The National Health Service in England has been on a rollercoaster ride of reform for over a decade. The journey started in 1997 with the white paper, The New NHS, and continued through the introduction of performance targets and standards. New systems for inspection and regulation were then introduced, followed by reforms to increase patient choice and competition. The most recent changes focus on quality and safety with improvement being led locally by clinicians (box).1 2 3 4 5 6 With a general election expected in 2010, and the opinion polls indicating the likelihood of a change of government, further reform seems inevitable. I have identified 10 lessons for policy makers from the experience of the past decade.