Tremendous progress has been made over the last forty years due to the second healthcare revolution, with the first healthcare revolution having been the public health revolution of the nineteenth century. Hip replacement, transplantation, and chemotherapy are examples of the high tech revolution funded by increased investment and, in the last twenty years, optimised by improvements in quality, safety and evidence based decision making. However there are still three outstanding problems which are found in every health service no matter how they are structured and funded: One of these problems is huge and unwarranted variation in access, quality, cost and outcome, and an analysis of unwarranted variation reveals the other two Overuse, which leads to waste, that is anything that does not add value to the outcome for patients or uses resources that could give greater value if used for another group of patients and often, patient harm, even when the quality of care is high
Underuse which leads to failure to prevent the diseases that healthcare can prevent, stroke and vascular dementia in atrial fibrillation for example, and often inequity