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The fact is that when VMMC was involved in the training and development component of the North East Transformation System (NETS, started in 20007) some Trusts benefitted (and continue to benefit) considerably; some less so; a small number not at all. 'Constancy of purpose' was indeed one factor in the relative success of some Trusts, as was committed leadership and a deep-rooted recognition that these kinds of programme take a long time to become fully embedded. Toyota-style Lean was just one element in the overall mix, and in the end it probably doesn't matter if the 'method' is TPS, 6 Sigma, the Unipart Way or any other flavour of continuous quality improvement. Changing the way NHS staff approach and think about their work is undoubtedly more important, but this is much harder to do. Powerful external factors often conspire to undermine this kind of culture change (for want of a better phrase) and it takes a very determined set of senior leaders to stay the course. Let's hope the five trusts are up for the long haul - good luck to them.