One effect of the unprecedented socioeconomic impact of Covid-19 has been to catapult the secretary of state for health and social care to the forefront of British politics. For the long month of April, with the prime minister either in intensive care with the disease or recuperating in isolation, there was no one with a more prominent government profile than Matt Hancock. It was, to say the least, an unusual predicament for a health secretary. Since the controversy around the target of 100,000 daily coronavirus tests and Boris Johnson’s return to work, Hancock has taken a small step back from the limelight. But if, in the final analysis, he is adjudged to have had a good pandemic, he could well be seen as a leader in waiting. On the other hand, if the UK’s death count ends up the highest in Europe, as it currently stands, and the reports continue to mount of shortages in protective clothing and problems with testing and tracing, then history’s equivalent of a surgical waste bin may well await him. Glory or infamy – those are the grand stakes in this unparalleled peacetime civil operation. Yet any halfway ambitious politician would relish the chance to be in Hancock’s shoes right now. And it’s rare that that can be said about the occupant of his office. Come the casino hour of our parliamentary system – the cabinet reshuffle – very few politicians entering No 10 hope to be named health secretary. It’s a post with no visible upside. When anything goes wrong in health, someone usually dies. And things always go wrong. On top of which, the terrain is knee-deep in well-organised interest groups, all demanding more of everything. A widespread wariness about the job was most memorably captured in the response of the pugnacious Labour politician John Reid when appointed in 2003 by Tony Blair. “Oh fuck,” he’s supposed to have said, “not health.” Kenneth Clarke, who was health secretary in the last couple of years of Margaret Thatcher’s premiership, says that over the years he has issued a warning to various successors, both Labour and Conservative: “You’re going to a political graveyard. If you can survive it, then you’re ready, really ready, for the heat of frontline politics.” Clarke describes the role as one of constant bombardment, unrelenting demands to do what others say, ceaseless criticism in the press, from opposition and interest groups, repeated declarations of a crisis and almost universal unpopularity, including among your cabinet colleagues. It sounds, I say, like the job from hell. “I thought it was just immense fun,” says Clarke.
He’s not being ironic. He really did savour the challenge. The key thing, he says, is that you have to be prepared to “roll your sleeves up and defend yourself”. If that conjures up an image of the health secretary working in a bare-knuckle boxing ring rather than a government department, then Norman Fowler makes a similar observation. “In my day,” he says, “the most important quality [of a health secretary] was an ability to fight your corner in the public spending battles.” As a belligerent spirit was the signature style of the first modern health secretary, Aneurin Bevan, perhaps it should be no surprise that, like ministerial red boxes, it has become part of the job description. The machismo might explain why the health ministry has been largely a male preserve. There have only been three female health secretaries, beginning in 1974 with Barbara Castle, who, it must be said, was no shrinking violet. (Virginia Bottomley and Patricia Hewitt were approached for this piece, but both declined to speak.) Although there has been some kind of minister for health dating back to the mid-19th century, it was not until a hundred years later, and the arrival in 1945 of Bevan, that the role we recognise today first took shape. A former miner who left school at 13, Bevan was a renowned political bruiser who drove through the National Health Service Act with unyielding determination.
He had to overcome opposition from his own Labour benches as well as from within the Conservative party and the British Medical Association (BMA), whose members disparaged him as the “Tito of Tonypandy”. But facing down his opponents, Bevan created a free-at-the-point-of-delivery health service for all, one that opened its doors on 5 July 1948. By the time he died 12 years after the NHS’s birth, Bevan had become a national hero. That can’t be said of any of his often unloved successors, although each of them has played a part in developing an NHS that has grown far beyond what Bevan envisaged. “The budget was £200m the year Nye Bevan introduced the NHS,” says Alan Johnson, health secretary under Gordon Brown. “It was £110 bn when I left the job.”
