Is efficiency the enemy of innovation and improvement? Are efficiency programmes oppressive, leaving healthcare staff no time to be creative and piling on burdensome bureaucracy, or are efficiency, innovation and improvement positively correlated?These questions were debated at the International Forum on Quality and Safety in Healthcare, in Gothenburg in April, and here we dip into that debate and pick out the key arguments.Featuring contributions from: Jason Leitch, national clinical director, Healthcare Quality and Strategy, Scottish Government.Frank Federico, executive director, Institute of Healthcare Improvement.Mohsin Choudry, national medical director's clinical fellow, Royal College of Physicians.Robbert Huijsman, professor of management and organisation of elderly care, Erasmus University, Rotterdam.For more on the Forum, see http://internationalforum.bmj.com/.This episode is the last in the first series of the Making the difference podcast. We'll be back in a month with series two.