NHS60: 'It was the toughest two years of my life'

Fascinating, fulfilling and worthwhile. Many agree that being secretary of state for health is one of the biggest - and most difficult - jobs in government. With so much at stake it is characterised by battles with the prime minister (particularly Margaret Thatcher) and the ever-present influence of organisations such as the British Medical Association. But past incumbents largely look back with pride, as reforms introduced as far back as the 1980s continue to shape policy and old foes forget their grievances. As Alan Milburn observes: "They all love you when you're dead."

Norman Fowler- September 1981 to June 1987

Norman Fowler was social services secretary, running the gargantuan Department of Health and Social Security during six of the most turbulent years of Margaret Thatcher's premiership. Assailed from the right by colleagues who thought the NHS a costly folly and from the left by opponents convinced the government wanted to privatise it, he recollects: "We forget just how hysterical the health service debate was in the 1980s. Whatever you did, there was a massive row about it."

He says his key to survival was to build the best possible team.

"It sounds obvious but it's not what every secretary of state did. Some didn't want the best ministers around them because they felt it might detract from their star quality. The one thing I did insist on with Margaret Thatcher was that I should pick my own people."

Among his team were future prime minister John Major, future health secretary Kenneth Clarke and health minister Edwina Currie.

Lord Fowler says heading such a vast and diverse department meant he avoided getting stale and enjoyed significant fire-power in the cabinet, although he would have preferred not to have been in the same job for so long.

Mrs Thatcher regarded him as "a good defensive player" but not one to transform the NHS. "I believed in evolution," explains Lord Fowler, who says that behind the scenes he repeatedly opposed "batty" alternative funding proposals.

"Those putting forward these ideas had no concept of the upheaval involved and the politics would have been totally disastrous. People didn't want a privatised health service."

His long service at the DHSS was invaluable in launching the groundbreaking AIDS awareness campaign of 1986.

"If I'd been new I wouldn't remotely have been able to spend the time I did on it." Initially planned as conventional public health advertising "with dense text", even this took months to get past ministers.

Only after persuading Mrs Thatcher to "stand to one side" and let a cabinet committee take charge did policy develop. "We made more and quicker progress on that issue than any other issue I can remember in government," he says.

Kenneth Clarke - July 1988 to November 1990

Kenneth Clarke became health secretary in the middle of Mrs Thatcher's NHS review, when she decided to split health and social security into two separate departments. The review - prompted by a funding crisis and conducted behind closed doors - contemplated replacing the NHS with private medical insurance.

Mr Clarke had previously been health minister for three years until 1985.

"I was rather surprised to be given the post of secretary of state because she must have realised I was a supporter of the NHS as it stood and I didn't think it was a department to which Margaret was likely to return me. She thought the NHS should be a service of last resort for people who couldn't afford to insure themselves. I was strongly opposed to that."

The review of the service, says Mr Clarke, "had really got nowhere in particular" other than to suggest tax relief for those taking out private insurance, an idea the then chancellor Nigel Lawson was resisting. Mr Clarke set about reviving proposals for a purchaser-provider divide that had been looked at but had not progressed.

"The department wasn't at all keen on reforming. It wanted a quiet life with a minimum of trouble from the trade unions. It thought there was nothing wrong except we'd got to do better in next year's public spending round. I remember the permanent secretary explaining to me he couldn't spare any staff to help me on the review.

"I left the Department of Health as I arrived – wondering what on earth these 6,000 people I supposedly employed were doing. It took quite a struggle to get a team together that I wanted."

The work meant making regular progress reports to Mrs Thatcher, with the chancellor and the then Treasury chief secretary John Major.

"These were ferocious meetings. This was Margaret's way of working. It was very good if you could stand the hassle. She'd challenge everything you said. It made you do the work and go away and think.

"Early on I tried to bury her under detail, which was a complete waste of time. All she wanted was more detail. You could deliver it late the night before and she'd have read it by next morning and be ready to continue the battle.

