4 March 2025

Last week, Amanda Pritchard, Chief Executive of NHS England, rather unceremoniously announced that she would step down within a month. Shortly after the announcement, Health Secretary, Wes Streeting, made it clear whose decision this was by saying, “we will…require a new relationship between the Department of Health and Social Care and NHS England”. It’s fair to say that this has been expected since Streeting first walked into DHSC in July 2024. He almost immediately set out that DHSC and his team would lead on the 10-year NHSE plan – previously these plans have been written by NHSE leaders.

Wes Streeting: The NHS Reformer

Streeting has set out a clear trajectory to significantly reform NHSE. First, he put an end to the dispute with Resident doctors, stopping strikes in NHSE. This was achieved with a lot of investment in resident doctors’ pay, but also by asking NHSE to significantly reform resident doctor working practices, one of his first major changes. Secondly, Streeting asked Lord Darzi to set out how broken NHSE is, buying himself some time to work out how to fix it. Finally, he will set out exactly how to fix NHSE in Spring 2025.

This clear decision from Streeting to change NHS leadership, which was sped up by Pritchard’s recent underwhelming performance at the Health Select Committee. With sizeable reforms to the NHS now expected on the way, and Streeting needs an NHS CEO fully on board with his plans.

For now, Sir Jim Mackey is the “transition” chief executive. Sir Jim will be well known to most, now running Newcastle hospitals. From 2021 to 2024, he was leading on NHSE’s elective recovery, one of the biggest jobs in NHSE. He was also in the running to be CEO of NHSE when Amanda Pritchard was appointed.

Sir Jim is seen as a more willing reformer, but importantly when Sir Jim ran elective recovery, he was clear that he is open to NHSE working closer with the Government. But the title “transition” suggests he might not be a permanent appointment, by his own admission he will be in post for one to two years.

The challenges Streeting faces next

Streeting is looking after the second biggest budget in Whitehall, it’s one of the few that is going up, while many are being cut. Consequently, he is going to be under enormous political pressure to deliver results and get waitlists down. Although he’s had some early success (waiting lists have now fallen for four months in a row) longer-term success will be a challenge. The average age of our population continues to rise and although Streeting might have been awarded an increase in spending by Rachel Reeves, the confident BMA will be looking for their fair share. The RCN have also said that the touted 2.8% pay increase for nurses would be an insult. To alleviate the pressure in this transition time Streeting will likely be asking Sir Jim to use his recent experience to laser focus on getting the elective waitlist down, instead of crafting and then driving the reforms that Streeting’s team is building in DHSC.

Streeting has also recently expressed his frustration at the duplication of roles in both DHSC and NHSE, which is often resulting in disagreements on policy. To tackle this, he has suggested shrinking NHSE and merging some teams with DHSC. The decision from Streeting to replace an NHSE CEO, and his message to Sir Jim that he has “a remit to radically reshape” ties, shows a clear reset and reframing of the DHSC and NHSE relationship, which had broken down. Combined with Streeting’s desire to cut the number of NHS staff, it’s clear that power now lies in the Department.

Some have interpreted this decision as a “power grab”, or something to keep health journalists busy while they wait for Streeting’s 10-year plan, or an expression of his pure frustration at the pace of change in NHSE. It is likely to be a combination of all three, but it certainly does show an increasing politicisation of the role of NHSE CEO, which previous NHS reforms have attempted to stop.

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