Nicholson is master of all he surveys after surprise decision

Make no mistake, the health secretary expected the NHS chief executive to last about a week under his leadership. Sir David’s friends say the expectation was mutual. The question was not if but when they would part company.

This out-of-the-blue appointment to arguably the most important job in the NHS without any kind of clear selection process is, in the words of one senior health observer, ‘a travesty’

Now, with Sir David not due to start his new job for 15 months and Mr Lansley expecting to stay at Richmond House until the next election, they have been fused together as the co-leaders of NHS reform for the next four years.

Two questions pose themselves: what happened and what does it mean?

The accepted wisdom surrounding the first question relates to “the Dorrell factor”. Stephen Dorrell’s interview with HSJ in November first clarified growing concerns that the commissioning reforms could seriously disrupt the NHS’s unprecedented efficiency drive. The health select committee chair also praised Sir David’s vision and grip on the cost saving challenge.

Now, it is claimed, the coalition’s power brokers have forced Mr Lansley to accept Sir David as the commissioning board chief executive in order to ensure the two policies work in harmony.

“Rubbish”, say those close to Mr Lansley. Other branches of government were only formally told less than an hour before the announcement. They admit Mr Lansley was surprised by how much he enjoyed working with Sir David and is not displeased the appointment might ease concerns about NHS finances, but claim the decision was his alone.

The future consequences of Sir David’s new job are less opaque.

For a start, the manner of the appointment undermines the government’s credibility in selecting senior health service figures.

This does not mean Sir David is the wrong man for the job. Indeed, the decision has been broadly welcomed. However, this out-of-the-blue appointment to arguably the most important job in the NHS without any kind of clear selection process is, in the words of one senior health observer, “a travesty”.

The excuse that Mr Lansley’s seven years as shadow health secretary meant he knew every possible candidate is a weak one for a government pledging itself to transparency.

This fait accompli is also unlikely to attract the strongest candidate for the chair of the supposedly “independent” commissioning board.

But the most significant outcome is the unexpected return of Sir David to the very top of the health hierarchy. The most powerful person in the NHS for the last five years is now set to occupy that position for at least the next three.

Why? For a start, withdrawing the offer before Sir David takes up the job would be highly embarrassing for the government. As a result, the NHS chief executive has effective carte blanche to drive the reforms as he sees fit during the next year.

Second, as NHS chief executive he controls the £20bn QIPP savings drive, while as commissioning board CEO-elect he is responsible for the shaping how the health service will spend its money in the future.

Sir David will ensure there is close alignment between the two. The 2011-12 operating framework declares: “Pathfinder consortia must demonstrate active ownership of the local QIPP agenda” - which is likely to come as a rude shock to many of them.

Sir David’s reputation as a centraliser - one he rejects - leads most to believe the board will exercise much tighter control on consortium spending strategies than Liberating the NHS suggested. Legislation may restrict that control. However, more significantly, Sir David now has the ability to shape the service in a way that ensures the framework in which consortia develop is one he thinks best.

• ‘Nicholson now master of all he surveys’

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