With large funding increases planned for the next five years, England's National Health Service (NHS) has embarked on an ambitious program of system reform. This paper considers the main reform strategies now being deployed and assesses three potentially competing assumptions underpinning them. The first implies that improvement mainly requires a sufficient supply of health professionals, properly supported. The second advocates more hierarchical control to offset self-interested provider behavior, and the third stresses the role of local incentives and accountability. How these reforms play out over the next five years will determine the future shape of English health care.