The health of the nation: NHS England needs new leadership

Chief executive Amanda Pritchard had been expected to depart as the new government looks for someone it thinks has "the right stuff" to lead NHS reform

I spent most of Tuesday writing and talking about defence, given the Prime Minister’s announcement that he will increase the UK’s military budget to 2.5 per cent of gross domestic product by 2027. (It’s a step in the right direction but there is no sense in which it solves all our defence-related problems, as I set out in The Spectator.) However, news does not stop for a star attraction or meekly wait its turn, and one of the other developments, which on another day would have led the news bulletins and muscled to the front of the headlines, was that the Chief Executive of NHS England, Amanda Pritchard, had submitted her resignation and will leave her post at the end of March.

The Guardian called Pritchard’s departure a “shock move”. It really wasn’t. There had been rumours since the new government took office in July 2024 that the ambitious and impatient Health and Social Care Secretary, Wes Streeting, would want someone of his own choosing at the head of NHS England, and, indeed, that he was not entrely satisfied with the institutional arrangement of healthcare provision (of which more later on). The likelihood of her departure was significantly increased after stinging criticisms from two select committees. The House of Commons Public Accounts Committee, publishing a report on NHS financial sustainability, said that “senior officials do not seem to have ideas, or the drive, to match the level of change required”. The Health and Social Care Committee, its members exasperated after a frustrating evidence session with Pritchard, took the unusual step of issuing a statement through the Chair, Liberal Democrat MP Layla Moran, saying it was “disappointed and frustrated” and “exasperated by the lengthy and diffuse answers that were given to us”.

Having worked on several of them, I will attest that criticism from a select committee need not be fatal to a career, for politicians or officials. But it is never an advantage, and it may have tipped the balance in terms of Pritchard from asking “why should she go?” to asking “why should she stay?” Relations between the Department of Health and Social Care and NHS England had deteriorated after October’s Budget, with the department pointing to extra funding of £22 billion but NHS England arguing that such a sum was still inadequate to effect the kind of transformation in delivery of healthcare the Secretary of State, and the government as a whole, is demanding.

The road to the top

Pritchard was the ninth NHS Chief Executive since the post was created in 1985 as a recommendation of Sir Roy Griffiths’ report on health service management. She is the first woman to hold the position, and will have served for three years and eight months by the time of her departure, longer than three of her eight predecessors but less than half the tenure of her immediate forerunners Lord Stevens of Birmingham (2014-21) and Sir David Nicholson (2006-14). It could hardly be called a planned departure.

She came to the post as an administrator rather than a clinician. There is no shame in that; NHS England is a huge organisation with a budget running into the hundreds of billions of pounds and firm grip on management is absolutely essential. She briefly (2005-06) led on health in the Prime Minister’s Delivery Unit under Sir Tony Blair, an institution at the centre of government which reported (through the Cabinet Secretary) to the Prime Minister and supported him on effecting changes to public services. Pritchard was Chief Operating Officer (2012-15) then Chief Executive (2015-19) of Guy’s and St Thomas’s NHS Foundation Trust, one of London’s major healthcare providers, and was then appointed Chief Operating Officer of NHS England and Chief Executive of NHS Improvement, the body which had overseen trusts and foundation trusts and supervised patient safety and innovation. The government by this stage intended to merge NHS England and NHS Improvement, hence Pritchard’s dual role, and confirmed its plans in a White Paper, Integration and innovation: working together to improve health and social care for all, in February 2021.

Pritchard was announced as the next Chief Executive of the NHS in July 2021, taking up the post a few days later at the beginning of August. Having been in effect Simon Stevens’s deputy for two years, she had been widely tipped for the post, though Mark Britnell, a former NHS manager at that time in charge of healthcare, government and infrastructure at KPMG, Tom Riordan, Chief Executive of Leeds City Council, and Doug Gurr, originally a civil servant before joining McKinsey and Company and running Amazon UK, were also among other names mentioned.

