At the first meeting of the NHS Commissioning Board - now named NHS England - following the publication of the Francis report, chair Malcolm Grant publicly and unequivocally backed Sir David Nicholson as chief executive of the organisation.

In the face of high profile calls for Sir David’s resignation in the wake of the report, Professor Grant said: “He is the person whose command of the detail of the NHS and [whose] commitment to its future we believe to be fundamental to the success of the board.

“We look, David, to you to provide us with leadership as we go through this exceptionally challenging set of changes.”

Those comments were made as the NHS commissioning system shifted from primary care trusts and strategic health authorities to clinical commissioning groups and NHS England. With the formalities of the transition complete, NHS England and the system now have a largely different set of challenges to focus on.

First, Sir David’s announcement of his retirement by March 2014 may contribute to a sense there are not a lot of strong and highly operationally experienced leaders at NHS England.

It means the appointment of a replacement chief operating officer and deputy chief executive, following Ian Dalton leaving the organisation, is likely to be delayed until Sir David’s replacement is found. Dame Barbara Hakin will continue to cover as interim.

It is widely accepted Sir David’s approach has been one of rigorous system and performance management. Despite the independence of CCGs, NHS England will be expected to retain a level of focus on operational performance.

The NHS 111 debacle and A&E performance dive demonstrate the organisation will need strong leadership and clarity of purpose if it is to prevent further difficulties emerging, and to deal effectively with those that arise.

Another large part of NHS England’s task is to lead change in the NHS, to ensure the system can deal with demographic and financial challenges.

This will require leadership and the development of a clear long term vision for the NHS. NHS England will have to describe how services can change to become sustainable. It also needs to sell the vision to the public, and begin implementing it.

It could be argued that it would be difficult for such a process to credibly be led by an individual who is leaving in less than a year. An alternative view would be that Sir David now has more freedom than ever to act boldly, and has a clear deadline, for instance to publish a ten-year service strategy, and set out how services should be reconfigured or reformed.

Another major task identified for NHS England is to lead a cultural change in the NHS. In the wake of the Francis report much has been said about the need for the NHS to become more open and more attuned to the experiences of patients.

Sir David’s detractors did not accept he personally could lead this change. Whether or not his departure affects NHS England’s answers to the issue of culture, it could well affect its ability to present itself to the public.