Department of Health gets a new boss
Samantha Jones, a former NHS manager who advised Boris Johnson, has been appointed Permanent Secretary at the Department of Health and Social Care
The appointment of Sir Chris Wormald as Secretary of the Cabinet in December created a vacancy for Permanent Secretary at the Department of Health and Social Care. Wormald had spent eight years at the head of the DHSC, an unusually long period, but was not a specialist in the policy area, having been Permanent Secretary at the Department for Education. Before that he had worked at the Department for Communities and Local Government and held senior roles in the Cabinet Office.
The Department of Health was not the only permanent secretary-level vacancy in Whitehall. Due to retirements and career progression, there are also openings at the Ministry of Justice (after Dame Antonia Romeo moved to the Home Office), the Department for Transport (from which Dame Bernadette Kelly is retiring) and the Department for Science, Innovation and Technology (where Sarah Munby is expected to return to the private sector). Four vacancies in 19 mainstream departments of state is a significant level of churn. There are also new appointments pending for the Chief of the Secret Intelligence Service and Second Permanent Secretary to HM Treasury.
The new Permanent Secretary at the Department of Health will be Samantha Jones. She has a much deeper background in healthcare than did Wormald when he was first appointed; she originally trained as a nurse and worked at Great Ormond Street Hospital before moving into NHS management. She had decided while still a trainee that she wanted to move into management, telling the chief nurse at Great Ormond Street:
I don’t know why I want to be a manager, but I’ve got four brothers. I’m too stroppy. I have to stand by my beds while the consultant does his ward round and I’m not allowed to speak until I’m spoken to—and I’m not having any of that.
She was Chief Executive of Epsom and St Helier University Hospitals NHS Trust in south-west London from 2007 to 2011, then spent two years as a director at Care UK, a private provider of residential care for older people. In 2013 she returned to the NHS as Chief Executive of West Hertfordshire Teaching Hospitals NHS Trust, where she was named Chief Executive of the Year by The Health Service Journal, and in 2015 she moved to NHS England as Director of New Models of Care, where she was responsible for designing new care models as part of the NHS’s Five-Year Forward View.
Jones returned to the private sector in 2017, working as an independent consultant before being appointed CEO and President of Operose Health, a primary care provider owned by the US firm Centene Corporation. In April 2021, Boris Johnson recruited her to work in Downing Street as his expert adviser on NHS transformation and social care, a huge and fiercely complicated brief. The worst of the Covid-19 pandemic had passed and some semblance of normality was at least on the horizon, and Johnson was preparing to tackle healthcare in a significant, long-term way for the first time in his premiership. The Queen’s Speech which opened the new Session of Parliament in May 2021 included what would become the Health and Social Care Act 2022, so Jones’s position as a Downing Street adviser offered the chance of considerable influence. There was also a theory at the time that she was being lined up to replace Sir Simon Stevens as Chief Executive of NHS England, whose retirement was announced around the same time, though eventually the role went to the ill-fated Amanda Pritchard (I examined her fall here in February).
Johnson’s premiership would begin to be derailed later that year by the scandal which was dubbed “Partygate”, which absorbed much of the Prime Minister’s energy. Sue Gray (now Baroness Gray of Tottenham), then Second Permanent Secretary in the Cabinet Office, was appointed to conduct an inquiry into the events surrounding “Partygate”, and in January 2022, she released an interim update on the progress of the investigation. One significant conclusion was that the institutional structure and organisation which supported the Prime Minister in 10 Downing Street was weak, under-resourced and lacking in clarity, and this apparently technical observation proved, albeit briefly, to be a great opportunity for Jones.
In February 2022, a restructuring of the machinery of government in Downing Street was announced and Jones was appointed Interim Permanent Secretary and Chief Operating Officer, “reviewing structures and operations in No 10” as part of the process of establishing an Office of the Prime Minister. Her management experience was emphasised, and Johnson referred to “bringing in the very best skills and management experience with a clear vision to unite and level up our country”. The fact that she had been involved in roles involving “transformation” was also mentioned.
