The British government's requirement for expert medical advice from the 1850s led to the development of a medical civil service, which reached its peak in size and authority in the 1970s. By this time the Chief Medical Officer (CMO) had direct management of a staff of over 170 medically qualified civil servants, who provided expertise on the development and implementation of new medical treatments as well as on broader health protection and promotion issues. The successive Whitehall efficiency reviews from 1979 onwards culminated in 1994 in the merger of the parallel medical and civil service reporting hierarchies in the Department of Health, effectively reducing the CMO's ability to call upon the support of medical civil servants, at a time of increasing new health threats such as AIDS and MRSA. This article uses government reports to chart the rise and fall of the British medical civil service. It discusses how, in the last ten years, the British government has become more imaginative in its use of temporary specialist medical advisers (tsars) brought in from the NHS, in relaxing the formal civil service hierarchies, and quietly abandoning the statutory Standing Medical Advisory Committee (SMAC). This article suggests that when the government has failed to give adequate support to its CMOs, the medical civil service has suffered from poor morale, experienced recruitment difficulties, and the ability to respond to health crises has been compromised. It highlights the chronic lack of historical awareness in the development of health policy in Britain