Some time around 2000 it became evident that the service the NHS provided would not be “transformed” to the extent that the government desired. The model was wrong. In England an impressive clutch of reforms were being implemented, partly set out in the NHS Plan: better regulation; more training, development, and staff; more “change management,” for example through collaborative programmes; more easily accessible guidance on best practice; better information and information technology; and pay modernisation. These would all help, but they would not be enough. Central directives, coupled with strong arm performance management, were highly effective but could be realistically applied only in a limited number of areas, and perverse outcomes were a high risk.

In short, it was recognised that the NHS could not be effectively run from the centre. And local NHS organisations did not have enough incentives to perform well. Why did it take a national …