'Most ministers can be brought to heel by threat of the sack, but not one with a global reputation well beyond politics'

The speech by health secretary Alan Johnson announcing the review of the NHS was an uneven affair (see 'NHS split over Darzi review's reach').

It ranged from an unrealistic assessment of the service's impact - the increase in life expectancy since the war is entirely due to the NHS and 'great scientific advances' apparently - to an awkward and unconvincing explanation for the torrent of reforms under New Labour.

The guts of his statement, the announcement of the review of the NHS by junior health minister Professor Sir Ara Darzi, says a great deal about where the power lies in the new Department of Health ministerial team, but less about the direction of policy.

New Labour, more than virtually any other government, has used reviews by eminent individuals to drive policy, Stern on climate change and Barker on land use to name just two. But it is highly unusual for that review to be led by a junior minister. This reveals just how much influence Sir Ara will wield.

The government will not be able to bury this review - it is an inside job. And since Sir Ara has been appointed with the express purpose of reconnecting the DoH with NHS staff, he will have to be allowed to argue their case. Most junior ministers can be brought to heel by the threat of the sack, but not someone who already has a global reputation well beyond politics.

Galloping ahead

The policy direction heralded by Mr Johnson's statement cannot yet be discerned. The new secretary of state is trying to ride two horses - one heading towards stability and an end to top-down meddling, the other galloping 'to the next stage of the transformation'.

But it may be possible for Mr Johnson to stay in both saddles, if he focuses on creating a climate of innovation, improvement and patient engagement at the front line. This appears to be the ground the Darzi review is trying to occupy.

The emphasis is on putting clinical priorities at the heart of decision-making; improving care with an emphasis on patient safety and long-term conditions; and improving access and integration.

Finally, he has been tasked with establishing a vision based less on central direction and more on patient control, choice and local accountability.

The review is a promising step for the new government, but central reviews aiming to deliver local freedom have a habit of losing direction. Will ministers really be able to let go?