It is a conundrum, and a source of deep frustration, that health systems seem so resistant to change. Safety and quality initiatives struggle to make care safer for patients.1 Restructuring health services seems to achieve little.2 Evidence based recommendations and standards pile up unheeded or poorly enacted.3 Blame for system resistance shifts depending on the observer. We make culprits of clinical culture, policy, politics, or the vested interests of industry. However, this inertia to change may be a more fundamental property of the health system.

It is often said that systems are perfectly designed to produce the outcomes that they do. Somehow, healthcare has come to be constructed so that it is resistant to new policies and practices, even across apparently dissimilar national systems. The struggle that characterises health reform may thus not be a function of poorly designed or targeted initiatives.4 We may instead be seeing what might be called system inertia, which is a tendency for a system to continue to do the same thing irrespective of changes in circumstance. Without seeking to understand the fundamental causes of system inertia we are unlikely to be able create the safer, more effective, and resilient health systems we all strive for.