NHSE accepted that any reform or change management programme cannot work without clinical engagement, and told us that it was now carrying out a range of activities to secure clinical support for the outpatients programme. NHSE explained that, among other measures, it was providing access to performance data at a local level, embedding clinical oversight at the regional level and having two national clinical directors involved in the programme at a national level.54 The NAO report suggests that there are signs that NHSE is now achieving better engagement on outpatients transformation.55 However, we heard that the model for outpatient care is the same one that has been in place for decades and that the whole model needs to change.56 The Department’s approach to making major changes