"We had lots of these meetings, tortuously thrashing out the details and getting them into the shape she wanted. We all enjoyed a good row."

Eventually a paper was put to the cabinet. "People think Margaret's cabinet was like Spitting Image, but she usually ran genuine cabinet government. We could sometimes have long policy discussions. But one of her classic techniques worked: instead of letting me present my paper, which she should have done, she presented it herself from the chair. She went through it and made it clear she agreed with it. Frankly, she bounced it through. Here was this fundamental reform of the NHS, which the present government is still having difficulty completing and getting right, which went through with five minutes' discussion."

The subsequent white paper, Working for Patients, was launched amid "very daring and slightly off the wall PR razzmatazz", with TV presenters hosting simultaneous video-linked roadshows. "I've still got the souvenir photographs. It looks very corny now."

Exhausted, the next day Mr Clarke went to a cricket match at Lord's, only to be summoned to take a phone call from Mrs Thatcher congratulating him on her perceived triumph of the white paper's launch, which had got a good press. "I told her all hell would let loose and not to be deceived by the first 24 hours. I warned her the BMA would go berserk and they did."

Almost 20 years later, Mr Clarke says that the present government "is following exactly the same principles as I did".

"They've gone much further than I could possibly have contemplated, using the private sector. I envy their freedom of action because they haven't got a political opposition. I had one for whom this was the biggest topic."

He now deplores the "explosion of staffing and pay, reduced workloads and contractual obligations and declining productivity" in today's NHS, noting that "ministers left to themselves tend to want a quiet life on the industrial relations front". The service's "huge surge" in spending was "very badly planned".

But the NHS has, he says, "improved in every way and always has ever since 1948, not least because of clinical advance but also because it's always had ever more resources put into it. Most citizens' experience of the NHS varies from good to excellent."

Virginia Bottomley - April 1992 to July 1995

Becoming health secretary after three years as a health minister realised a long-held ambition for Virginia Bottomley. "Until I die I'm sure this will be the job that has most marked my career," she says.

Educated in the social sciences, Ms Bottomley had been a social worker and Lambeth magistrate before entering the Commons. She felt ideally suited to a role she found "with all its pressures, totally absorbing; completely fascinating, fulfilling, demanding and worthwhile".

Her unusual pedigree for a Conservative MP gave her a different outlook from most of her party colleagues, "those who used the Thatcherite language of the market to antagonise the old Fabians". Many felt she was "too much of a Guardian woman for their liking".

Ms Bottomley pushed through a public health white paper, The Health of the Nation. "I had a fearful battle and was nearly kneecapped by all my colleagues, who hated it. They were constantly calling me 'Nanny Bottomley' but I'm quite stoical and resilient."

Regarding the job as custodial, not party political, she tried to recruit as her special adviser Philip (now Lord) Hunt, then director of the NHS Confederation; he later became a Labour health minister.

After the 1992 general election the heat had been taken out of the reforms as a political issue and her main role was to bed them in. "In politics you sometimes want a window-breaker and sometimes a glazier. Ken Clarke was definitely a window-breaker and I'm much more a glazier."

She remembers the BMA giving her a standing ovation, such was her commitment to cutting junior doctors' hours. "I thought – rather vainly – 'perhaps this will be in the newspaper'. But it wasn't because I was naive about how the press operates. I never rang journalists, ever. In today's age of spin, that's extraordinary."

Her style was "earnest", she says. "I laugh at myself looking back now. I was always criticised for using too many statistics. Now brilliant politicians are people who paint big pictures and I don't think I'm good at that. Having that lightness of touch is a skill I certainly don't have and I rate it a lot."

Stephen Dorrell - July 1995 to May 1997

"If you take office for the last two years of an 18-year spell, the chances of your leaving great monuments are relatively remote," says Stephen Dorrell, who was health secretary in the last days of John Major's government.

