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This study examines mortality rates for 12 surgical procedures of varying complexity in 1498 hospitals to determine whether there is a relation between a hospital's surgical volume and its surgical mortality. The mortality of open-heart surgery, vascular surgery, transurethral resection of the prostate, and coronary bypass decreased with increasing number of operations. Hospitals in which 200 or more of these operations were done annually had death rates, adjusted for case mix, 25 to 41 per cent lower than hospitals with lower volumes. For other procedures, the mortality curve flattened at lower volumes. For example, hospitals doing 50 to 100 total hip replacements attained a mortality rate for this procedure almost as low as that of hospitals doing 200 or more. Some procedures, such as cholecystectomy, showed no relation between volume and mortality. The results may reflect the effect of volume or experience on mortality, or referrals to institutions with better outcomes, as well as a number of other factors, such as patient selection. Regardless of the explanation, these data support the value of regionalization for certain operations.

The impact of medical care on the quality and length of life of the population has been poorly documented. The rapid growth of evidence of efficacy of therapy for individual medical conditions now offers the opportunity to create an inventory of benefits. A method for creating such an inventory is described, as is its application to a selection of condition-treatment pairs, chosen for their high incidence of prevalence, their serious outcomes, and the demonstrated efficacy of their treatment. An aggregate effect of medical care on life expectancy is found to be roughly five years during this century, with a further potential of two years. Although there is no overall index of quality of life analogous to life expectancy, our inventory demonstrates the enormous burden of pain, suffering, and dysfunction that afflicts the population for which medical care can provide a large measure of relief.

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The doctor and the patient enter the examining room and the door is closed. For One of us (AE) has suggested that the seeds of poor service, fragmentation, and rising costs were planted in the very structure of the NHS.4 That structure has survived -because of the quality and dedication of the people who work in it and the underlying social commitment to equity, but it lacks strong incentives for the improvement of care and service. In fact, the incentives regarding improvement in the NHS have been perverse: better performance may be associated with higher workload but without a commensurate increase in resources. The widely criticised waiting lists for inpatient surgery are one result.Recent reforms in the NHS have been directed toward establishing structures and incentives that can encourage quality and efficiency.5 The reformers of the NHS intend to make it more sensitive to the needs of those who depend on it for service and care and to encourage providers of care to discover better ways to do their work. Under the new rules those who improve their performance would benefit from increased resources with which to handle their expanding share of the medical marketplace.The central idea is to create incentives for improvement by creating internal "markets" among components of the health care system. Under the new rules the district health authorities become selective purchasers of services that they were formerly obliged to "purchase" only from themselves. It now becomes the duty of the general manager of the district health authority to seek better deals for the patients for whom he has responsibility. With a fixed budget it is in both the patient's and the manager's interest for the authority to contract for services not only at lower prices but with better outcomes, as a poor outcome may necessitate further treatment at additional cost. When the general practitioner is the budget holder it is similarly in his or her interest to contract for the most cost effective care available.From the perspective of classical economic theory structural reforms based on a market model seem to offer a particularly attractive solution. They suppose improvement to occur as a result of reliable, natural laws of economics in which customers and providers find efficient solutions to their respective needs and constraints. With three basic components-freely available information on the quality of available goods and services, consistent and rational buyers, and competent producers-a market can unconsciously

resonance diagnostic procedures. Documents of the Natizonal Radilological 43 National Radiological Protection Board. Board statement on radon in homes. Protection Board, 1991. Documents of the National Radiological Protection Board 1990;1(1). 41 International Commission on Radiological Protection. Lung cancer risk from 44 Department of the Environment. 7'he householder's guide to radon. 2nd ed. indoor exposure to radon daughters. ICRP publication 50. Ann ICRP London: Doh, 1990. 1987;17(No 1). 45 Roscoe RJ, Steenland K, Halperin WE. 1lung cancer mortalitv among non-42 Committee on the Biological Effects of lonising Radiation. Health r'sks of'radon smoking uranium miners exposed to radon daughters. JAMA 1989;262: and other internally deposited alpha emitters (Beir 11). Washington, D)C: