The setting of uniform standards presents a challenge for health and social care systems anywhere in the world. In the past 5 years, standards for the National Health Service (NHS) in England have been set out in a series of national service frameworks (NSFs). The latest in this series, the NSF for long term conditions, was released in March 2005 and presented some new challenges and novel solutions that have relevance for policy development in both the UK and other countries.

Previously published NSFs in the UK have provided standards for cancer, coronary heart disease, mental health diabetes, older people, children’s services, and renal disease. Each set a series of 12 or more standards, and most included clearly defined national targets that service providers were obliged to meet. Many were easily measurable process targets, for example: “No patient should wait longer than 2 weeks for initial consultation in cases of suspected cancer”,¹ and “Thrombolysis should be given within 60 minutes of calling for professional help, in all eligible cases of acute myocardial infarction”.² Ring fenced funding was made available to help providers to achieve these targets, and a series of “milestones” was drawn up, defining the services that should be in place by specific dates.

While there can be no doubt that these targets have raised awareness and changed healthcare provision in many respects, their value has been challenged in many quarters.^3,4 Importantly, by focusing on specific steps in the care pathway, they may divert attention from other critical steps. For example, a large study of over 5000 cases of breast cancer in the south of England showed that while the time to initial consultation had decreased, the time from first appointment to actual treatment had actually increased, and …