One of the most pervasive beliefs in government is that quality in the NHS is a function of individuals who need buttons pressed and levers pulled by targets to deliver optimal performance.1 This is misguided. The most intractable problems in health care—the lack of communication, leadership, and teamwork; the lack of integration; and the lack of any meaningful, patient focused, quality framework—are systemic or cultural.2 3 4 5 And targets have only made them worse. If you treat people like knaves and pawns, they will behave like them.6

Perhaps the most influential management revolution of the past century was led by Taiichi Ohno at Toyota.7 Systems or “lean” thinking saw Toyota become the world leader in manufacturing; applied to health care it is again showing the way. Flinders Medical Centre in Australia was one of the first to take up the principle and after two and a half …