The Darzi review has shed new light on the challenge of letting go of central control. The idea that staff can be clinicians, partners and leaders is an engaging way of conveying that leadership needs to be widely dispersed.

Nigel Edwards is wise to identify local leadership as the biggest challenge we face and we have to see a completely new context in which it can flourish. He makes the point that the current system is as much the product of evolution as intelligent design. A complexity theory perspective, which uses nature as a metaphor, would perhaps argue that we have not allowed evolution to shape development enough. Achieving positive outcomes as a means for sustainable survival will help but there needs to be some letting go of control throughout the system.

The NHS was founded on a centralist post-war settlement. Aneurin Bevan's vision was that the sound of a dropped bedpan in Tredegar would reverberate in Westminster. This centralist legacy will prove difficult to relax.

Jake Chapman of the think tank Demos shows in System Failure: why governments must learn to think differently how easy it is to underestimate the deeper fears involved in letting go of control. Without offering clear prescription, policy makers risk being seen as dithering. Managers who fail to exert control risk being regarded as weak. There is always the spectre of being replaced by those who claim they can predict and that they will control, even if reality renders this a lie. Embracing the unpredictable and unknowable nature of complex systems can challenge self-esteem and a person's perceived worth in a centralist culture.

The next stage review particularly focuses on clinical leaders. For doctors there is the added cultural challenge of abandoning the habit of "knowing best" and the pretence of certainty.

A recent deeply reactionary article, "Wake-up call for British psychiatry" in the British Journal of Psychiatry, provides some evidence of the scale of the challenge. It was a call for medical leadership of teams and the privileging of medical and diagnostic ways of viewing the user's experience. The storm of protest it evoked - not least from other doctors - is both a reminder of how working to dominate a complex system can damage relationships and of the use of multiple perspectives and approaches to inform reflective practice and organisational learning.

Jake Chapman argues that these challenges to letting go can only be addressed by making an explicit virtue of working with complex systems as they really are. This will require support from those above, who need to create a culture of positive risk taking where people are supported to innovate at the edges of their comfort zones. In the words of Winston Churchill: "Success is the ability to go from one failure to another with no loss of enthusiasm."

Inviting innovation and experiment requires acknowledging that mistakes will be made or we cannot learn and will just play out the patterns of the past.

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