It was, to say the least, a challenging time to assume the leadership of England’s health service. The vaccination programme against the Covid-19 pandemic had begun the previous December at the same time as a new and deadlier Alpha variant of the virus was becoming predominant, but throughout the first half of 2021, restrictions on the public were gradually lifted. However, at the end of May, yet another variant, known as Delta, was identified and a third wave of infection began weeks before Pritchard took over as Chief Executive. Rates of hospitalisations and deaths were lower than before, not least because of the rapid success of the vaccination programme, but the strain on NHS resources remained acute.

The number of people waiting for hospital treatment reached a record high of 5.61 million in July, of whom 1.8 million had already been waiting at least 18 months. The government promised an extra £10 billion a year over three years for the NHS in England funded by a 1.25 per cent increase in National Insurance, but even the irrepressible Boris Johnson, enemy of gloomsters everywhere, admitted that “waiting lists will get worse before they get better”.

Pritchard therefore faced at least three major tasks: the continued management of a pandemic, record-breaking waiting lists and the implementation of structural changes and closer integration within NHS England as set out in the government’s White Paper. The arch-Blairite Matthew Taylor, Chief Executive of the NHS Confederation, representing health managers, welcomed her appointment:

Amanda is the continuity candidate and her appointment ensures she will hit the ground running when Sir Simon [Stevens] leaves. This role is arguably the most significant across the entire public sector and with a new health secretary [Sajid Javid] getting up to speed, this continuity at the top of the NHS will be vital.

Nick Triggle, the BBC’s health correspondent, observed drily that Pritchard would be “responsible for navigating what many believe will be one of the NHS’s toughest winters”, while Dr Jennifer Dixon of the Health Foundation stressed the importance of the new Chief Executive’s “proven credentials as a senior NHS leader and manager”.

There was certainly a feeling that Pritchard, having been de facto deputy head of NHS England since 2019, had vital experience of how the health service had already weathered the Covid-19 pandemic and would need no learning period on issues like workforce planning or financial sustainability. That was all the more valuable given that Sajid Javid had only been appointed Health and Social Care Secretary at the end of June after the ignominious departure of Matt Hancock, a politician who brought more bravado and self-belief than efficiency or administrative rigour to the role. As early as September 2021, however, she was having to fight to rein in the boisterous Prime Minister: Johnson wanted to commit the NHS to treating 30 per cent more patients in 2023/24 than before the Covid-19 pandemic, but Pritchard warned this was not possible and restricted him to saying that it was his “aim to be treating about 30 per cent more elective patients”.

Managing the health service

There is a harsh truth that NHS England on Pritchard’s watch did not get to grips with waiting lists, which not only continued to rise but in fact rose more quickly. Having sat at 5.6 million when she took over in August 2021, the number of patients waiting for treatment climbed to a peak of 7.7 million in September 2023 and as of September 2024 was only slightly under that number. The target to treat patients within 18 weeks had not been met since 2016.

This failure to improve was in spite of initial increased funding. Health expenditure in England, excluding Covid-19 spending, had risen from £153.1 billion in 2021/22 to £181.7 billion in 2022/23, though this then fell to £171 billion in 2023/24 due to government’s demands for efficiency savings. The spring budget in March 2024 saw then-Chancellor of the Exchequer Jeremy Hunt announce an additional £2.5 billion in day-to-day revenue funding for 2024/25 and an extra £3.5 billion in capital investment. In essence, NHS England was barely managing.

The general election of July 2024 was perhaps a foregone conclusion in terms of the winning party, even if the scale of Labour’s victory (of the Conservative Party’s defeat) came as a surprise. Many found the campaign dull, but in health policy there was something notable happening. While both major parties, as they almost always do, promised more money, more staff and better facilities and equipment for the NHS (“the closest thing the English have to a religion”, as former Chancellor Nigel Lawson memorably described it), they were also talking about the need for institutional and systemic reform to go hand-in-hand with additional resources, to a degree which was highly unusual.

