Sir David Nicholson’s last speech to the annual NHS Confederation conference as the leader of the service reflected all the traits of his seven years in control.

His passion, commitment, and drive were undeniable, but he failed to acknowledge mistakes which had undermined patient care, gave little time to the role of local clinical commissioners, and saw centralised direction as the overriding driver of change.

Early in his hour long address to the Liverpool audience, he admitted that a key reason behind his decision to quit after seven years as chief executive was that he had become the story over the Mid Staffordshire scandal. He also pointed out that within the last decade mortality rates across the NHS have halved; it must seem cruel to him to be taking the blame for one, but attracting little credit for the other.

His frustration with politicians spilled out. His angry defence of GPs against widespread criticism seemed in part aimed at health secretary Jeremy Hunt, and he accused Coalition ministers of wasting the first two years in power on structural upheaval when they could have put their weight behind service changes such as fewer sites for children’s heart surgery. The “tyranny of the electoral cycle” cannot be allowed to paralyse vital reforms, he argued.

But his speech was at least as notable for what it did not say. He discussed the issue of NHS culture at length, but there was no admission that an excessively centralised, controlling, target driven culture has contributed to many parts of the NHS failing to put the patient at the heart of what they do.

He summed up the message from the Francis Inquiry as “listening to patients and doing something about it,” but said nothing about how NHS England would change its own behaviour to allow that to happen.

He talked about NHS England in terms indistinguishable from the old NHS executive. Nothing in the content or tone portrayed a willingness to embrace the idea that what was, until recently, called the commissioning board was no longer supposed to be directing the service.

Nicholson described clinical commissioning as a “powerful thing,” but there was no discussion of the role of clinical commissioners in changing the culture among staff or improving care.

This is not an issue of semantics. Managers from different parts of the country routinely complain that NHS England’s local area teams are behaving with abrupt, directional style of strategic health authorities at their worst.

He warned that the fragmented structure of the new NHS meant there was even more need for a strategy around which all the disparate organisations in the system can align. He is right, of course. The difference now is that setting the direction of the service is supposed to be far more of a shared endeavour.

His plan for building that strategy in his last “10 months”—although he has perhaps five before his successor is named—is to push the politicians aside so the NHS can “make the argument with our patients” about changing the way the it delivers services. If he makes any progress in that debate it will be time well spent.

(He should, however, stop referring to it as a “big conversation,” the term Tony Blair used for a failed initiative to reconnect with the voters in 2003.)

Nicholson is proud of the role he played in writing the NHS Constitution, and closed his address by reading from that eloquent expression of the service’s core values. His voice dropped away as he struggled to keep a grip on his emotions.

Nicholson’s successor will need to match him for drive and ambition—in which he has few peers—but adopt a leadership style which allows staff throughout the service to give expression to their own passion for the NHS, just as he has throughout his service.

Richard Vize is a journalist and communications consultant specialising in health and local government. He was the editor of the HSJ 2007-2010.