Health policy in much of the developed world is concerned with assessing and improving the quality of health care. The USA, in particular, has identi®ed speci®c concerns over quality issues12and a recent report from the Institute of Medicine pointed to the considerable toll of medical errors.3 In the UK a series of scandals has propelled quality issues to centre stage45and made quality improvement a key policy area.6 But how are quality improvements to be wrought in such a complex system as health care? A recent issue of Quality in Health Care was devoted to considerations of organisational change in health care, calling it ªthe key to quality improvementº.7 In discussing how such change can be managed, the authors of one of the articles asserted that cultural change needs to be wrought alongside structural reorganisation and systems reform to bring about ªa culture in which excellence can ¯ourishº.8 A review of policy changes in the UK over th