The Conservative manifesto summed up the approach by declaring that the party would “invest in and modernise the NHS”. Although it had been in government for 14 years, it promised “the NHS’s first ever Long-Term Workforce Plan”, leading to “driving up productivity in the NHS and moving care closer to people’s homes”. This ambition to “shift care away from hospitals and into local communities” was a substantial task for a health service which had become dominated, both in terms of perception and of the most persuasive case for greater resources, by acute care. In addition, a re-elected Conservative government would place patient choice at the centre of its policies: it would “protect and promote patients’ right to choose the NHS service that is right for them” and “grow opportunities for all types of providers—NHS, charity or independent sector—to offer services free of charge to NHS patients, where these meet NHS costs and standards”.

Many of the plans in the Labour Party’s manifesto were similar in focus but also in broad sweep. One of Sir Keir Starmer’s five “missions to rebuild Britain” was to “build an NHS fit for the future”, and, like the Conservatives, he was explicit that this was not merely about funding. “Investment alone won’t be enough to tackle the problems facing the NHS; it must go hand in hand with fundamental reform,” Labour promised (or warned, depending on the perspective). These reforms would include making the NHS “not just a sickness service, but able to prevent ill heath in the first place”, giving it “a greater focus on the management of chronic, long-term conditions”. The party would also “harness the power of technologies like AI to transform the speed and accuracy of diagnostic services” and establish an “NHS innovation and adoption strategy in England”. In essence, Starmer and Streeting, the Shadow Health and Social Care Secretary, wanted to get ahead of illness, to prevent it or diagnose it early and thereby reduce the burdens on other parts of the health service further along the path.

This was a healthy, innovative and nuanced approach to healthcare, even if little more than the superficial numbers and general “vibe” made much impression on voters. It at least suggested a willingness to grapple with long-term challenges and finally confront the impossibility of a healthcare system designed in the 1940s providing adequately for a population of the 2020s without major change. It carried a strong suggestion of institutional reform, which is a double-edged sword: as I wrote in September last year, the NHS has been bedevilled by a tendency on the part of politicians towards almost-constant revolution. Between 1995 and 2012, there were eight major pieces of legislation affecting the structure of the NHS, five other major reorganisations and nine secretaries of state.

In addition, it was obvious that, whichever party was in government, the leadership of the NHS in England would be working in an acutely political and sensitive environment. Ministerial expectations would be high, because public expectations would be high, and there would be little room for error or indulgence of missteps or lack of progress. Inevitably this would be a more delicate area in which to work if Labour came to power, simply because the senior leadership of the NHS, from Pritchard down, at least had some familiarity with Conservative ministers and advisers (although the ministerial turnover had been absurdly high: Pritchard saw five tenures of secretary of state, with Steve Barclay serving twice, in the three years between her appointment in 2021 and the general election in 2024).

Making the transition

When Sir Keir Starmer assembled his cabinet after the general election, almost every shadow cabinet member transferred to the corresponding ministerial brief, so it was (rightly) regarded as a done deal that Wes Streeting would become Secretary of State for Health and Social Care. The rest of his ministerial team was moved smoothly across too: Karin Smyth, who became Minister of State in charge of secondary care, Andrew Gwynne, social care minister, and Baroness Merron, Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health, had all shadowed the policy area. Two shadow health ministers were sent elsewhere, Abena Oppong-Asare becoming Parliamentary Secretary at the Cabinet Office and Feryal Clark moving to the Department of Science, Innovation and Technology. Meanwhile the second Minister of State post, responsible for primary and adult social care, went to the able and experienced Stephen Kinnock, who had previously been Shadow Immigration Minister.

Pritchard accompanied Streeting on his first ministerial visit, to a general practice surgery in St John’s Wood, only four days after the election. While she could hardly do otherwise, she endorsed his early decision to divert resources from hospitals to primary care in order to “fix the front door to the NHS”, and she sent an email to NHS England employees which underlined that “we are all keen to make” the new government’s “three big strategic shifts”: moving the emphasis from hospitals to primary care and community services; making better use of technology and data; and improving prevention to help people stay well rather than waiting to treat their illnesses.

