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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 November 24; 335(7629): 1100.
PMCID: PMC2094151
Review of the Week

When Blair went to market

Reviewed by Tony Delamothe, deputy editor, BMJ

Blair's Damascene conversion to market forces was one of the many differences he had with Gordon Brown, a new television series has shown. Where does that leave the NHS under Blair's rival, asks Tony Delamothe

Explicitly about the relationship between former prime minister Tony Blair and his chancellor, Gordon Brown, this programme provided an interesting insight into some of the key moments of the Blair government's relationship with the NHS. It also gave some hints as to what to expect from the Brown government.

First off was Blair bouncing Brown into providing five years of 5% annual increases in the NHS budget, which would bring UK spending up to the European average. Blair chose Sir David Frost's television programme for his momentous announcement one Sunday morning in January 2000. Minutes after the programme “Number 10 hit the phones.” It being a Sunday, all the facts and figures were locked up in Whitehall offices. About the time the Department of Health's chief economist had made the figures add up (using the sophisticated calculator of his daughter's boyfriend) it dawned on Blair's advisers that Blair had not told his chancellor about the biggest spending announcement they would ever make.

Even this early in his government there was a hint that Blair had to resort to guerrilla tactics to achieve what he wanted in the face of Brown's implacability. Insiders commented: “Gordon Brown saw himself as the senior partner” . . . “For much of his time [Blair] couldn't get his way.” Already by then Frank Field, Blair's new broom in pensions, had been dropped: “Gordon was adamant that nothing was going to happen.” Whenever money was involved, the question of who was really boss was never properly resolved, and even led to an abortive plan to drop Brown early in the government's third term.

Bitter divisions surfaced between Blair and Brown over how to reform health and education. True to form, both men wanted to do it their own—different—way. Before the 1997 election, Blair had anathematised the use of markets to improve public services: “First of all we'll get rid of that Conservative internal market that has caused so much damage in the National Health Service. We've had enough of running it like a supermarket—it's not a supermarket, it's a public service.”

But within a few years, Blair underwent a Damascene conversion, the reasons for which we'll presumably have to await publication of his diaries. He became convinced that hospitals and schools needed market incentives to improve: “A quasi-market situation, where you can contest the service or the consumers get greater choice, injects this greater sense of dynamism. Contestability, competition—it's basically breaking down the monolith of the old public services.”

Brown's response to this distinctly non-Labour view was to emphasise the limits and failures of markets. “Our clear and robust defence of markets must be combined with a clear and robust recognition of their limits. In health, not only is the consumer not sovereign, but a free market in health care will not produce the most efficient price for its services, so that many market failures in health, if taken individually, challenge the adequacy of markets to provide efficient market solutions.”

Blair and his then health secretary, Alan Milburn, were pushing for foundation hospitals, with freed up management and financial controls. Brown's response was a 50 page memorandum setting out his objections to their proposed financial regime. This time, presumably the option of announcing it as a fait accompli on Frost was out, and a compromise was thrashed out.

At the time when he might have handed the premiership to Brown, he decided he needed to stick around to carry his domestic reforms through. “There were certain things I wanted to get absolutely secure and bolted down before I left.”

How insecure and unbolted down they were became apparent in the week the programme was broadcast. Not five months after Blair handed over to Brown, the government announced that one of its main routes to inject contestability and competition into the NHS has been cut by two thirds (see News, doi: 10.1136/bmj.39405.462431.94). Can a politician really believe that something can be set so firmly in stone that a successor can't dynamite it at will?

Ultimately, “What you owe people is your conviction: you owe them the duty to do what you believe to be right.” Not necessarily “be right,” Blair was at pains to explain, just to do what you believe to be right. He said this in the programme in the context of his public service reforms but he's said it before regarding his decision to go to war in Iraq. It begs the question: are strong convictions enough for a politician? Do we elect them just to visit their convictions on us? I can envisage what conviction based medicine would look like, and it's not a pretty sight.


The Blair Years: Blair and Brown (episode 1)

BBC 1, 18 November at 9 pm

Rating: ****

Articles from The BMJ are provided here courtesy of BMJ Publishing Group