The health service executive should be established immediately and given a clear mandate by Government to plan and drive the reform agenda. There are many stakeholders in the process who must be involved. They must be allowed to contribute but responsibility and accountability for the reform agenda should reside with the health service executive. Taxpayers, other members of the public and the Government must get not only a modern health delivery system but effective management and better value for money. Better management and better value for money are obstacles regardless of the national economic picture. Delivery of these two elements will require a new culture in the health system. Is anyone addressing this matter? Structural change will not deliver it. We must improve the capacity of management in the system.