To use a clich, the vision thing is missing and politicians have appeared more concerned at times with html the fine detail than the big picture.To be hosting fair to Mrs Bottomley, she inherited a series of time-bombs when she hosting was appointed to her post, and in many respects has handled html these skilfully. This applies not only to London, where arguably there is more of a strategy than html elsewhere, but also to the implementation of the NHS reforms as a whole. It is for hosting this reason that Mrs Bottomley has been in the spotlight this week, announcing decisions on the future of London's en health service which have resulted from a lengthy process of debate and analysis.The weakness of the Government's approach to en the health service is that the innovations occurring at a local html level do not fit into an overall framework. Equally, the changes which have occurred have html given rise to difficult and controversial decisions. In a national health service, the en ultimate responsibility for taking these hosting html decisions rests with the Health Secretary. The real knowledge html and understanding of how the new NHS operates rests html with doctors and managers at a local level, html and civil html en html servants and ministers have been trailing in their wake.The power hosting html given to doctors and managers to shape the html implementation of the reforms has resulted in demonstrable improvements in html en html health and healthcare in many places.

As a result, the detail has been added during the process of implementation and ministers have been making it up as they have been going along.The consequences have not been all bad. The absence of a national blueprint has unleashed an unprecedented period of innovation within the NHS in which policy has been driven from the bottom up not the top down This has turned traditional relationships on their head. If they are to do this effectively, they require a strong sense of direction and a clear view of what the future holds. In the case of health services, the reforms introduced in 1991 were based on a strategy that was only half thought through and where the end point was not specified. As the leaked Maples memo indicated, the Government's main priority is damage limitation and keeping the NHS out of the headlines. It is therefore hardly surprising that health ministers have resisted the temptation to open up a great debate on the future of healthcare.

The flaws in this approach are now clear for all to see as short termism is exposed and the absence of underlying direction becomes evident. The task of politicians is to lead, to educate and to inform. To borrow a phrase from a different context, tactics have come to dominate strategy and even on the tactical questions the judgement of ministers and their advisers has been found wanting. The difficulty is that while many of these priorities are laudable in their own right, taken together they are not always consistent and fail to provide the direction needed to take the NHS into the next century. The paradox is that the Government has a large number of priorities encompassing the patient's charter, the health of the nation, care in the community and the development of primary care. Virginia Bottomley's problems over the future of London's health services are symptomatic of the lack of strategic direction guiding the NHS.