You are responsible for a £110bn budget and the health of the nation, but with an average of only two years in the job there is no time to lose. Andy McKeon describes what you should expect in your first days as secretary of state for health

Richmond House

Richmond House, where you will find your agreeable – yet strangely paperless – office

Richmond House, where you will find your agreeable – yet strangely paperless – office

There you are having a quiet, self-congratulatory lunch to celebrate your election victory when the phone rings. It is the prime minister, asking you to be secretary of state for health. You are delighted and accept.

The next day, even if it is a Sunday, you shake Sir Hugh Taylor’s and Sir David Nicholson’s hands as you walk through the door of Richmond House. They guide you up to the really rather agreeable double aspect fourth floor office overlooking Whitehall. The next stage of your political career starts here.

You are now the person responsible for a service that touches everybody’s life in England, with a £110bn budget and a staff of more than a million

You are now the person responsible for a service that touches everybody’s life in England, with a £110bn budget and a staff of more than a million. As if that wasn’t enough there is also social care and the nation’s health, both of which can pose the most difficult handling questions.

Of course, if the secretary of state is the same before and after the election (Alan Milburn, Norman Fowler) it will be possible to slip into the same routines and style. All parties know what to expect. The one regret from the minister might just be that all those difficult problems that might have become someone else’s responsibility are still there.

There will also be a lot to fall back on if the individual has been in the department before and has been promoted like Ken Clarke, Virginia Bottomley, Stephen Dorrell, Alan Milburn (again) and Andy Burnham. Much will be familiar – the issues, the people, the routines. Some ministers take over with a lot of previous government experience, gliding between posts and learning in the process what matters most when picking up a new brief (William Waldegrave, John Reid, Alan Johnson).

Being a shadow health secretary beforehand helps a lot. But the toughest assignment is when the individual has no direct experience. Frank Dobson, for example, had never been a minister and had only been a shadow health minister some years before. He can’t have prepared much for the post in advance. Not even those pre-election briefings with the permanent secretaries. And his number two on the health team hadn’t been a health specialist either.  It’s a prospect that would terrify many people. Experience of being a politician really counts at that point.

If you are new and from a different party, the first thing you might notice as you gaze around the office is that there is not a shred of paper anywhere. This is not because the department has gone paperless. Far from it. Indeed, under the influence of consultants McKinsey, 100-page slide packs explaining policy options in great detail will soon thud onto your desk. No, the absence of paper is because incoming governments are not permitted to see the detail of the workings of the previous administration. Starting from scratch is the order of the day.

Then, as with any new job, the briefings begin, tailored of course to the individual and their knowledge. They can start from a basic level – right down to what a primary care trust is. The structure and workings of the NHS can be very complicated and at times potentially baffling to an outsider.

This is also a challenge for the officials doing the briefing. Reputations can be won or lost depending on how clearly they set out, without hesitation or deviation and in no more than two minutes, exactly how decisions on service provision get made and who is responsible for them. In doing so include the many people and organisations potentially involved – the local clinicians, the PCT, the oversight and scrutiny committee, the trust, the SHA, Monitor etc. A simple answer of ‘You, secretary of state’ is probably not the best one.

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Briefings will be carefully orchestrated and involve few people. Getting out and about will always be a diary challenge. One surprising point is that although the department employs over 2,200 staff and contractors the usual people you will see in meetings will be drawn from a very narrow cast of the most senior people in the department, whatever the issue.

Indeed, when after a while, individuals pop up whom you have never seen before, it is time to worry. It is usually a sign of crisis. An unexpected turn of events will have exposed a little known area to a very fierce media and political spotlight – a problem with a medicine or a high profile service failure.

There will be some urgent issues to attend to so the business of the NHS can proceed – an appointment to make, an order to approve. But what needs to be progressed as quickly as possible is implementation of your policy commitments.

This is what is expected. The prime minister has given you a clear brief, possibly backed up by a formal letter. Time is short. There have been 10 secretaries of state since 1990, so the maths is easy - two years is a very short time to achieve any real change.

Indeed, it usually allows just enough time to produce a white paper followed by legislation and will bring you to the point when implementation starts on the ground. Dutch colleagues have said that it takes 20 years for changes to mature and operate at their peak (in which case the purchaser-provider split and commissioning should be in their pomp, but that is another story).

Translating those broad sweeps of manifesto policy can prove tricky and time consuming when it gets down to the detail. To help, you will have perhaps two (new) special advisers. One may have little health knowledge. There will also be advice and guidance from No 10. One of the features of the Labour government in 1997 was the close involvement of No 10 in policy matters from the very start with an advisor – Robert Hill - attending all meetings. But not Treasury, where relationships have been much more formal and separate.

Then there will be your ministerial team. It will be a new team, but unlike, say, a trust board, there will be no time for bonding sessions, storming and norming, or quiet reflection. The rush of events and the pressure on time will dominate.  

There will be some minor personal points to attend to. Do you want a change of pictures from the government art collection? Do you want the office layout changed (note not new furniture) – a choice made by only one secretary of state in 20 years. Then it is on to the in-tray.

Here the challenge is the same whoever occupies the office. How can £15-20bn be saved and at the same time quality improved, the NHS made more responsive and new technologies taken up? How can the NHS contribute to regenerating the UK’s economy through growing life science industries? What should happen following the department’s review of arm’s length bodies and all those PCT proposals on community services that are waiting for an immediate answer? What will be your stance with Treasury in the next comprehensive spending review - the funding level may be protected but what will be delivered for it? How will you get broad consensus on funding long-term care? How will you narrow health inequalities?

Finding answers to these questions with tight resources while getting agreement of colleagues across government is difficult. Picking a way through the many interest groups whose views don’t change from government to government make the job even more demanding.

As one minister confided: “Nothing prepares you for working in a government department.” Keeping two jobs going – constituency MP and secretary of state and cabinet minister - as well as keeping abreast of party politics is extremely demanding, especially after four weeks of intense electioneering, even if you are buoyed up by victory.