to create "win-win" relationships. By extension, critics of competition maintain that the NHS should do the same. These developments have been reinforced by concerns about the increase in management costs associated with the introduction of competition.Estimates suggest that the NHS reforms may have resulted in up to £lbn extra being spent on administration, although changes in definitions make it difficult to be precise. This is because of the need to employ staff to negotiate and monitor contracts and to deal with the large volumes of paperwork involved in the contracting system. Ministers have responded to these concerns by streamlining the organisation ofthe NHS and introducing tight controls over management costs. They have also encouraged the use oflong term contracts in order to reduce the transaction costs of the new arrangements.Out of the ashes of competition has arisen a different policy agenda. This owes less to a belief in market forces than a desire to use the NHS reforms to achieve other objectives. The current agenda centres on policies to improve the health of the population, give greater priority to primary care, raise standards through the patient's charter, and ensure that medical decisions are evidence based. These policies hinge on effective planning and coordination in the NHS and all have been made more salient by the separation of purchaser and provider roles on which the reforms are based.In particular, the existence of health authorities able to take an independent view of the population's health needs without being beholden to particular providers has changed the way in which decisions are made. To this extent the organisational changes introduced in 1991 have served to refocus attention on those whom the NHS exists to serve, even though the effects were neither anticipated nor intended when the reforms were designed. Like a potter moulding clay, only in the process of creation has the shape of the product become apparent. The effect of this policy shift has been to open up common ground between Labour and the Conservatives, notwithstanding the differences that remain.Yet before the obituary of competition is written, the consequences of a return to planning need to be thought through. The NHS was reformed precisely because the old command and control system had failed to deliver acceptable improvements in efficiency and quality, and the limitations of planning must also be acknowledged. While competition as a reforming strategy may have had its day, there are nevertheless elements of this strategy which are worth preserving. Not least, the stimulus to improve performance which arises from the threat that contracts may be moved to an alternative provider should not be lost. The middle way between planning and competition is a path called contestability. This recognises that health care requires cooperation between purchasers and providers and the capacity to plan developments on a long term basis. At the same time, it is based on the premise that performance may stagnate unless there ...

Clinical experience provides clinicians with an intuitive sense of which findings on history, physical examination, and investigation are critical in making an accurate diagnosis, or an accurate assessment of a patient's fate. A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. Three steps are involved in the development and testing of a CDR: creation of the rule, testing or validating the rule, and assessing the impact of the rule on clinical behavior. Clinicians evaluating CDRs for possible clinical use should assess the following components: the method of derivation; the validation of the CDR to ensure that its repeated use leads to the same results; and its predictive power. We consider CDRs that have been validated in a new clinical setting to be level 1 CDRs and most appropriate for implementation. Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction. JAMA. 2000;284:79-84