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I wholly agree with Umesh above. Culture, values, leadership...essential.

My greatest concern is that the lean approach might standardise pathways so much that patients cease to be individuals and become numbers in the system. Clinicians must be able to repond to and make judgements about people as individuals. Everyone will have the same battery of tests, accounting for some of the USA's high GDP spend, but the person will be forgotten.

My local Shrewsbury and Telford Hospital Trust is one of the five involved. Culture, values, behaviours, empowering front line staff...these are essential, but the root of this Trust's problems are financial and structural, and it is acknowledged that a major reorganisation of acute (and community and primary?) healthcare is needed in Shropshire if it is to be sustainable. The answers lie here at home with the decision makers who need to get on with it and make change happen. We've been researching and consulting and planning for two years (NHS Futurefit) and now we can wait no longer for radical change. Please someone who is paid a lot to do this...act now. SATH relies on bungs from TDA of £14+m a year to survive. Can't go on much longer can it?