Secretary of state for health (2010 ranking: 1)

Andrew Lansley once passed the HSJ100 round the shadow cabinet table to demonstrate how highly regarded he was within the health community. Should he do the same with the cabinet this year, perhaps the most worrying thing for the health secretary is that most will be reassured that he is placed second to the reliable Sir David Nicholson.

Mr Lansley was unable to prevent concerns afflicting the reforms building up a momentum which resulted in the embarrassment of the Health Bill’s legislative “pause”. Even after that - and the Future Forum listening exercise, the direct involvement of the prime minister and his deputy, a wide range of concessions and further delays, the bill clearing the Commons and the first stages of Lords scrutiny - Mr Lansley is just as isolated in his unabashed championing of the reforms. He still sees a silk purse, everyone else is simply getting to work on the pig’s ear.

The health secretary remains supremely knowledgeable about the service (and there will be books written about how someone with such a feel for the subject could so spectacularly misjudge the politics of reform). That knowledge - and his position - still means he is highly influential.

But the agenda is now being driven from elsewhere. The focus on waiting times and access to care comes straight from Downing Street. The Treasury keeps close tabs on the myriad financial challenges - from quality, innovation, productivity and prevention to the private finance initiative. The day to day running of the service is, of course, in the safe hands of Sir David.

As health secretary Mr Lansley is badly damaged - only the prime minister’s loyalty, dislike of reshuffles and the desire to ensure the Conservatives, and not their coalition partners, are seen to be driving health reform keeps him in post. The health secretary may be set adrift after the bill is made law, more likely he will be with us until spring 2013.

But, and this is admittedly a big but, there is a possibility that we may be about to see the best of Andrew Lansley. Freed from the pressure of setting overarching policy direction or defending controversial legislation, Mr Lansley may be about to come into his own.

His unarguable knowledge of what constitutes good health outcomes could produce a challenging and imaginative first “mandate” for the NHS Commissioning Board. The health secretary’s long commitment to improving and increasing patient information could see him accelerating an important area of policy that has laid dormant for at least three years. His understanding of the need to reconfigure health services (and the courage that comes from suspecting your days are numbered) could see him providing the political cover for more iconic decisions such as the downgrading of Chase Farm’s A&E.

In Italy they have just elected a technocrat to take charge as the country’s economy teeters on the edge. As the NHS faces its most challenging year since the 1980s, maybe Andrew Lansley is finally in the right place at the right time. Stranger things have happened.