In recent years, NHS reform in England has focused on stimulating competition between providers and increasing choice for patients. Many NHS organisations are now as much businesses as they are public bodies; if they fail to design services around patients and meet their needs, they should start to lose custom as well as incurring the wrath of government. But just how good are they at satisfying their 'customers' - the patients? Could these NHS businesses, for example, survive in a genuine marketplace? In 2008 Donald R. Keough, the former president of the Coca-Cola Company, published an influential book, "The Ten Commandments of Business Failure", in which he argued that, while success is hard to predict, businesses that fail share common characteristics: they stop taking risks; become inflexible; isolate themselves; assume infallibility; play the game close to the foul line; don't take time to think; put their faith in outside consultants; love bureaucracy; send mixed messages; are afraid of the future; and, lose their passion for work. Far too many 'businesses' in the NHS are doing all of these things, with the results Keough described. They put patients last, not first, as successful businesses would do. Creating more autonomous organisations and giving them commercial incentives is only part of the solution. Across the NHS, a change in culture is required. For now, NHS businesses remain enmeshed in state bureaucracy, inclined to dance to the tune of their shareholders - the government and Whitehall - rather than starting with what patients want and need. They must do all in their power to break this stranglehold, while government must stop interfering and let them put patients first.