and an annual survey of patients' experiences of NHS care. 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. It also considers aspects of politicians' professional leaders' and managers' abilities to address the challenges of quality improvement.