This in itself presented a challenge. To divert money from hospitals meant deprioritising emergency and elective procedures, and therefore lessening the pressure on reducing waiting lists; yet the Labour Party had promised to provide 40,000 more appointments every week to bring down waiting times. Streeting had also declared in a speech on his arrival at the Department of Health and Social Care the day after the election that “the policy of this department is that the NHS is broken”. Although he spoke of “a team effort” and “the mission of my department”, such a blunt assertion that the system was not merely failing but had in fact failed could hardly be a comfortable message for the Chief Executive who had been at its head for three years.

Streeting also ordered an immediate independent investigation into the condition of the NHS in England, to be conducted over a matter of weeks by leading surgeon and former health minister Professor Lord Darzi of Denham. The result of this investigation was delivered in September and made damning criticisms of the management of the health service over a number of years, including long waiting lists, underperforming accident and emergency departments, variable quality of care, low productivity and money being spent in the wrong areas. Many of these problems were blamed on sustained lack of capital investment. Like Streeting’s description of the NHS as “broken”, this litany of failures could not do other than pass a condemnatory judgement on those who had overseen health policy over the previous 15 years, and the most recent of those, in official rather than ministerial terms, was Pritchard.

Right from the beginning of the relationship between Streeting and Pritchard, therefore, there was an inherent tension. Chief executives of the NHS, perhaps because they enjoy greater autonomy and operational independence than some senior civil servants, are personally identified with success and failure to a much greater degree than, for example, a permanent secretary running a mainstream Whitehall department. Nigel Crisp (2000-06) had taken early retirement in part because NHS finances were under severe pressure and, as he admitted, “not everything has gone well”; David Nicholson (2006-14) had left his post because of earlier failings in West Midlands Strategic Health Authority, of which he had been Chief Executive, but also because there was a more general sense that the NHS was still sometimes failing patients and families in terms of care and accountability.

(By contrast, it was exceptional and attributed substantially to political manoeuvring by Downing Street when in 2020 the head of the Diplomatic Service, Sir Simon McDonald, stepped down “at the request” of the Prime Minister, partly due to disagreements over Brexit, and Jonathan Slater was dismissed as Permanent Secretary at the Department for Education after a fiasco over GCSE and A-level results. There was similar astonishment in September 2022 when Liz Truss, having just become Prime Minister, sacked Sir Tom Scholar, Permanent Secretary to the Treasury. In none of these cases was it a straightforward issue of accountability for institutional failures.)

Another complicating factor was the importance of the health portfolio. Streeting had been Shadow Health Secretary since November 2021, holding the same ministerial brief as anyone in the Shadow Cabinet except Rachel Reeves, the Shadow Chancellor, John Healey (Defence) and Ian Murray (Scotland). Improving the NHS was one of the Labour Party’s five “missions”, and a poll conducted just before the election showed that 52 per cent of those planning to vote Labour were doing so because the party would be “better on the NHS/healthcare”. Another poll in May had demonstrated that the “NHS/Hospitals/Healthcare” was the most important issue facing Britain, being named by 35 per cent of respondents (second was “Inflation/Prices” on 29 per cent). While it remains broadly true that oppositions don’t win elections but governments lose them, Labour had clearly benefited enormously from a persuasive case that it would do more to improve the NHS than would returning the Conservatives for a fifth time.

Moreover Wes Streeting is ambitious. Most politicians are, to varying degrees, some more plausibly than others (think of Gillingham and Rainham MP Rehman Chishti’s candidacy in the Conservative Party leadership election in the summer of 2022), but there is a common feeling that to admit openly to ambition is somehow disreputable, disloyal to the current leader or distastefully boastful. Streeting did not wholly abide by that convention; in an interview with The Guardian in June 2023, Simon Hattenstone noted that:

Fans see him as a future prime minister with an inspirational backstory… others see him as just another slick Oxbridge opportunist with his eyes on the prize.

That Streeting had written a memoir at the age of 40, One Boy, Two Bills and a Fry Up, struck his critics as another plank in a future leadership platform, but he was not attempting to hide a desire for the highest office.

