One of the most thought-provoking aspects of the paper by Pearson and Macintosh (2001) is the simple observation that the management practice described is in any way noteworthy. After all, it amounts to little more than a description of care, some measurement of outcome, and the incorporation of basic software. If this is exceptional, what is going on elsewhere? A public brought up on American medical dramas and media medi-hype might reasonably assume that this was already the norm. Sadly, it is not. Before looking at the Cairns experience, I would therefore like to consider why defined care has yet to be widely accepted.