While Lord Darzi's review of the NHS is to be warmly supported, it is astonishing that it contains almost no reference to nursing or to ward and team leaders.
The irony is that chief executives who are serious about delivering Darzi will have to focus on issues that he hardly mentions.
Quality will not be improved without a focus on nursing and unless the people who lead day to day are at the centre of local action. Who is most likely to ensure that care is "as safe and effective as possible with patients treated with compassion, dignity and respect"? The vast array of mechanisms proposed by Darzi including quality accounts and observatories are no substitute for supporting the leaders with the opportunity and expertise to influence what happens to patients.
The workforce report is Sir John Tooke's rather than Darzi's, and none the worse for that. It clearly re-establishes medical control of the medical workforce plans and greatly strengthens the position of the medical director. Both the chair of Medical Education England and the director of medical education will be accountable to the NHS medical director so we know who is in charge.
There is much to be welcomed in the workforce report, not least the four-point plan for nursing: reaffirming the role of the nurse, improving and measuring the quality of nursing care, modernising career and educational pathways and recruiting and retaining the best candidates. Let us hope ministers and senior colleagues will give as much attention to this plan as to other aspects of Darzi.
The arrangements for workforce planning are based on sound principles. The report rightly gives the employers the responsibility for determining workforce plans. However there is a danger that in expecting primary care trusts to bring together the combined service and workforce plans for their local health economy, and in giving strategic health authorities a prominent role, trusts may be tempted to take a back seat. The system will only work if foundation and other NHS trusts take it seriously and give a lead.
Acute trusts employ the most staff and must make workforce planning their business. PCTs and SHAs should accept that workforce planning will be meaningless without trusts. Employers must take the lead.
The proposal for health innovation and education clusters has tremendous potential to transform relations between providers of services and partners in higher education.
Deaneries could play a vital role with their unrivalled access to all the partners. The prospect of clusters being commissioned to provide professional education and training is one of the radical ideas to emerge from the Darzi process. The NHS is at last developing organisational arrangements that offer opportunity for innovation and improvement - organisational development rather than structural change. The clusters may be the best means to put employers in the driving seat on workforce issues.