I’ve never been ashamed of aiming high and going as far as my talents will take me. I’m in politics to get things done. I want to change things for the better, and where better to do that than being head of the cabinet? Prime ministers have huge power, so why would you not want to do that job?

His ambition had, so rumours went, been on full display in the previous year when Sir Keir Starmer was under investigation by Durham Constabulary, accused of attending a Labour Party event in April 2021 which had allegedly broken the Covid-19 lockdown regulations then in force. Having called for Boris Johnson to resign after receiving a fixed-penalty notice for breaching regulations, Starmer undertook to resign himself if he was found similarly in breach of the rules. The Labour leader claimed to be confident he had not broken any regulations, but there was a still a ripple of panic in the Opposition; a joint fundraising event held with Batley and Spen MP Kim Leadbeater at the home of stalwart party donor Lord Alli was seen by Streeting’s critics as the Shadow Health Secretary going “on manoeuvres”. There was even implausible talk of Leadbeater forming a joint ticket with Streeting to be Deputy Leader of the party if both Starmer and Angela Rayner were forced to resign.

This undoubted and undenied ambition matters because Streeting knows that reforming and improving the NHS is a task at which he cannot fail. The Prime Minister seems to prefer stability and longevity among his colleagues, and has already (perhaps rashly) committed to the Chancellor, Rachel Reeves, and the Foreign Secretary, David Lammy, staying in their respective posts until the end of the parliament. Streeting can expect, therefore, to remain at the Department of Health and Social Care for some years, perhaps until the election. That gives him a degree of stability and certainty to address the far-reaching and profound reforms he and Starmer have promised, but it also means that he may have nowhere to hide nor any exit route from failure. He understands this very clearly, and in the 2023 Guardian interview said presciently:

If I can take the NHS from the worst crisis in its history and make it fit for the future, and that’s all I ever achieve in politics, I’ll retire feeling very proud of that… And if I got a chance to be a Keir Starmer or Tony Blair or Gordon Brown or Wilson or Attlee, I would die happy.

It would be misleading to suggest that Pritchard’s position was doomed from the start of the new government. A few days before the election, Streeting had expressed “total confidence” in her, and gone out of his way to emphasise that he genuinely meant the statement rather than making it for reasons of political convenience. It was striking that he was not willing to extend the terms of his confidence to every individual in a leadership position at NHS England, saying instead:

I’m not… getting into the business of being judge, jury and executioner on individuals who don’t have the opportunity to kind of speak back for themselves.

That he had singled out Pritchard suggests he had not decided she was an insuperable obstacle. By contrast, it was reported that Streeting wanted to remove Richard Meddings as Chair of NHS England and install a more trusted and amenable figure to increase his influence over the organisation. Meddings, a chartered accountant and banker who had became an experienced quangocrat, had been appointed in March 2022 under Boris Johnson; Streeting was said to be considering as a replacement a senior figure from the Blair/Brown era, with former Health Secretary Alan Milburn, ex-Home Secretary Jacqui Smith and Baroness Morgan of Huyton, a former minister and a key Number 10 ally of Tony Blair, among the potential candidates.

Throughout the autumn and winter, there were no obvious fatal ruptures between the Secretary of State and the NHS Chief Executive. The pair often appeared together and provided plentiful photo opportunities for the media. When the Budget was delivered in October 2024, the Chancellor was able to announce an additional £25.6 billion in cash terms for the Department of Health and Social Care over the next two years. Given the “black hole” in the finances to which ministers referred endlessly and the generally downbeat assessment of the economy, this was no small sum, but it was very quickly apparent that much of the additional funding would immediately be absorbed by the pay settlements Streeting had reached over the summer for junior doctors, nurses and other NHS staff.

