The multitude of reforms to which the NHS in England has been subjected in recent years means it is impossible to say precisely which of them have had what effect, according to a co-author of the Nuffield Trust’s study.

From targets and choice to national service frameworks, new inspectorates and private sector involvement, the NHS’s decade-long drive to improve quality of care had been “the most ambitious and wide-ranging” in the world, said Professor Sheila Leatherman, an adviser to the US National Forum on Quality Improvement in healthcare. But it had become fragmented and needed refocusing, she added.