If ‘education, education, education’ was the mantra of the incoming Labour government in 1997, ‘delivery, delivery, delivery’ has been the refrain from 2001. Reforming and modernizing the NHS to deliver the scale and quality of health services required for a demanding 21st century public has been one of Labour's biggest policy pledges. It remains perhaps its most serious challenge in its second term of office. Failure here will both seriously undermine the New Labour project and inflict serious damage on the arguments for publicly financed, publicly provided, health services with universal access. Achievement of a modernized health service and radical improvements in delivery are seen to require more than just the planned large cash injection: they also require health system reform. Major reforms of the health systems of developed nations over the past two decades have been largely structural in content. Through the 1970s and 1980s, changes to the hierarchical arrangements of the NHS presaged more radical plans for a rearrangement of players into purchasers and providers and the introduction of the internal market. This reaching for competition—created by structural rearrangement—mirrored upheavals in healthcare elsewhere in the world. Various combinations of managed competition and managed care have been tried and are evolving in the USA, Australia, New Zealand and many parts of Europe. In opposition, Labour decried the internal market. Once in power they kept many of its structural elements (the crucial separation between operational and strategic responsibilities) while updating the rhetoric (eschewing the language of competition, embracing instead cooperation and partnerships). Their major reform effort focused on quality issues1, developing a plethora of agencies such as the National Institute for Clinical Excellence, the Commission for Health Improvement, the National Clinical Assessment Authority, and the Modernization Agency. The latest round of NHS reforms (‘Shifting the Balance’2) again emphasizes structural changes as a means of driving improvements in delivery.