Margaret Thatcher, preserver of the NHS. Yes, really

Spitting Image Margaret Thatcher
(Fairly) safe in her hands: a Margaret Thatcher Spitting Image puppet in Grantham Museum. © Copyright Richard Croft. Licensed for reuse under a Creative Commons Licence.

Today sees the funeral of Baroness Thatcher, the prime minister who saved/crippled Britain, giving new hope to/tearing the soul out of its communities and reforming/undermining the public sphere, delete according to preference.

But it’s more complicated than that. If it wasn’t, the NHS would not have survived her leadership in its current form. It turns out that, when Margaret Thatcher said “the NHS is safe in our hands”, she was pretty much right. She changed it, but not nearly as much as you would have expected.

If we had been run by Spitting Image’s rubber suit-wearing puppet for 11 years, ‘free at the point of use’ would surely have gone or been greatly weakened. Spitting Image Thatcher would have introduced means-tested ‘hotel’ charges for overnight hospital stays, co-payments for operations and fees for visiting a GP, along with a massive expansion of private healthcare. This would have moved the UK’s healthcare system towards the state-supported but not run insurance models of continental Europe (although it would not have been sold that way). Perhaps some hospitals would have been privatised.

And it might well have been accepted. New, detailed research by the King’s Fund reveals that opposition to NHS charges is strong, but by no means absolute. People say they are against in general, but then express support the likes of charges for better accommodation, for work that is not clinically necessary or for the rich. Margaret Thatcher could have made some of this happen, but didn’t.

The one significant thing Margaret Thatcher did to the NHS was to introduce the internal market purchaser/provider split, as well as hive off social care, near the end of her leadership in the NHS and Community Care Act 1990. The internal market has been weakened and rebuilt several times over the intervening three decades, but is now firmly in place in England (clinical commissioning groups purchase, hospitals and the like provide). While there is much debate over its value or lack of it, it has proven possible to reverse – Scotland and Wales have done so – and it leaves the NHS’s core free use principle intact.

Margaret Thatcher’s leadership was more complicated than it seemed, with contradictions on many issues. On public health, her government ran the terrifying AIDS Tombstone advert, which carried an appropriately powerful message about a powerful threat – but also the antithesis of leaving individuals to their fate. She was a fighter for liberty – unless you were a football fan who was would have been forced to obtain an identity card to see league games, under legislation passed in 1989 but never implemented. (Described in depth in this free PDF sample of my book on ID cards, Card declined.) She got British money back from Europe – and authorised the channel tunnel and the single market. An editorial in the latest issue of French news magazine Le Point quite seriously asks if “la Dame de fer” should be seen as one of the “pères fondateurs de l’Europe”.

If Baroness Thatcher had been the absolutist leader she is presented as having been (partly by herself), we would now be worrying about whether our insurance would cover our hip replacement at BGT Capital Healthilife plc (formerly Barts, Guy’s and St Thomas’ hospitals, but the branding consultants thought that saints’ names and the word ‘hospital’ had the wrong connotations). But while the privatisations she championed moved whole sectors of the economy from the public to the private sector, they hardly touched the health service. Even in England, the NHS remains free at the point of use for all the big things, is still mostly owned and run by the state and performs the vast majority of healthcare work. In Scotland and Wales, the qualifications in the last sentence were almost entirely removed after devolution, despite 18 years of government by Mrs Thatcher and John Major.

Margaret Thatcher’s NHS legacy is that she didn’t change it very much.

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