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This paper argues that the NHS in England cannot meet the health care needs of the population without a sustained and comprehensive commitment to quality improvement as its principal strategy. Despite a succession of well-meaning policy initiatives over the past two decades, the paper argues that the NHS in England has lacked a coherent approach to improving quality of care. It describes key features of a quality improvement strategy and the role of organisations at different levels in realising it, offering 10 design principles to guide its development. A quality improvement strategy of this kind has never been implemented at such a scale and the challenge in doing so is immense - yet the paper argues that the NHS has no real alternative.