This morning while “hanging out” in the offices of NHS England I was reminded of “the best book ever written about the politics of the NHS.” I was reminded of it because I bumped into Cyril Chantler, who first gave me a copy of the book; but I also found myself talking about it to my friend Harpreet Sood. So I’ve dug out my BMJ review and here it is. ( I recognise that posting this conflicts with the heading of these blogs, but what the hell.)
J Enoch Powell. A new look at medicine and politics: 1975 and after. Pitman Medical 1976. 2nd edition.
Cyril Chantler, one of Britain’s wisest doctors, likes to give people a photocopy of Enoch Powell’s book on medicine and politics and tell them that it’s the best thing ever written on the NHS. Younger readers may not have heard of Enoch Powell, but he was a Tory minister of health in the early 60s. He’s most famous for his racist “rivers of blood speech,” and I can remember protesting oustside his Belgravia home. Could he really have written the best book on the NHS?
I think that Cyril is right. One of Powell’s strengths is that he was a distinguished classicist and writes beautifully, with directness, clarity, and wit: it’s like reading Tacitus on the NHS. Another strength is his inability to dissimulate, the source of his catastrophic speech, his weakness as a politician, and his most famous observation that “all political careers end in failure.”
Powell addresses many topics that are as alive today as they were 50 years ago. Rationing has always been a difficult word for politicians to use and was banned outright during Tory rule from 1979 to 1997, but Powell regarded rationing as inevitable and wrote in 1966 “The task [of rationing] is not made easier by the political convention that the existence of any rationing at all must be strenuously denied.” He continues: “The worst kind of rationing is that which is unacknowledged; for it is the essence of a good rationing system to be intelligible and consciously accepted.” Powell would surely have welcomed the National Institute for Health and Clinical and Excellence (still known as NICE), not least because he despaired of limiting the “cascades of medicines pouring down British throats” when as a minister he was confronted by “an array of parties all severally interested in maximizing the value and volume of the drugs supplied.”
Another contemporary issue is whether the NHS can in some way be insulated from politics. Powell is clear that it’s impossible. “The plain rule is that wherever the taxpayers’ money is being spent, a minister must be held responsible for how it is spent.” He imagines how a member of parliament might respond to a constituent dissatisfied with the NHS if it was administered by a body like the BBC: “My dear Sir, I have no standing in this matter: you must complain to the Corporation, and if you do not like their answer I can only advise you to grin and bear it.”
Powell is strong on how doctors and politicians necessarily have different views of the world in that whereas “the politician practices the subordination of individual judgement, the doctor glories in the development and the exercise of it.” He makes his famous observation that “The unnerving discovery every Minister of Health makes at or near the outset of his term in office is that the only subject he is ever destined to discuss with the medical profession is money.” And he despairs that because the Treasury is the sole source of funds for the NHS those working in the service must constantly denigrate it in order to win more funds, which is why the BMA is known to some as the British Misery Association.
The book seems to be impossible to find. I was given a photocopy by Cyril, but you seem to be able to read much of it here: