Abstract
To date, improvement in health care has relied mainly on a "top down" programme by programme approach to service change and development. This has spawned a multitude of different and often impressive improvement schemes and activities. We question whether what has been happening will be sufficient to achieve the desired scale of change within the time scales set. Is it a case of "more of the same" or are there new and different approaches that might now be usefully implemented? Evidence from the social sciences suggests that other perspectives may help to recast large scale organisational change efforts in a new light and offer a different, though complementary, approach to improvement thinking and practice. Particularly prominent is the recognition that such large scale change in organisations relies not only on the "external drivers" but on the ability to connect with and mobilise people's own "internal" energies and drivers for change, thus creating a "bottom up" locally led "grass roots" movement for improvement and change.