It is currently £140bn. Even accounting for inflation, that’s an extraordinary increase; yet whatever the figure, it’s never enough. The NHS is the fifth-largest employer in the world. It’s a gargantuan operation that necessarily contains large inefficiencies and daunting shortages. But we pay less per head of population for our health system than any other major western nation. That’s one reason the NHS is perennially viewed as underfunded – even though health is about the only government department whose budget has never been cut. Nearly all governments are accused of shortchanging the NHS, but in particular Conservatives, who have traditionally been seen as, at best, reluctant supporters of the NHS, and more often as would-be privatisers. All the Conservative former health secretaries I spoke to think this accusation is unfair and inaccurate, and bemoan the fact that they had to spend rather too much time in office contesting a falsehood. Nonetheless, Margaret Thatcher was once keen to see the UK adopt a US-style private insurance-funded health service. And from time to time, a Conservative thinktank or backbench ideologue will revisit the proposal, to keep the dream alive. Fowler, who served as health secretary for six years under Thatcher, accepts these points. “But,” he protests, “the significant thing is that those ideas have never got anywhere. And if they didn’t get anywhere under Margaret Thatcher, they’re not likely to get anywhere under any other prime minister.” Matt Hancock’s immediate predecessor, Jeremy Hunt, complains that whatever he did in the job, he always faced the same charge of having a secret agenda. “I was accused of starving the NHS of funds as a way of persuading the public that the only option was privatisation,” he says. “I then secured a £20bn rise in budget and the very same people said on Twitter: ‘Ah, he’s fattening the NHS up for privatisation.’” In fact, Conservative spending on health was limited for most of Hunt’s time in office and during that of his predecessor, Andrew Lansley, at least by comparison with the boom times of the Labour governments of Tony Blair and Gordon Brown. In large part this was due to the austerity measures that the Coalition and Conservative governments imposed, following the 2008 financial crisis. Some critics have suggested that the shortfall in protective clothing for NHS staff witnessed in this pandemic is in part a legacy of underfunding during Hunt’s tenure. “I felt throughout my time as health secretary that it did need more resources,” Hunt concedes. “There is more you can do on efficiency, but in the end only so much, and it needed more resources.” In 2016, while Hunt was still in office, Exercise Cygnus was conducted to test how the UK would respond to a pandemic. According to leaked sections of the report, which has never been published, it was found that the country was not ready to cope, particularly in the area of social care. Hunt still maintains that austerity was the right policy to put the economy back on its feet, but he adds: “I don’t want to minimise the fact that this was a very tough period for the NHS.”
Hunt is now chair of the Health and Social Care select committee, in which position he has questioned some of Hancock’s decisions during the pandemic, such as prematurely discontinuing community testing. He’s reluctant to put Hancock on the spot, but says the key concern is to ask if we’re following the most effective international policy. “It’s been very clear that international best practice for managing coronavirus has been in Asia. I think because China’s totalitarian it was thought there was not much point looking too closely at what was happening there, because they can do things we could never do in a free society. But I think we could have looked at [South] Korea, Taiwan, Singapore, which are all democracies.” One fan of Hunt’s work on the health select committee is Alan Johnson. “I think he’s doing a great job as chair,” he says, which is probably not the verdict he would give on Hunt’s time in office. Like Hunt, Johnson emphasises the drive to improve patient care as his biggest motivating factor when he was health secretary. He therefore had little time for those who perceived any outsourcing of services as backdoor privatisation. “You talk to people on the left and the job of the NHS is to employ public service workers,” he says, shaking his head in our FaceTime call. “Not to improve disgraceful waiting times.” For all his modernising zeal, Johnson says the NHS’s greatest strength is its old-fashioned social solidarity, a quality, be argues, that Conservatives don’t really understand. “It’s against all the philosophy they’ve imbibed.” The irony, then, is that social solidarity has never been more loudly promoted among Tories than by this current government. The NHS has been rebranded “Our NHS”, its workers hailed as national heroes, invoked at every turn by politicians and applauded every Thursday evening by the public. Although the form of expression is new, the sentiment is not. The NHS invariably features at the top of the list of institutions of which Britons feel most proud. The problem for health secretaries is that this national pride can manifest as an over-protectiveness – “Hands off the NHS” – that leaves them limited room for manoeuvre.
