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Is Professor Michael Rawlins an unlikely revolutionary? As chair- designate of the National Institute for Clinical Excellence - to be established within the next year - he could potentially preside over sweeping and fundamental change in the NHS's clinical practice of an order scarcely dreamed of even two years ago. On the other hand, NICE could prove to be an irrelevant, ineffectual sideshow. In which direction will Professor Rawlins steer it? (See News, page 2.)

As chair of the Committee on Safety of Medicines he appears to have performed solidly and reliably, if unspectacularly. Like so many others occupying pivotal positions of power under New Labour, he has the almost obligatory north-east connections, which may help bolster ministers' confidence in him when the going gets tough, as it assuredly will and possibly quite quickly. But Professor Rawlins has a much lower profile than some of the names rumoured to have been in the running for the NICE job, which has fuelled speculation that he was not the first choice.

Why might others have turned down the role, and how does that bode for NICE's prospects? Combining appropriate stature in the medical profession with the time available to carry out the chair's role properly, no doubt severely limited the field of candidates. Recently retired presidents of royal colleges or others of that ilk may have been the first to spring to ministers' minds. If they turned down the job, it would be unsurprising if it was because the duties seemed too burdensome - or too ill-defined - for someone aspiring to a lighter workload towards the close of their career.

Then consider the uncertain nature of how NICE will be funded. Clawing money from existing effectiveness bodies is not a plan to inspire confidence. And what guarantees have or have not been forthcoming that NICE will be granted all the powers it needs to achieve its aims? To be effective it will unavoidably have to court controversy. Will Professor Rawlins have the stomach for it? We must wait and see, but it has to be said that NICE appears to have the odds stacked against it.

That is a pity, given that the public mood is calling out for someone to assert the principles of quality and clinical effectiveness in every corner of the NHS, from Bristol to Brechin.