Observations Back to the Future

Memories of Thatcher

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2434 (Published 17 April 2013) Cite this as: BMJ 2013;346:f2434
  1. Richard Smith, director, UnitedHealth Group chronic disease initiative, and editor of BMJ until 2004
  1. richardswsmith{at}yahoo.co.uk

A former BMJ editor reflects on what Margaret Thatcher’s years as prime minister meant for medicine and healthcare

My early years at the BMJ were 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. 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. 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. This 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 to reduce 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. 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 clear, but again it was of no interest to Thatcher and her government.

Thatcher was leader of the most radical right wing British government of the 20th century, but, in contrast with what has followed (and what may be to come), she largely stayed away from the NHS, recognising the public’s deep affection for it. 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. The 1989 editorial by Lock called “Steaming through the NHS” (BMJ 1989;298:619) 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 was 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,” as Lock described it. “The aim,” he continued, “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 changes to the NHS 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.”

I was caught up in all this rhetoric. The Millbank Quarterly asked me 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 seem that radical, they did sow the seeds of further changes: the rise of management and the introduction of market mechanisms. 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,” as this “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.

A thoughtful piece on the BBC website by the historian Dominic Sandbrook says that much of what has been attributed to Thatcher probably would have happened anyway (www.bbc.co.uk/news/magazine-22076886). 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 had she never existed.

Certainly attempts to reorganise the NHS continued after Thatcher. Labour, when it eventually came to power in 1997, reversed some of Thatcher’s changes, 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.


Cite this as: BMJ 2013;346:f2434


  • Competing interests: RS has never voted Tory and probably never will.

  • This is an edited version of an article that was originally published as a BMJ blog. To read the full blog, together with archive links, go to blogs.bmj.com.

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