As such, they often find themselves caught between contradictory instructions: improve the service and leave it alone. Fowler knows the syndrome well. “Put it this way,” he says, “one of the most serious bursts of applause I’ve ever had was when I was introduced at a conference of medical experts as the only secretary of state who didn’t try to reorganise the health service.” Clarke is less familiar with that kind of resounding applause. He embarked on a major overhaul of management, creating an internal market inspired in part, he says, by a need to head off Thatcher’s more radical proposals. It led to a series of massive rows between the prime minister and her health secretary. “Someone once told me we had 14 meetings about it,” he says, both amazed and amused by the number. “She was even more combative than I am. It was basically a bureaucratic shambles,” he says of the service he set about reforming, “as there was no proper management or control of the system.” In spite of his own restructuring of the NHS, which he says has stood the test of time because no one has reversed it, Clarke doesn’t think constant organisational reform is a good thing. “That must sound off coming from me. But you can’t have every secretary of state going in for an upheaval like that.” In a highly competitive field, perhaps the greatest upheaval was wrought by Andrew Lansley, David Cameron’s first health secretary. He is the exemplar of a longstanding NHS paradox – decentralisation from above. The more he argued for local empowerment, the more he micromanaged the transition, bolstering GPs, creating Public Health England, abolishing primary care trusts and much else besides. The consensus among his fellow health secretaries is that the reforms were misjudged, confusing and unnecessary. “I think Cameron thinks of [the Lansley reforms] as the biggest mistake he made,” says Johnson, cunningly recruiting the former prime minister to make his point. A little more diplomatically, Clarke says that he’s not convinced the reforms were “the main thing the health service needed”. Andy Burnham, who took over from Johnson and then shadowed Lansley, suggests that many of the changes have subsequently been abandoned or ignored. If reorganisational exhaustion in the wake of Lansley dampened the appetite for re-envisioning the NHS, Covid-19 has removed it from the agenda for the foreseeable future. For all its terrible toll of death and devastation, a major pandemic is a clarifying experience. Suddenly, discussions about rationalising regional management structures are beside the point. There is instead a unity of purpose and a galvanising sense of clear battle lines. It’s no coincidence that the most common political metaphors employed in the Covid-19 debate are military ones. Just as every defence secretary works to avoid war, but only really comes into his or her own when war breaks out, no health secretary wants a pandemic, and yet it’s their career-defining moment.
If Fowler is remembered by some clinicians for his executive light touch, he is better known for his performance during the Aids crisis in the mid-1980s. It’s easy to forget, amid the relentless news coverage of Covid-19, but HIV was a killer virus for which there was no treatment when it first came to light. It has since killed tens of millions around the world, though in the UK today, HIV is seldom fatal. Initially, it sparked enormous fear and stigmatisation, particularly of the gay community, which suffered a disproportionate number of deaths. But it was a period that Fowler looks back on with most professional and political satisfaction. “The whole health service worked together; no question, no arguments,” he says. “And when it acts together it really is a wonderful service.”
