Merging the permanent secretary and NHS chief executive roles: ‘a major mistake’?

The early 2000s provide lessons – and warnings – for what it would mean if the roles of permanent secretary and NHS chief executive were combined.

Do not let two become one. The jobs of permanent secretary and NHS chief executive should not be merged.

One can only hope that this idea is a brief and passing fevered dream. One that will never emerge fully formed into the cold light of day. But, if the Health Service Journal is to be believed, the new Secretary of State for Health and Social Care is considering merging the job of being the permanent secretary at the department with that of the NHS chief executive.

In other words, going back to the five-and-a-half-year period up to March 2006 when Nigel (now Lord) Crisp held both jobs – as opposed to the whole of the rest of the time since the mid-1980s when the job of being chief executive of the NHS has been separate.

Before they go any further with this idea, ministers should consult. And it will be remarkable if they can find anybody – but anybody – who thinks that the idea was a success, the one possible exception being Alan Milburn, the health secretary who instigated the merger in 2000 and who is now the department’s lead non-executive director.

The NHS did indeed make appreciable progress over the period during which the jobs were merged. But it did so despite the merger, not because of it. It was the huge amounts of extra cash that were pouring into the service that saw to that, combined with a bunch of reforms that included the introduction of the tariff, foundation trusts and more patient choice, along with extra capacity, in the shape of the private sector and the independent sector treatment centres, which were essentially privately run surgical factories for NHS patients. But it was in this period too that the NHS achieved the truly remarkable feat of over-spending two years running at a time of record growth – the final overspend being the one that finished Lord Crisp’s tenure and saw Patricia Hewitt, as Secretary of State for Health, separate the two jobs out again.

Lord Crisp has his own account of what led to the overspend. But the core point here is that the task of being permanent secretary of the department is a job that goes much wider than being chief executive of the NHS (which is itself a job big enough for anyone to fill). The permanent secretary, as things stand, is the official who is the accounting officer not just for the NHS but for the whole range of other ministerial responsibilities:  for example, for social care policy and funding, for the Health Security Agency (think pandemics, Salisbury, and Porton Down), for the large elements of public health that are not part of the NHS, for key relations with the pharmaceutical and medical device companies via the Medicines and Healthcare Regulatory Agency (MHRA) and National Institute for Health and Care Excellence (NICE), for the bodies that regulate health professionals, and for broader relations – with the Cabinet Office and other Whitehall departments along with the international ones that include the World Health Organisation.

In other words, the two jobs are too big for one person to do and when combined something is going to suffer – as it did, more than arguably, when they were combined before. Patricia Hewitt was crystal clear that separating out the two jobs was ‘the right thing to do’, while her health minister at the time, Norman (now Lord) Warner, described the merger as ‘a major mistake’.

The idea that they again might become one is clearly ringing alarm bells all over the place. Sir Jim Mackey, the current chief executive, recently told the NHS Confed Expo conference that the service’s operational independence must be protected as the final arrangements at the centre are settled.

You can look at the [NHS Modernisation] Bill and think it’s a centralising thing, we’re building in too much control, [giving] ministers too much control. There has to be operational freedom in all this, otherwise we’ll grind to a halt.
Sir Jim Mackey, NHS Confed Expo 2026

He was, he said, encouraging ministers to talk to a wide range of former permanent secretaries and chief executives about ‘what worked and what didn’t work in the past’. He named Sir David Nicholson, a former chief executive, and his acting predecessor Sir Ian Carruthers, and former permanent secretary Dame Una O’Brien. But a whole host of other names could be added – including Sir Hugh Taylor who succeeded Lord Crisp as permanent secretary and Sir Richard Douglas, a former long-standing finance director who is now a non-executive director at the department. They should also, of course, ask Lord Crisp who by 2009 was himself advocating a degree of separation of the management of the NHS from the department. That would help create a department ‘for’ health, he said, when in his time, with everything combined, the running of the NHS ‘trumped almost all other considerations’.

When those conversations have been had, we at least stand a reasonable chance of waking up to discover that this was indeed nothing but a fevered dream.