He says: "By 1995 most of the heavy lifting had been done. I'd like to think in my time we gave the reform programme a chance to breathe. We drew some of the political venom out of the argument."

And despite lingering opposition "there was a developing willingness to see the point of what we were trying to do. People were relatively weary of the arguments of principle and more interested in making it work. I tried to focus on solving practical problems rather than having great ideological debates."

In fact, Mr Dorrell achieved surprising consensus. His white paper, A Service with Ambitions, can be seen as the precursor of much Labour health policy, and his Primary Care Act was passed with all-party support. Some colleagues questioned why the Conservative government was "giving political oxygen" to the NHS so near to what was clearly going to be a difficult election.

Drawing up the white paper, Mr Dorrell says he gathered senior managers and told them: "'You'll never get me to say this on a public platform but you'll be thinking about how you're going to live under a change of government. I can't be part of that process, but the reality is there's a shared agenda between myself and most Labour health ministers, in particular about pathways of care and focusing on responsiveness to patients.' I told them this was their opportunity to put their priorities on paper.

"There's very little that comes out of the DH now that couldn't – with some changes – be reconciled with what we were doing in the mid to late 1990s."

He sees "big improvements" in today's NHS but bemoans the "over-centralising managerial dead ends" represented by too many targets and too little respect for healthcare professionals.

"If we'd followed through the consensus that was emerging I think we'd have made a lot more progress in the last 11 years with the money that was provided."

Alan Milburn - October 1999 to June 2003

Ask current senior NHS managers to name their top three health secretaries and Alan Milburn is nearly always among them.

Mr Milburn himself laughs at this. "They all love you when you're dead," he jokes. "That's not my memory of how it was but it is very nice people feel like that."

He came to the job of secretary of state for health from the Treasury in October 1999, having previously been a health minister for a year under Frank Dobson. Almost immediately he ran into one of the worst winters the NHS had experienced. Trolleys were stacked up in accident departments and the press was full of pictures of the patients on them.

"It was a dreadful winter, one of the worst on record," he recalls. "It was tough for the health service and tough politically. Getting through that was one of the most difficult times."

The 2000 NHS Plan was already being worked on and it fell to Mr Milburn to implement it."That was the second most difficult period: pushing through some of the reforms that are now broadly accepted as the right direction of travel."

He did it by setting himself up as the patient's champion. "My number one job as secretary of state was to look after the NHS patient," he says. He remains convinced the NHS Plan set the health service in the right direction.

"We redesigned the health service around the needs of patients. I am very proud of that and very pleased with the progress that's been made on a lot of the changes I was responsible for."

He lists these as choice, standards and inspection regimes, the creation of foundation trusts and primary care trusts and introducing diversity in provision.

"These are all now part of the accepted architecture of the modern health service."

Mr Milburn is sometimes accused of "throwing mud at the walls in hope that some of it would stick" rather than having an overall strategy in place.

He admits the NHS has been through a period of unprecedented change in the last 20-30 years, which certainly accelerated in the last 10 years. But a lack of overall strategy? No.

"When I became secretary of state, there were lots of good things about the NHS but lots of things wrong as well, such as a lack of responsiveness and poor waiting times. People often look for a magic silver bullet but the truth is that in an organisation as large and complex as the NHS you have to fire a lot of bullets.

"You have to have national standards, local autonomy, inspection, a system of rewards and incentives for individual members of staff and organisations. Then you get some progress."

And there has been progress, he emphasises.

"I think back 10 years and what was then regarded as the core problem in the NHS was a woeful infrastructure and capacity, leading to long waiting times. It's not been solved completely but we are in a different position and that's as much about reform as investment."

Mr Milburn remains the politician and won't admit to difficult relationships with any of the key players with whom he engaged. He prefers to accentuate the positive.

"The joy of being health secretary is you meet [such a] wonderful and diverse range of committed people who want to make the system work."

He attributes some of his reforms to these meetings. "The idea for foundation trusts basically came from discussions with NHS managers from some of the best organisations in the country."

