OBJECTIVE: This study explores the views of senior managers regarding their experience of participating in the Clinical Services Redesign Program (CSRP) in New South Wales and the impact of that Program. METHODS: Semi-structured interviews were conducted in 2007 with 42 senior managers working in the NSW health system. RESULTS: Managers reported being increasingly oriented towards efficiency, achieving results and using data to support decision-making. The increased focus on managing performance was accompanied by concerns about the narrowness of the indicators being used to manage performance and how these are applied. The value placed by interviewees on the use of 'competition' as a lever for improving services varied. Leadership was repeatedly identified as important for long-term success and sustainability. No one was confident that the CSRP had yet been sufficiently embedded in day to day practice in order for it to keep going on its own. CONCLUSION: Our findings are generally consistent with the extensive literature on change management, performance management and leadership. Some cultural change has taken place in terms of observed patterns of behaviour but it is unrealistic to think that CSRP can on its own deliver the desired deeper cultural changes in the values and assumptions underpinning the NSW Health system. There is some evidence of dysfunctional aspects of performance management but no call for the focus on performance or redesign to be abandoned.