Nigel Edwards on Darzi's big ideas

But mostly it is what the service has been asking for. The main aims of changing how patients relate to the system and using measurement, standards and the motivation of professionals to drive change are welcome. But it is clear that, as usual, implementation is going to be the most difficult part.

The review comes after a long process of largely deeply interconnected reforms. So unless there is a willingness to unravel what has gone before, any review depends heavily on the path chosen earlier in the decade. The logic of the reforms pushes towards a focus on outcomes and less on structure and process because it is long overdue and some levers for directly influencing the system, particularly providers, have been relinquished.

The current system is as much the product of evolution as intelligent design, so there is a need to provide some integration, stitching of loose ends and a better narrative. This too tends to lead to proposals that are about the details of policy design rather than big ideas.

This presents a problem. The political world - particularly the press, think tanks and politicians - likes radical big ideas. People get noticed for thinking the unthinkable, even if it is not do-able. Little weight is given to experience or past failures. However, a review that takes account of the accumulated history of reform requires a more careful approach that refines what has worked, recognises what is wrong and is honest about what needs to change.

So any criticism that the review does not contain new big ideas is misguided. In fact there is one not so new, but somewhat neglected, big idea sitting at its heart.

Last year, the NHS Confederation produced a report with the Joint Medical Consultative Committee which challenged medical leaders to define what it would be like to work in a reformed NHS rather than simply detailing problems with the current reforms. The doctors we interviewed identified measurement and feedback, incentives and leadership as crucial parts of driving the improvement.

The review picks up this theme; its proposals complement other parts of system reform and are more comprehensible and attractive to clinicians. It proposes that quality should be defined and measured, the results published and staff given the leadership tools to make the changes, the incentives to do it and rewards for achieving it.

The definition of quality and its measurement is intended to be clinically led and for the clinicians themselves and their organisations. So unlike much previous policy on quality the idea seems consistent with the quality guru W Edwards Deming's big idea that it should be designed into the process rather than inspected for afterwards.

Providing patients with a complete description of what they should expect may also be a significant driver of change.

From a management perspective the review contains most things the confederation's members told us they wanted and avoids most pitfalls feared from previous experience.

Finding an eye-catching big idea to launch usually ends up badly. The two areas that were pre-briefed - on social enterprise and the National Institute for Health and Clinical Excellence - revamp existing policy. It avoids organisation restructuring and creating too many new ones.

But the review has notable omissions. Inequalities, social care and the role of the independent and third sector did not get much mention. Inequalities and social care are the subject of parallel exercises, although I hope the development of metrics will include these areas. Other signals show the independent and third sectors are now an integral part of the provider system.

Dangers lurk in how some of the broad statements of direction get translated into detailed policy and how implementation is managed. The focus on quality is quite a subtle message and it will be easier for attention to focus on high visibility reconfigurations or local changes in the structure of general practice - particularly if this is co-ordinated at a regional level. There is also a danger of impatience resulting in the old pattern of instruction, and of new policy reinforcing the message that people should look up for guidance and direction.

The review illustrates just how little government reform can do once the focus shifts from targets and structures to quality and outcomes other than ensure a consistent message, remove obstacles, encourage the flow of information and in a few places provide some incentives and prods. Even where it can act, the costs, benefits and potential unintended consequences need to be weighed up, particularly when intervention may be viewed suspiciously.

Clear beneficiaries of the review are strategic health authorities, which have acquired medical directors, clinical advisory groups, responsibility for innovation prizes, clinical leadership fellowships, leadership development, workforce planning and other potential levers on providers. They will have the challenge of trying to be performance manager, system manager and a facilitator of improvement. Experience shows how difficult this can be. Care will be needed, particularly if these levers create doubt about providers' ability to control their own destiny.

There are major technical issues about developing clinical measures and in ensuring patient experience and satisfaction measures truly reflect the quality of services. The more these measures are used for cross-sectional comparisons the more significant this is.

After so many years of central instruction these changes will need high quality local leadership. Of all the changes of the last 10 years this shift in culture could be the hardest yet; without it the review will not be enough to move the system on.