It was rumoured that initially a serving permanent secretary was being sought for the role, and Antonia Romeo, then just over a year into her position as Permanent Secretary of the Ministry of Justice, had supposedly been approached, but had turned down the opportunity. Johnson then changed tack, and had clearly been impressed by Jones’s work as his adviser on the NHS, and her outsider status may have appealed to him in a desire to shake up a moribund and dysfunctional system within Downing Street.
By the summer, it seemed as if Jones’s role was going to be even more influential than at first anticipated. The nascent Office of the Prime Minister would assume control of areas including oversight of domestic policy, legislation and national security from the Cabinet Office, leaving more quotidian issues like management of the Civil Service and relations between departments. But Jones was also reportedly keen to streamline the organisation and reduce headcount, as well as controlling access to the Prime Minister and reducing the number of attendees at meetings. This was seen as a diminution of the power of the Cabinet Secretary, Simon Case, whose standing had been damaged by his involvement in “Partygate”, and who would now exercise much less direct control over the centre of government.
On paper, the plans for the Office of the Prime Minister represented potentially the biggest and most ambitious changes in Downing Street for decades, perhaps since the Heath government of 1970-74 (I looked at some attempts to strengthen the Prime Minister’s executive power here in November 2023). Some suggested they were an acknowledgement that Johnson at his best had relied heavily on powerful deputies and other advisers, whether as Mayor of London or Editor of The Spectator, to translate his ideas into implementation and to keep him in some senses focused on his responsibilities. Moreover, the mood music seemed to be changing subtly: in February, the gentle implication had been that Jones was going to manage the transition process of creating the Office of the Prime Minister and overseeing the search for a permanent Permanent Secretary, but by May it was more or less assumed that the substantive role would be hers if she wanted it while Johnson was in office.
That, of course, was the key consideration. “Partygate” was proving highly damaging to Johnson’s reputation, not so much for honesty, because no-one had ever thought that he was a fundamentally truthful person, but for effectiveness and electoral appeal. At the local elections in May 2022, the Conservatives had lost 485 councillors and control of 11 councils, and many defeated candidates pointed the finger of blame at the Prime Minister. On 6 June, he faced a vote of no confidence among his MPs, and his victory by 211-148 was hardly decisive. A fortnight later the party was soundly beaten in by-elections in Wakefield and Tiverton and Honiton; a week after that, the Deputy Chief Whip, Christopher Pincher, had to resign after drunken and sexually inappropriate behaviour at the Carlton Club. On 5 July, Rishi Sunak, the Chancellor of the Exchequer, and Sajid Javid, Health and Social Care Secretary, resigned within minutes of each other, and the government began to collapse. Johnson announced his resignation on 7 July.
Jones had been regarded as one of Johnson’s advisers rather than a Whitehall lifer, and the new Prime Minister, Liz Truss, took delight in disruption, which she often mistook for effectiveness. Once her victory in the Conservative leadership election of July-September 2022 was apparent, the media had already begun to anticipate major changes at the centre of government. She kissed hands as Elizabeth II’s 15th prime minister on 6 September, just two days before the Queen died, and set about picking her team and swinging the axe.
Mark Fullbrook, a veteran strategist and lobbyist who had spent more than a decade at Sir Lynton Crosby’s C/T Group, became Downing Street Chief of Staff, with Ruth Porter, a former special adviser to Truss, as his deputy; Sir Stephen Lovegrove, National Security Adviser, was moved aside to make way for diplomat Sir Tim Barrow, with whom Truss had worked when she was Foreign Secretary; and Truss’s Principal Private Secretary from the Foreign, Commonwealth and Development Office, Nick Catsaras, moved to the equivalent position in Number 10. But the Office of the Prime Minister was scrapped and there was no role for Jones in the new Downing Street line-up.
Even in politics, contracts are contracts, so Jones became Expert Advisor to the Secretary of State for Health and Social Care until the end of the year to see out her notice. After Dr Thérèse Coffey’s brief time under Truss, Rishi Sunak, having become Prime Minister on 25 October 2022, appointed Steve Barclay, who had been Health Secretary for the last two months of Johnson’s government before being dropped by Truss. It was not a move welcomed in the NHS, and Alastair McLellan, editor of The Health Service Journal, had written of Barclay’s first appointment in July, “never has a politician arrived in the post of health secretary trailing a worse reputation among NHS leaders”.