There is also another feature of pandemics that can bring the best out in politicians. As few, if any, health secretaries come from medical backgrounds, they usually find themselves deferring to clinical expertise. This is especially true in a pandemic. The difference is that the art of communication – the politician’s area of expertise – also becomes increasingly important. In Fowler’s case, he had the job of informing the public and reforming its behaviour – primarily, encouraging the use of condoms. Hence the government’s bold advertising campaign “Don’t Die of Ignorance”, which grabbed the nation’s anxious attention in 1987. “The campaign was criticised for being over the top, but the follow-up survey showed that over 90% of the public agreed with it,” says Fowler. He also had to do battle with Thatcher, and some of his cabinet colleagues, who were either squeamish or positively damning about issues of gay sexual practice and intravenous drug use – the main conduits of HIV transmission in this country. “I got totally frustrated in 1986,” he recalls. “It was a national crisis and I didn’t think we were making the progress we should be making in a national crisis. I remember being asked: ‘Do we have to have this section on risky sex?’ The whole point of the advertisement was to explain to people why they should avoid what they called risky sex!” Given the prime ministerial scrutiny he was under, I ask him whether it’s at all liberating for a health secretary if your boss is, as Johnson recently was, out of commission. “I never had that luxury,” he laments. “Theoretically, it’s not an ideal circumstance.” Fowler is not the only health secretary in living memory who faced a pandemic in office. “I was three days into the job when a global pandemic was declared with swine flu,” says Burnham, adding as a humorous aside: “As he exited the door, Mr Alan Johnson proved again that he’s a master of political timing.” Interestingly, Johnson recalls the pandemic as something that happened on his shift. “What took up most of my time?” he asks. “Well, there was the pandemic, of course.” In the event, regardless of who was in the hot seat, the H1N1 swine flu was not nearly as life-threatening as first feared. Some critics consequently suggested that the Labour government and the two health secretaries overreacted. But both men highlight the fact that a pandemic was top of the government risk register and they were well prepared to deal with it. Just as a flawed or under-resourced plan can leave a health secretary on the defensive, the more successful a strategy is, the less people get to see how bad things might have been. In a political sense it’s a lose-lose situation. “It was kind of a fraught terrain in those early days of swine flu,” remembers Burnham. “I made mistakes wrestling with these issues and sometimes came down on the wrong side.” He regrets putting the worst-case scenario statistics in the public domain – 60,000 deaths were predicted at the upper end, but there were actually fewer than 500. He also recalls a “car crash” TV interview with Andrew Castle, whose daughter had had a seriously adverse reaction to Tamiflu, the prophylactic issued to children. “I came away thinking, I’m not the person to be defending Tamiflu on national television,” he says.
His advice for Hancock is to resist the temptation to front the message too much on TV. Hunt, however, has only praise for what he says has been a strong communications campaign with a clear message – we spoke before the much-criticised change from “stay home” to “stay alert”. That said, he believes a longer-term strategy should be clearly outlined. “People need to understand how we’re going to exit the current situation.” Clarke picks out Hancock as a good performer among some less impressive government ministers, but he offers a word of caution directly to the young health secretary. “My advice to you will be, don’t start giving forecasts when we’re dealing with a total unknown here, and don’t start making forecasts on testing.” Several of the former health secretaries thought that Hancock made himself a hostage to fortune with his promise of reaching 100,000 coronavirus tests by the end of April. But all agree that it won’t be until an inquiry is held after the crisis has passed that any worthwhile or lasting judgments can be made on the government’s and Hancock’s handling of the pandemic. In the meantime, Burnham thinks the best thing to come out of the crisis is that the NHS will no longer be under any kind of existential threat, real or imagined. “Nobody will privatise it now; nobody will introduce different funding models. It’s finally entered into that sort of sacred space.” He argues that social care provision should be folded into the NHS. While he’s long supported this option, he says the case is irrefutable now the limitations of the social care system have been thoroughly exposed by Covid-19. “How can someone who is so essential that they are caring for another human being not be paid the living wage?” he asks. “It’s shameful.” There seems little doubt that social care is the neglected side of the portfolio