Richard Smith: Memories of Thatcher

Richard Smith My early years at the BMJ were very bound up with Margaret Thatcher. I started as an assistant editor a month before she became prime minister in 1979 and was appointed editor just before she was dethroned as prime minister in 1990. Whatever I write about her will evoke fury in some quarter, and despite our present prime minister saying that she saved the country it’s probably still too early to make a confident judgement on her performance. But I have my memories.
(Like all memories these will be incomplete, confused, and mixed up with stories and dreams. I’d also forgotten until half way through this blog that I once blogged before about Thatcher, suggesting that like it or not we are all to some extent Thatcherites now).

I saw her only once, at a Queen’s garden party. It was after she’d been deposed, and what struck me was the messy line on her neck where her thick make up ended. They, whoever they might be, would not, I thought, have allowed that when she was my prime minister. It suggested frailty, perhaps foreshadowing the forgetful woman depicted by Meryl Streep in The Iron Lady.

My first association with Thatcher and health was the attempted suppression of the Black report. It was a report on inequalities in health commissioned by Labour when still in power from Douglas Black, a former president of the Royal College of Physicians. The attempt at suppression was farcical and guaranteed that the report gained far more attention than it would have done if published in the normal way. No Tory politician would use the word inequalities. “Variations” was the politically correct term. Similarly “rationing” was a non-word replaced by “priority setting.”

Also suppressed in those early days was a government report on alcohol that showed clearly that increasing its price was the most effective way of reducing the harm it caused. Newspapers kept discovering this report and splashing it over the front page as an “exclusive.”

Thatcher didn’t seem to want to hear any evidence that didn’t fit with her view of the world and, like a dictator, tried to suppress evidence and language that she didn’t like. But a civil service shocked by her uncivil ways was either incompetent at suppression or unwilling to carry it through.

I was, and still am, keen on public health, and Thatcher with her ideological commitment to individualism and disbelief in society never liked public health. The sociologically inspired series of articles I wrote for the BMJ on alcohol policy would not have appealed to her if they’d ever got anywhere near her, which, of course, they didn’t.

Her priority was to improve the economy, and one consequence of her “monetarist” economic policies was a dramatic rise in unemployment. So Stephen Lock, who was then editor of the BMJ, got me to write a series of articles on unemployment and health. The evidence on the harmful effects of unemployment was very clear, but again it was of no interest to Thatcher and her government.

Public health doctors have unanimously hated Thatcher and her legacy, and to show his scorn Gabriel Scally, a public health doctor, tells us on Twitter that his response to her death is to contribute to the memorial fund for Michael Foot, who was truly a great politician. Foot was the leader of the Labour Party when it was crushed in Thatcher’s first election as prime minister in 1979. As the job of a politician is to get elected and make things happen it seems unlikely that history will judge Foot to be a greater politician than Thatcher. More intellectual, more compassionate, yes.

Thatcher was leader of the most radical right wing British government of the 20th century, and she fought the miners and the unions and privatised many national industries. But compared with what has followed (and may be to come) she largely stayed away from the NHS, recognising the deep affection for it in the population. Her innovations were professional management (hardly radical), the purchaser provider split (which never really got going in her time), and GP fundholding.

But it felt like radical change, even destruction, at the time. One of the pleasures of writing this blog has been to reread the 1989 editorial by Stephen Lock called “Steaming through the NHS.” It caused a great stir, and perhaps contributed to the idea current at the time that the doctors provided the main opposition to Thatcher. The miners were crushed, the unions emasculated, and the Labour party in a mess, but the doctors were standing up to Thatcher.

“Steaming” was a fashionable crime whereby “a gang runs amok through a crowded train demanding money at knifepoint.” “The aim,” continued Lock, “is achieved through bewilderment and fear, much as in Clausewitz’s description of total war.” The government, he argued, had used the same strategy, proposing reforms at breakneck speed without consulting doctors. The proposals were “difficult to debate” because of “the shallowness of the original rhetoric” and the lack of detail. Nevertheless, wrote Lock, “it is not fanciful to talk about the end of the traditional health service.” Becoming ever more passionate, at the end of the editorial he saw “a return to the poor law.”

This was 24 years before the current death of the NHS, and it reminded me of a lecture 10 years ago from Laurence Buckman, once chairman of the BMA’s committee of GPs, where he said he’d been giving lectures on the “End of general practice” for 30 years. No doubt he’s still giving them.

I was caught up in all this rhetoric. I was asked by the Millbank Quarterly to write a piece on the NHS in an issue to honour Rudolf Klein, the great NHS commentator of the time. In my draft I wrote of the NHS enduring its worst crisis ever. I showed the draft to Gordon McPherson, deputy editor of the BMJ, and he listed many crises that he thought worse.

But perhaps Lock was right to see this as the end of traditional health service in that although the changes don’t in retrospect look that radical they did lay seeds that have led to further changes: the rise of management and the introduction of market mechanisms.

Lock foresaw “large scale privatisation” and despaired, like present protestors, against reform that “the picture is now so complex and confused that few outside the NHS appreciate just how far it will decline from its present level.”

He warned doctors against “trying to counter a blitzkrieg with intellectual arguments” and called for “a total refusal…to implement the proposals for general practice budget holding and hospital opting out would negate much of the enterprise.” This was a call for insurrection. Lock ended by calling on doctors to speak with one voice, something that probably won’t happen until the Martians invade.

Another memory is of what I think was a clash with this clarion call, although I can’t quite remember the timing.

What I do remember is a meeting of the BMA Council where some members argued that the BMA should mute its opposition to NHS reforms until after a decision had been made on the annual increase in doctors’ pay. (This was ironic after Ken Clarke, the secretary of state for health, had been castigated for saying that whenever he met with doctors he reached for his wallet, echoing a predecessor Enoch Powell’s observation that he seemed to talk to doctors only about money not medicine or health.) One member said that to keep on protesting would be a “red rag to a bull.”

The debate was, however, splendidly ended by Chris Booth, the then president of the BMA, ignoring the protocol that presidents should stay out of politics and saying that it would be “a red rag to a cow” and that doctors should fight for their principles not their incomes.

A thoughtful piece on the BBC website by Dominic Sandbrook, a historian, says that much of what has been attributed to Thatcher probably would have happened anyway. Big forces, particularly globalisation and the end of belief in a planned economy, meant that Britain would have had to make many of the changes Thatcher instigated even if she had never existed.

I went recently to see The House, the play set in the whips’ offices in parliament from 1974 to 1979, and was reminded of the chaos of those years. Absorbed in finishing my degree, enjoying myself, and wrapped in the optimism and self absorption of youth, I’d somehow failed at the time to notice how bad things were. Jim Callaghan, the prime minister before Thatcher, advised young people to emigrate and the rubbish was piled in the streets.

Certainly attempts to reform the NHS continued after Thatcher. Labour when it eventually came to power in 1987 reversed some of Thatcher’s reforms, particularly GP fundholding, but soon returned to the path that she had set, only with more energy. Although opposed by the BMA, reforms in a similar vein have continued ever since.

Sandbrook, the historian who argues that much of what happened under Thatcher would have happened anyway, notes how she has become a huge symbol, inspiring “more songs, books, plays and films than any other British leader since Oliver Cromwell.” History may ultimately remember her, he suggests, for being a woman and, even though she despised feminism, illustrating the biggest development of the century, the changing role of women. This would be deliciously ironic.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Competing interest: RS has never voted Tory and probably never will.