Simon Stevens, the new head of NHS England, has a daunting task ahead

April Fools’ Day heralds the start of the era of Simon Stevens, the NHS manager turned Milburn/Blair health adviser and co-architect of the NHS Plan who, after much soul-searching, is taking on the big job as head of NHS England after a decade working in the US with private healthcare group, UnitedHealth.

His appointment was greeted warmly within the service. He is widely seen as having accepted the post because he cherishes and understands the NHS and, by dint of his undisputed talents (knowledge, fresh thinking, determination), as the best person to keep the service sustainable in the tricky times fast unfolding. But his honeymoon will be short. A maiden speech planned for his first day in the job, in a hospital in northern England, may help identify his big ideas.

It is understandable, if cliched, to see the arrival of a new NHS chief executive as akin to that of a new occupant of No 10: huge job; lots of pressure; £100bn budget; intense media scrutiny; events may throw you off-course; there’s never an easy time to take on such a post. But it is no exaggeration to say that Stevens’s in-tray is daunting – scary, even.

Hospitals are bursting at the seams. GPs, too, are so overworked their leader is warning that “general practice as we know it is under severe threat of extinction”. The 211 clinical commissioning groups (CCGs) are a work in progress. Frankly, so is NHS England. NHS staffing is a problem, yet care must be great everywhere, all the time. Morale is poor; a result of overwork, stress, last year’s upheaval, perceived badmouthing by politicians and four years of low or no payrises. Shifting to seven-day services will be tough. The required “transformation” of service delivery, particularly moving services out of hospitals, has not happened. When it does, as it must, dozens of mini-Kidderminsters may ensue, (where an independent MP is elected standing on the single issue of saving their local hospital services). And NHS England’s forecast £30bn gap by 2021, between its resources and the demand for care, has to be bridged somehow.

How much freedom will Stevens have? Not that much, potentially. His organisation will still have to implement the Department of Health’s mandate. The CCGs’ impending two-year and then five-year plans will largely dictate the direction of travel, unless he rips them up. Money is another major constraint. And while government backing is essential, that may prove elusive if hospitals are to be run down.

Will he get more money to help smooth upcoming painful changes? The consensus is that the NHS is facing a decade of austerity. But its budget will inevitably have to rise in real terms. If not, services and/or care standards will visibly decline, patients will notice and bad headlines will follow – not an option. Persuading ministers of this, or – even harder – somehow saving money while improving care will sorely test his skills.

Stevens’s success will hinge on his relationships: with his NHS England colleagues, the 1.3 million-strong NHS workforce more widely, the public and the media – and, especially, whoever is in No 10. Senior people in and around the NHS are especially keen to know the answer to one question: will he be our leader and champion, and defend us if necessary, or will he prove to be the government’s man in the NHS, for example by further extending competition?

“He was appointed on David Cameron’s watch and will want to have a productive relationship with him,” says one of his new senior colleagues. “But with the election just over a year away he should be careful not to be too close to the PM in the meantime.”