Several trends have worked to support the ideology of concordance in the modern context of high levels of chronic (and expensive ) illness among the ageing populations of modern industrial societies . Many people have to live with the long-term consequences of illness and disability. A choice of treatment is often available, and the benefits of treatment may be uncertain or marginal. In such circumstances, it is increasingly seen to be up to the individual to assume at least some responsibility for decision making in accordance with his personal outcome goals and tolerance of risk. Contemporary notions of citizenship accord priority to an individual autonomy and self-determination which is expressed directly in the exercise of choice : the role of patient is reconstituted as that of reflexive consumer. Concordance also fits well with the current policy focus on patient-centred medicine. This is promoted as a means of improving the quality of care through responsiveness to patient preference and assessment . It is also assumed to be a means to the delivery of more efficient, accountable and cost effective services .