A chief executive who already runs two west London hospital trusts now carries responsibility for NHS England's London region as well. Lesley Watts, chief executive of Chelsea and Westminster and The Hillingdon Hospitals, has assumed the role of interim regional director following Dame Caroline Clarke’s departure to lead the newly established NHS Online Trust. Hannah Witty, the deputy regional director, covered first, on the understanding that it would last two or three months. That estimate has stretched, because the search for a permanent successor has not concluded. Watts's experience is not in dispute. The arrangement still raises the matter of why the same small group of senior figures is so often asked to fill the gaps.

The sequence of events points to a clear pattern: a regional director moves to a new national organisation, with a deputy taking over the role on an interim basis. A serving trust chief executive is brought across. Each step is defensible on its own terms, and each draws on the same limited pool of people who have run large provider organisations and understand how regional oversight works in practice. Senior leadership in the NHS moves in a loop between trusts, regions, national bodies and newly created organisations, and the loop is tight.

The pool is narrow partly by design. Chief executive posts carry heavy personal exposure. Performance data is published, deficits are scrutinised, and regulators intervene early when a trust slips. Tenures are often short. Those who survive accumulate credibility, and credibility becomes the scarce commodity every appointing body wants. Meanwhile the next generation looks at the exposure, the pay relative to comparable private sector roles and the public criticism, and many decide against applying. Deputy and director roles rarely offer enough breadth to make the step feel safe, so the pipeline thins before it reaches the top.

Structural uncertainty makes this worse. The regional directorates sit amid unresolved questions about oversight and integration, including how they will relate to the Department of Health and Social Care after the announced changes to NHS England. A permanent appointee would be taking on a post whose remit may be redrawn within a year or two. Strong external candidates have little reason to accept that risk, and appointing bodies have little reason to rush. Interim solutions follow, and interim solutions favour people already known to the system. Each reorganisation produces more recycling, and the NHS has had many reorganisations.

The costs are practical. London holds a dense concentration of acute trusts, long waiting lists, persistent financial strain and complicated relationships with integrated care boards. A person leading two trusts and a region has a finite diary. Oversight of neighbouring providers by someone who also runs a provider requires explicit handling of conflicts of interest, which is manageable but demands care. There is a subtler cost as well. When the same people circulate, they carry the same assumptions, and a service that needs productivity gains and new models of care ends up drawing on a narrower range of ideas than its problems require.

Policymakers can address part of this. Settling the regional structure before recruiting would allow permanent appointments on stable terms. Publishing succession plans for the most senior regional and trust posts would expose weak pipelines early. Fixed secondments with proper backfill would stop serving chief executives being stretched across two jobs, and recruitment from local government and other large public services would widen the field. Ministers also bear much of the responsibility for pay and the personal consequences of failure, both of which would require attention.

The London appointment is a sensible short-term answer from an experienced leader. It also shows how little slack the system holds. A health service that must borrow a serving chief executive to run a region has a succession problem, and no new organisational chart will solve it. The next structure will need leaders, and the supply of them is being drawn down faster than it is replenished.

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