One crack did appear at the end of January. Streeting presented a policy paper to Parliament entitled Road to recovery: the government’s 2025 mandate to NHS England, setting out the priorities he wanted the health service to pursue. Nothing in the substance was surprising, but its tone could be interpreted as a combination of dissatisfaction and warning, a shot across the bows of Pritchard and NHS England’s leadership. The paper advised that “the NHS must learn to live within its means” and that “the government’s investment in the NHS against a challenging economic and fiscal backdrop must be matched with reform”. It continued:

The public welcomed the Chancellor’s decision to prioritise the NHS, but they remain sceptical about whether the money will be well spent. It is our responsibility to make sure that it is. I will be closely monitoring performance against the budget. The culture of routine overspending without consequences is over.

When it went on to outline how the organisation should be managed, there was an irrefutable implication that it was not currently being run on these lines. Streeting instructed NHS England to:

ensure the right financial management and control frameworks are in place to support the delivery of mandate objectives within the parameters set out in the financial directions, delegated spending authorities and controls issued by the department.

It was an implicit rather than an explicit critique. There was no suggestion that Pritchard, the low-key “continuity candidate” for the top NHS job in 2021, was the sole or primary problem, but it was becoming valid to ask if she was the solution

Resignation

Amanda Pritchard oversaw a high level of stasis in NHS England. Certainly before the general election she was not able to make any serious headway in reducing waiting lists, such an important public and political indicator of the condition of the health service, and by sheer virtue of her position and length of tenure, it was impossible to exempt her wholly from any responsibility for the failures identified by Streeting, Lord Darzi and others. The surprisingly blunt criticism from two select committees mentioned at the beginning did not enhance her career prospects, and may have proved to be the causa proxima of her resignation, but they do not tell the full story.

More likely are two interlinked factors. The first is her status as an avatar of three undistinguished years of substantial spending and disappointing returns. Waiting lists are gradually reducing, but the quantum of the reduction remains dwarfed by the numbers overall: NHS England announced earlier this month that the backlog had fallen from 7.48 million to 7.46 million. It takes a true Dr Pangloss to read those figures and concentrate on the 0.02 million (20,000) difference rather than the overall seven and a half million. It may be evasively imprecise—politics often is—but Pritchard simply doesn’t look or sound like a leader who can help shift the needle to the extent ministers, not to mention patients and families, require.

The second factor is a superficially technical one: Streeting wants to have greater control over NHS England, perhaps to the extent of ending its statutory independence. Before the general election, it was rumoured that Labour might combine the posts of Chair of NHS England and junior health minister in the House of Lords to bring NHS England and the department closer together quickly and without, or in advance of, time-consuming structural changes.

One outcome of the government’s mandate to NHS England published in January is that the organisation must save £325 million this year. Part of this will be achieved by cutting 2,000 jobs, some 15 per cent of its headcount; in a message to staff, Pritchard explained that “we need to reduce duplication and add real value to the work of the NHS, complementing DHSC’s role”. This focus on eliminating “duplication” is believed, not without reason, to be part of a larger plan by Streeting effectively to bring NHS England under his control as Secretary of State. This control is expected to be enhanced when the government publishes its 10-Year Health Plan for the NHS in May.

Whether greater integration and ministerial control is a good or a bad thing, Pritchard is entitled to conclude that her job as Chief Executive of NHS England would change beyond recognition under such reforms, and after a meeting with Streeting on Monday this week, she is reported to have decided that it was not the role she signed up for. One source described her decision as a “logical choice”. A track record from which notable success is absent; a fraying relationship with a ministerial chief; the prospect of a role diminished in scope, responsibility and independence; and public and humiliating criticism by select committees represent a concatenation of circumstances which are not necessarily, taken one by one, issues on which careers will founder. Collectively, however, they put Amanda Pritchard in a position in which she was vulnerable to being toppled.

Whether Streeting gave a final, decisive push or allowed her to come to her own conclusions is uncertain. While it is not a genre noted for its frankness and authenticity, his written response to her resignation was warmer than mere protocol required. He claimed to have “mixed emotions” and paid tribute to Pritchard’s having “been extremely supportive of me and this Government’s reform agenda”, saying that she had “never given less than 100 per cent to your role”. Telling her she should be “enormously proud” of her leadership, and praising her “integrity and wavering commitment”, the Secretary of State perhaps gets to the heart of the matter when he acknowledges:

I can understand why you have chosen this moment to pass the baton to a new leadership team to lead the NHS into the next phase of its history.

