The financial chill enveloping the NHS has only served to reinforce David Nicholson’s position as the most powerful person in healthcare.

After months of politicians refusing to come clean about the implications of the collapse in public finances for healthcare, the NHS chief executive blew the issue wide open by saying in his annual report that the service needed to save up to £20bn.

He can point to an organisation which has its current spending pretty much under control, has been warned about what is coming and told to prepare, and which has quality embedded into its agenda.

Mr Nicholson earned praise from many managers for “telling it like it is” at this year’s NHS Confederation conference. While politicians were still claiming that spending on the NHS would increase in real terms, he said bluntly that managers had to plan for real term cuts: “I’m a manager, not a politician,” he said pointedly.

He has surrounded himself with an able team - many of his lieutenants are also in the top 20 - and has consistently given the service a strong story on where it is heading, the challenges it faces and what is expected of it. He has gone a long way towards hard-wiring the Darzi messages on quality and productivity into the NHS.

He has championed the issue of the quality of leadership in the NHS to provide the service with a new generation of top managers.

Mr Nicholson has seen some of the less glamorous ends of the NHS - he worked in mental health and learning disabilities - but has solid acute trust and regional experience. He was briefly chief executive of NHS London before being bumped upstairs.

He works hard to keep his centralising instincts under control and sticks to the mantra of “look out not up”, while keeping a firm grip on the service.

His big challenge for the coming year will be coping with the likely change of government and managing his relations with the new team of health ministers, who see a radically different structure for the top ranks of health policy and management.