Changing cultural visions in the NHS.

Vision for the NHS, mid 1980s to mid 1990s (General Management and The Internal Market)Vision for Labour's “New NHS”, late 1990s (The Third Way)
Macro/system level factors
Basis of economic relationships:Competition (contracts)Cooperation/partnership (long term service agreements)
Governance:Market discipline“Third way”
Key objectives:EfficiencyEfficiency/equity/quality
Rate of change:“Big bang”Evolutionary
Locus of change:Top down“Everyone's business”
Flows of information:Confidential/commercially sensitiveOpen/transparent
Basis of performance assessment:Finance/activity/volume“Balanced scorecard”
Micro/clinician level factors
Basis of practice:Professional judgementEvidence based
Basis of control:Mutuality/trustAudit, external verification
Clinical performance information:ConfidentialPublicly available
Participation in audit (e.g. confidential enquiries):DiscretionaryMandatory
Accountability:Largely opaque (professional self-regulation)Transparent: corporate and clinical governance
Public confidence:HighDiminished
Continuing professional development:DiscretionaryMandatory
Ethical basis:Hippocratic oath/patient firstCorporate objectives