It is gently done by the standards of public life, but it sounds like recognition that, as both select committees had identified, she is not the leader to take the NHS through a period of profound, perhaps unprecedented, change.

Next steps

Pritchard will formally leave her post on 31 March. As an interim measure, she will be replaced by Sir James Mackey, Chief Executive of Newcastle Hospitals NHS Foundation Trust, who will work alongside her throughout March then take the reins completely on 1 April. At 58, he is an experienced pair of hands who was a candidate in the early stages of the competition for Chief Executive of NHS England in 2021. He is a qualified accountant who joined the NHS in 1990: he served as Chief Executive of NHS Improvement from 2015 to 2017 (described in the advertisement for his replacement as “manifestly not a role for the fainthearted”), then returned to his native North East as Chief Executive of Northumbria Healthcare NHS Foundation Trust. In September 2021, he agreed to work two days a week as National Director for Elective Recovery at NHS England. He was also acting interim Chief Operating Officer of NHS England for two months after Sir David Sloman retired in September 2023.

Mackey is a well-respected figure regarded, as his career indicates, as someone who will approach tough challenges with straightforward practicality. There are two features of his appointment which are worth noting. Firstly, he has been given an explicit “remit to radically reshape how NHS England and DHSC work together”, and Streeting said that “he knows the NHS inside out, can see how it needs to change, and will work with the speed and urgency we need”. This leaves very little doubt as to Streeting’s intended direction of travel: although NHS England (originally the NHS Commissioning Board for England and still so called in legislation) was established by statute under the provisions of the Health and Social Care Act 2012, it will be brought so close to the Department of Health and Social Care and work so closely in parallel with it that the two will almost become synonymous. There may be more explicit changes proposed in the 10-Year Plan for the NHS, though Streeting may wish to avoid the hard yards of legislative change.

The second aspect is that Mackey is described by NHS England as “Transition CEO”. The government’s preferred candidate for Chair of NHS England in succession to Meddings, Dr Penny Dash, told the House of Commons Health and Social Care Committee that her understanding was that Mackey’s secondment would be for a period of one to two years, and that finding a permanent replacement for Pritchard was not an immediate priority. It would be logical to conclude, therefore, that Mackey will undertake the task of radical restructuring over a two-year period with the luxury of putting noses out of joint where necessary and without having an absurdly short deadline (by comparison, Sir Ian Carruthers, interim Chief Executive of the NHS between Crisp and Nicholson, only served for six months).

There are reports that some NHS staff regard Pritchard’s departure and the remit given to Mackey as a “power grab” by Wes Streeting. It may well be just that; the 10-Year Plan may reveal more detail. But the precise structure of the NHS in England and which body carries out which function is secondary, at best, to the overall task of reforming healthcare and making it high quality and sustainable. Moreover, this task is one of survival for Streeting, and perhaps for the government too. If Starmer were to enter a general election campaign some time in 2029 with waiting lists still north of six or seven million, with patients still on trolleys in hospital corridors, with some clinical outcomes as poor as they are now and with the NHS’s finances lurching from one crisis to the next, his chances of re-election will be very slender.

Amanda Pritchard probably did make what the anonymous source called a “logical choice” in stepping down from her post this week. She had reached the point, at least reputationally, where she was running to stand still, and it was very hard to imagine her carrying the credibility and authority to transform the delivery of healthcare in England over a sustained and inevitably gruelling period of four years or so until the next election. A transitional figure like Jim Mackey may be a clever move on Streeting’s part, but there are still more parts of the jigsaw to fall into place. Ultimately, though, the success or failure of NHS reform will depend on the determination to take unpopular decisions and the capacity to absorb and acknowledge but not be overwhelmed by criticism exhibited by those who have in the short term the most skin in the game: ministers, and especially Wes Streeting and Sir Keir Starmer. It is the ultimate “high risk, high reward” scenario for them, and they have no way out.