Significantly, Barclay had been Downing Street Chief of Staff during Jones’s time as head of the Office of the Prime Minister. The two had seemingly formed a good working relationship, and it continued in the last months of 2022. Although her appointment came to an end in December, in February 2023 she was recalled to be a Non-Executive Director at the Department of Health, a part-time position, and in September became Lead Non-Executive. But it did not last long; whether because of Barclay’s replacement by Victoria Atkins in November 2023, or because she felt the government’s days were numbered, Jones left the DHSC at the end of the year and returned to the private sector.
Now Samantha Jones returns to the Department of Health yet again, this time as Permanent Secretary. Professor Sir Chris Whitty, the Chief Medical Officer for England, has been running the department ad interim since Wormald’s departure in December; while Tom Riordan was appointed Second Permanent Secretary in September last year. Riordan joined the Civil Service Fast Stream in 1990 but moved to Leeds in 1997, working for the Yorkshire Forward regional development body, latterly as CEO, then spending 14 years (2010-24) as Chief Executive of Leeds City Council.
Since Jones was last working at the Department of Health, the abolition of NHS England has been announced and Sir Jim Mackey appointed Transitional CEO, with a brief to merge the organisation into the Department of Health and a number of new senior colleagues. Dr Penny Dash has just been appointed Chair of NHS England, and there is a new Chief Financial Officer, Elizabeth O’Mahony, new Co-Medical Directors for Secondary Care, Professor Meghana Pandit, and Primary Care, Dr Claire Fuller, a new Elective Care, Cancer and Diagnostics Director, Mark Cubbon, a new Financial Reset Director and Accountability Director, Glen Burley, and a new Clinical Transformation Director, Dr Vin Diwakar.
Healthcare policy is central to the government’s stated ambitions, and its political fortunes. Labour’s manifesto for last year’s general election identified cutting NHS waiting times as one of its “first steps for change”, while one of its five “missions” is to “Build an NHS fit for the future”. One of Wes Streeting’s first major acts as Health and Social Care Secretary was to ask surgeon and former health minister Professor Lord Darzi of Denham to undertake an independent investigation of the state of the NHS which was published in September. He subsequently launched a major public consultation on the future of the NHS which will inform the government’s 10 Year Health Plan currently being drafted, due to be published in “the spring” (a very flexible term, as those familiar with Whitehall will know). In January, Streeting laid before Parliament a new mandate for NHS England, with a focus on improving access to care, reducing waiting times and observing rigorous financial control.
Jones is therefore stepping into a highly charged policy area in the relentless and withering glare of public scrutiny. Streeting, who is able and ambitious, and understands that delivering some credible degree of success in reforming and improving the NHS is critical not only to the government’s success but also to his own political fortunes. He is more than 20 years younger than the Prime Minister and there is no reason why he should not legitimately aspire to lead his party, but if he is adjudged to have failed as Health Secretary it will undermine his chances of higher office, perhaps fatally.
On a structural level, Jones faces an unusual situation. The Permanent Secretary at the Department of Health has for 30 years effectively shared leadership and responsibility with the Chief Executive of the NHS (from 2013, Chief Executive of NHS England). The exception was Lord Crisp, who combined the posts between November 2000 and March 2006; although a great deal was achieved during that period, Crisp was ultimately forced out of office and the experiment of double-hatting has not been repeated.
This division of labour remains in place in some senses. But Sir Jim Mackey, who is expected to serve for one or two years as Chief Executive of NHS England, is overseeing the organisation’s absorption into the Department of Health, a process which will in the fulness of time require primary legislation; NHS England (technically the NHS Commissioning Board for England) was established under the provisions of the Health and Social Care Act 2012 and as a statutory body it can only be abolished by statute. He is technically on secondment from Newcastle upon Tyne Hospitals NHS Foundation Trust, where he has been Chief Executive since the beginning of 2024, so his role is limited in time and scope, and his approach to the job is likely to reflect that.