His only reservation today is whether the NHS will finish its journey.

"I talk to people in the NHS almost on a daily basis and [the NHS Plan] is still regarded as the bedrock of what people are trying to do. The NHS is on a journey. It was a 10-year plan and we are broadly making progress in the right direction. The question now is whether the journey will be completed or truncated. There is, in my view, no third way."

Patricia Hewitt - May 2005 to June 2007

Patricia Hewitt is remarkably frank about her time as secretary of state for health.

"It was the toughest two years of my life but it was also the most rewarding."

Perhaps that is no big surprise. Ms Hewitt arrived in post a few weeks before news of the NHS deficit broke and forced the health service to address this in a period she acknowledges was "incredibly difficult and painful" for everyone.

And although she successfully wooed doctors at the 2006 BMA conference, she was booed at the Royal College of Nursing congress, a first for a Labour health secretary.

Ms Hewitt also oversaw the legislation that banned smoking in public places."That is the really big change that is already making more difference to people's health, as distinct from how we look after them when they are ill, than anything in the last decade."

She adds: "It's one of those areas where you really have to think through how you reconcile individual freedom with protecting people, especially for a government that's always being taunted with being the nanny state."

But she admits that what really made her time in the post so difficult were the NHS's financial problems. "Everybody was shocked that, given the tens of billions of pounds we had invested, it could end up with a deficit."

It was not so much the size of the deficit – which compared to the overall NHS budget was small – but the fact that it was doubling every year. There were several underlying problems contributing to this, says Ms Hewitt, the biggest of which was a culture in which the NHS was said to be dealing with life and death and therefore money did not matter.

"I was constantly being criticised for putting money before patients," she says. "What I kept trying to say to people was that it was because the NHS deals with life or death we have to get the money right. Every penny being wasted is a penny being denied to a patient who needs care."

She felt the old NHS system of balancing the books by taking away from those that had made a surplus to pay off the debts of those with a deficit was grossly unfair and no incentive to improve.

And the fact that the NHS was wasting vast sums was apparent in the wide variation in performance that, thanks to Alan Milburn's reforms, was becoming transparent. "There was no longer any hiding place for poor performance," she says. "But I never had any doubt that it had to be done."

"Now I have heard so many people say 'God, it was tough but now we have freedom and can do what we want to do'."

Ms Hewitt also admits to one major regret. "The mistake we made with Commissioning a Patient-led NHS in creating terrible uncertainty for health visitors, district nurses and primary care trust staff."

Commissioning a Patient-led NHS, concerned with realigning PCTs so that they could become efficient commissioners, came out in July 2005. Meanwhile the DH's commercial directorate issued a tender document which seemed to open the way for tendering all PCT provider functions.

There are various versions of these events and here is Ms Hewitt's: "My focus had simply been the issue of the PCTs," she says. "It was very clear we needed to allow at least some of them to merge and I was clear this should be a genuinely bottom-up process.

"While I was focused on that, the department had been pursuing the idea of a complete separation of the purchaser-provider roles, which understandably caused immense distress. When I realised what was going on I just stopped it."

Her excuse? "That's one of those mistakes you can make when you are very new as a minister, and we had to spend several months unwinding that and reassuring people they were not going to be cast off."

The separation of purchaser and provider remains a live issue and Ms Hewitt's feeling is that it will evolve according to local need.

"But I think [current NHS chief executive] David Nicholson is absolutely committed to what we were trying to do to devolve power to the service within a framework that puts the focus on the patient. And I am confident the Darzi review will take that forward."

She also dismisses as "absurd rhetoric" accusations of privatising the NHS by bringing in the independent sector. Patients want choice and trusts respond by upping their game, she says.

Ms Hewitt was not a popular health secretary but has been praised for improving policy making and engaging professions in the reform process.

"I think it is true I spent more time than any health secretary for a long time just listening to staff and engaging with the professions," she says.

"I feel very lucky to have had the chance to do the job."