With one bound he was free. By Christmas eve, Alan Milburn had been relieved of the trials and tribulations of the new NHS reforms for a seat at the Cabinet table as overlord of all public spending - thanks at least in part to the proof copy of a forthcoming biography of Peter Mandelson going astray in the corridors of Westminster.

Such are the vagaries of political life that after a mere 20 months in post, presiding over plans which may drastically alter the lives of the NHS's million staff - not to mention its patients - the minister in charge has been beamed up at a moment's notice. Healthcare professionals will ponder the contrast with their own careers: even those in the notoriously precarious role of chief executive are usually forced to live a little longer with the consequences of their decisions.

Three of the five health ministers appointed in May 1997 have now left Richmond House, leaving only Frank Dobson and Tessa Jowell from the original line-up. Ironically, most pundits predicted that Mr Dobson would be the first to go; instead, he remains the unlikely political constant amid the turbulence of the NHS reform programme. There are precedents: six months before the internal market reforms were due to go live, the then health secretary, Kenneth Clarke, was moved by Mrs Thatcher - who departed herself a couple of weeks later.

What difference will Mr Milburn's transfer make to the NHS reforms? His successor, John Denham, is described as a man for details. He will need to be. It will fall to him to steer the legislation through Parliament and oversee the launch of primary care groups in April, implementing plans largely finalised by others. He will have to step into the middle of delicate negotiations with the medical profession, not only on PCGs but on clinical accountability. Mr Milburn's strategy here was to drive his proposals at a hectic pace to disorient opponents and capitalise on the public mood after Bristol. Mr Denham may well be advised to follow suit.

Mr Milburn built his reputation on manager-bashing rhetoric; Mr Denham arrives with no such baggage, and he should take full advantage of that. The reality of implementing policy change had taught Mr Milburn eventually to moderate his grey-suit outbursts - he had come to realise how heavily he relied on NHS managers for the success of his plans. But they in turn never quite trusted him or ceased to view him as arrogant. To that extent, Mr Denham will enjoy a fresh start. He should take care not to squander it.