in the Department of Health and Social Care, the unloved child forever in the shadow of its revered sibling. It would amount to a massive undertaking and significant investment to bring social care under the NHS umbrella. Whether or not it’s something Hancock will consider, it’s hard to believe that what Johnson calls the “scandalous crisis in adult social care” can be allowed to continue after the viral dust has settled. There have been no shortage of predictions – some wildly optimistic, others darkly ominous – about the post-Covid-19 world. The first task, obviously, is to make it a post-Covid-19 world, and in that endeavour the health secretary has a vital role to play. It’s far too early to know what the outcome will look like, or when it will arrive, but perhaps we can tentatively suggest that in the next cabinet reshuffle the word on the health job won’t be a four-letter one. In brief: how was it for them? Norman Fowler, Conservative, in post 1981–1987
Key issue How to mount an Aids public awareness campaign. Initial view of the post? “I knew all the problems. [But] it was not at all clear where the political advantages were.” Most satisfying aspect of the job? “It goes back to Aids again. With something like the virus, you know more than your medical experts about how to communicate to the public.” Greatest strength of the NHS? “It’s an institution that is valued and recognised by the vast majority of the public.” Greatest weakness? “It tends to be a bit of a political football.” Do you think public health workers are adequately rewarded? “You could make a very strong case for looking at all this again, particularly with nurses, who have been working, at times, at peril.” Kenneth Clarke, Conservative, in post 1988–1990
Key issue How to reform the NHS without adopting an American system. Advice he was given? “You’ve got to find a concession to give the BMA at least once a year.” His own advice? “The aim of any decent department minister is to get the prime minister to take as little interest in the subject as possible.” Most satisfying aspect of the job? “Knowing that you’re trying to make a difference to something that is vitally important – the wellbeing of the country.” Do you think public health workers are adequately rewarded? “Yes, though it’s gone up and down over the years. They’re much better paid now than they were in my time.” Alan Johnson, Labour, in post 2007–2009
Key issue “We had a bad deal with the drug companies that was supposed to last for six years. I pulled it and went through the whole process again to get a better deal on drugs.” Most satisfying aspect of the job? “The feeling that you were in a small way part of something so crucial to people’s lives. That was a privilege.” On Matt Hancock’s performance: “I’m not really impressed. I don’t think Matt Hancock’s as good as he thinks he is.” Do you think public health workers are adequately rewarded? “By the time we left office they were a lot more adequately rewarded than they had been. But it’s slipped back again; so no, I don’t think they’re adequately rewarded.” Andy Burnham, Labour, in post 2009–2010
Key issue Organising the response to the H1N1 swine flu pandemic. Most satisfying aspect of the job? “There was an independent review that said the response to the swine flu was highly satisfactory.” What did you find difficult about the job? “I inherited stuff I never felt comfortable with. I would point to the use of the private sector. I was never an advocate of that.” Do you have sympathy for Matt Hancock? “I thought it was awful when one of the newspapers had a Number 10 briefing against him. That was a cruel moment. I think he needs to be given the benefit of the doubt. It’s a tough gig and he’s made some obvious mistakes, but given the severity of what he’s been dealing with, he’s not doing badly.” Do you think public health workers are adequately rewarded? “Let me talk about social care workers: 58% of carers, the majority of whom are women, do not receive a real living wage. That’s disgraceful.” Jeremy Hunt, Conservative, in post 2012-2018
Key issue The imposition of new contracts for junior doctors which led to prolonged strike action. Most satisfying aspect of the job? “My greatest satisfaction was in some of the interactions I had with patients and families who had really suffered badly as a result of something going wrong. They were people actually who kept me going for nearly six years.” Biggest surprise? “I found out that 150 people a week die in the NHS because of errors in their medical treatment. I was gobsmacked by that. Then I discovered this was actually true all over the world; this is what happens in medicine.” Have you ever been interested in privatising the NHS? “I’ve always been a passionate believer in the NHS. There’s something about what the NHS stands for which speaks to the best of British values.” Do you think this pandemic calls for the help of former health secretaries? “I think there’s a role for people outside politics to come in in moments of national crisis. There are times when you need people who can – to use that horrible business phrase – JFDI things.”