Since NHS chief executive Sir Alan Langlands announced his departure, the government appears to be thinking hard about how to replace him.
But unless it is willing to address some of the more far reaching issues besetting NHS management, the service may simply write off any changes it makes as rearranging the deckchairs on the Titanic . His departure provides an opportunity for a more radical look at how the NHS as a whole is managed, especially the relationship between the centre and those responsible for local service delivery.
I will never forget how supportive Sir Alan could be in times of crisis. When Cambridge health authority was under the media spotlight over the child 'B' case, he did not interfere. Once he trusted your judgement he let you get on with it. Riding to the rescue was not his style.
Instead he offered wise counsel, and above all managed the potential political outfall with his customary understated effectiveness. He did not need to seek the limelight. This is just the kind of transformational leadership the NHS requires. Not only is the NHS a highly complex business, currently going through a change process as big as any private sector service industry, but it remains the largest organisation in Europe. It demands strong, effective executive leadership.
There is welcome talk of bringing together the three separate components of the Department of Health - the NHS, social care and public health. In a world of joined-up government this must be right . But if this were to herald a return to an old-style mandarin-run department of state it would provoke real anxiety in the NHS - which needs the kind of dynamic, upfront leadership anathema to those traditionally at the top of the civil service.
Creation of a DoH strategy unit is welcome. For too long the top-of-the-office has focused exclusively on short term targets and on developing policy down individual streams of activity, unable to find the time and space to reflect on the longer term and to see the whole picture. The arrival of Chris Ham, Jo Lenaghan and the others will provide the DoH with a remarkably talented, eclectic group of free thinkers.
But they must not become subordinated to ministers' inevitably short-term needs. They must resist the pressure to draft ministers' speeches. Instead they must immerse themselves in the critical long-term issues of incentives for change, funding arrangements, the management of demand and the emerging shape of the hospital service and primary care. Then there are the rumours of a 'modernisation board'. Some may see this as further evidence of government spin-doctoring. But in the past, the service's only opportunity to engage in central policy formation was the Thatcher government's invitation to the then regional health authority chairs to sit on the policy board. How much more refreshing to see ministers sitting down regularly with those at the leading edge of nursing, medicine and management.
Politicians view the NHS more as a nationalised industry than a quasi-autonomous federation of local agencies.
Many HA chief executives say the centrally driven service agenda is forcing out the wider health agenda more than ever before. Many debate whether they have the means to take the lead locally in putting together partnerships which depend for their success on local priorities, when they themselves are so tightly, centrally constrained.
Some even suggest that local authorities may now be in a better position to assume this role. Whether this is right or not, the implications for HAs are profound. They are equally dramatic for trusts. Leading change locally for them means a greater focus on giving confidence to people within their organisations, striving for clinical performance improvement. This needs executives with a toolkit of approaches to clinical service improvement which many boards do not yet possess, and self-confident, assertive non-executives of a sort we rarely see.
In the light of Bristol, Shipman and the government's desire for more consistent countrywide delivery, accountabilities need to be clearer and tighter. This calls into question local boards' roles, chief executives' dual accountabilities, primary care trusts' confused internal accountabilities and regional offices' performance management role.
Local NHS organisations exercising community leadership are provided with the legitimacy for the tough decisions they will always have to take on the secretary of state's behalf. To be seen simply and solely as his local agents will erode that legitimacy.
But we are a long way from refining what constitutes this community leadership role in the new environment. This is where government's review of the NHS's management arrangements should start.