It is obviously relevant that Jones does not come from a civil service background. She spent a short time at NHS England in 2015-17, and was a permanent secretary for a brief time in Downing Street, but she is cut from very different cloth from, say, her predecessor, Sir Chris Wormald, who had been a civil servant for 25 years by the time he became Permanent Secretary at the Department for Health, and, indeed, has never worked outside central government. Her direct experience of the NHS in senior management roles may be an advantage in tackling the implementation of policy and its translation from Whitehall to the front line. It is also worth noting that several of her previous positions have involved managing organisational change and transition, which will obviously be relevant over the next few years as the government seeks to make fundamental changes to the way the NHS works.
Rupert McNeil, who was Government Chief People Officer and worked alongside Jones, was highly complimentary about her experience and suitability for the role at the Department of Health. He told The Financial Times: “I don’t think there is anyone else who combines her intellect and grip with the depth and breadth of her experience of our incredibly complex healthcare system”. Certainly, ministers may have felt that, given the immediate priorities in healthcare policy, her previous positions as a “doer” were more important than someone with a more traditional background as a “thinker” in terms of Whitehall policy advice. (It is an arbitrary and artificial distinction, of course, and absent in the best civil servants, but that doesn’t mean there is not an element of truth reflected in it.)
It is interesting to note that both Jones and her Second Permanent Secretary, Tom Riordan, have worked primarily outside Whitehall (although Riordan began his career as a civil servant at the Department of the Environment. By contrast, most of the directors general at the DHSC, the most senior grade below permanent secretary, have more tradition mainstream backgrounds. Although it is increasingly common for permanent secretaries to have spent time away from central government (Gareth Davies, Sarah Munby, Susan Acland-Hood, Sir Olly Robbins), Jones is a rarity in having spent almost all of her career working elsewhere. The history of Whitehall suggests this kind of mixture can be a productive cross-fertilisation of experience and skills, or a source of cultural, behavioural and personal tensions.
Inevitably, Jones’s experience working in private healthcare, at Care UK and then at Operose Health, have aroused suspicions and raised hackles on the Left. It is a perennial fear that governments of either political party are attempting to “privatise the NHS”, and Streeting has expressed his openness to private sector involvement in dealing with backlogs and waiting lists for NHS patients. The Good Law Project, Jolyon Maugham KC’s self-appointed and underperforming scrutineer of public “probity”, has highlighted the number of donations Streeting has received from private healthcare sources to reinforce these anxieties.
This is not so much an issue of policy, as governments have supposedly been on the verge of surrendering the health service to private providers or stealthily introducing “creeping privatisation” for 30 or 40 years now. The amount of NHS spending on private sector services has not expanded significantly for 10 or 15 years, and headline figures are often misleading since “the private sector” in terms of commissioning services includes almost all general practitioners, dentists, pharmacists and opticians. It may, however, matter in terms of presentation; at least part of the task of reforming the NHS will depend on managing the organisation’s workforce, so confidence and morale are important.
It is also fair, I think, at least to put on the record, though without prejudice, the fact that Jones has had an extremely rapid turnover of jobs since she went into the private sector in 2011, with at least eight distinct roles in those 14 years. Some of this, of course, is the result of circumstance; the abrupt end to her time as head of the Office of the Prime Minister, for example, was almost entirely due to Liz Truss’s decision to do away with the structures she inherited from her predecessor. Nevertheless a finger should be placed on that page for future reference.
Given the currently economic, strategic and political climate, there are no “easy” permanent secretary positions. A relatively new government with an historically large parliamentary majority but a startlingly swift collapse in public support, to judge by opinion polls, finds itself facing not only enormous policy challenges but also an administrative machine which may believe simply does not work, or does not work nearly as well as it could. In addition, ministers seemingly cannot decide if they are staunch allies of stoical and dedicated public servants or realistic and courageous disruptors willing to take on a sclerotic bureaucracy; often they give the impression they are both, which also means they are neither, but can cause lingering and damaging antagonism.
Samantha Jones brings a wide range of experience to her new role, and, by many accounts, a strong will and ambition to succeed. She can say with confidence that she knows how the NHS operates in real life, how the private sector works and what the interface between the two is like. She has also worked in organisations going through substantial and sometimes painful change. She will also need to demonstrate an ability to work across Whitehall with colleagues and other departments, and formidable interpersonal skills with ministers and advisers. Streeting and the department, and by extension the government as a whole, have a lot riding on her.