This is an interesting perspective that was spolied by a disappointing side swipe. I think that it is incorrect to say that managers didn't use the opportunity to improve productivity during the growth years. It takes more than a management team to change a culture and random interventions from national or regional leaders to advance waiting times targets for example created an enviroment where the way to be successful was to buy clinical co-operation rather than improve services through challenge and redesign. Quality in healthcare has seen significant improvement particularly when managers and care professionals work closely together to improve the patients experience of care. We will need to guard against trading productivity for quality over the next decade.