by Gordon Brown
Advancing his thesis of prime-ministerial government in his book The British Cabinet, John Mackintosh made the point that the prime minister’s powers of patronage – his right to select ministers, advisers and officials – made his appointees far more dependent on him than ever he was on them. But Mackintosh was writing in the 1960s. Since then, the transformation of the media and public perceptions has magnified the role and personality of the prime minister as the public face of the government. This is even more true (as we shall see at the end of the next chapter) when it comes to foreign affairs where, in a departure from past practice, prime ministers are now in regular contact with their counterparts around the world.
Unlike the American president, Britain’s prime minister is not directly elected and is certainly not the head of state. Nonetheless, the prime minister is now defined by their relationship with the public via the media rather than with Cabinet. Every day, twice a day, my spokesperson met the press and had to be ready not only to respond to every passing issue of the moment but also to convey my personal view of it. I had considered ways round this, such as the idea of sharing the role of spokesperson among a group of ministers on rotation and having them make their press briefings to camera rather than in a closed room full of journalists. Certainly it would have been considered a dereliction of duty on the part of the prime minister if at any point their spokesperson was unavailable to speak and answer questions for the government. A restoration of what we traditionally thought of as Cabinet government was simply not possible when the engrained expectation was for the prime minister’s office to answer instantaneously the media’s questions on any remotely important government action.
Our politics needs collective decision-making and, as I have suggested, no leader can succeed without an expert and committed team working alongside them. But no Cabinet – not even one sitting in permanent session – could keep up with the demands for such instant responses. Instead, the process of government came to rely even more on a close-knit team at the centre. Even if Cabinet was supposed to be the sole inner circle of decision-makers, there came to be another inner circle. Our critics referred to them as ‘courtiers’, a ‘cabal’, a ‘clique’, but someone had to deal with the stream of issues that constantly arrived on the prime minister’s desk every day. Formally these advisers – who were, in the main, young, up-and-coming and very bright experts in their own right – may have had no power to make decisions but in practice they became among Britain’s most important decision-makers. Indeed, much of what the Cabinet now does according to textbook constitutional theory is, in practice, done by these advisers acting as a kind of unelected Cabinet.
It was not, I found, a good system for governing, nor is it one that will endure without mounting criticism. The problem lies in the lack of accountability. Tony’s solution was to use so-called Orders in Council to formally empower his top two advisers, but while this legitimised their decision-making power it did not make them any more accountable. We can, and perhaps should, devise rules that hold all those who take decisions to account. In my three years in No. 10 I tried, with varying degrees of success, to ensure greater ministerial control over the decision-making process. In May 2007, and later again in November, I asked Ed Balls to be minister in charge of No. 10 and the Cabinet Office, but understandably he preferred to be a departmental minister in his own right and I felt it wrong to deny him that chance. He was probably right to refuse: whoever I brought into that job would, I knew, be constantly accused of being an unelected second prime minister. But without more ministerial oversight than a prime minister or a junior minister or two can provide, government with advisers can all too easily become government by advisers, and even government for advisers. As the complexity and scale of government grows ever greater, the legitimate demands for accountability mean we will have to find new ways – a reorganisation of No. 10, reform of the Cabinet Office, a better system for appointing ministers and stronger parliamentary scrutiny – both to manage this century’s new inner circle of decision-makers and to hold it to account.
CHAPTER 12
2008: REFORM BEFORE THE STORM
2008 was to bring the global financial storm, but in advance I had marked it out as the year of reform. I chose New Year’s Day to make my first visit of 2008 – to Wexham Hospital in Slough – where I announced we would celebrate the sixtieth anniversary of the NHS by rebuilding it for the next sixty years. The NHS, I said, was not just a public service but a personal service. It was, and would remain, universal, but it could not be one-size-fits-all. Patients should be able to choose not only their doctor: they should have in their own hands a far wider range of choices about how, where and when they were treated. Health was on the agenda again. Then, unexpectedly on 2 January, a fire broke out at the Royal Marsden Hospital in London, a leading cancer treatment centre, destroying half of the roof. The next day, I spent time with patients who had been evacuated to nearby Royal Brompton Hospital and met fire officers at Chelsea Fire Station.
The following week, in a speech at the Florence Nightingale School of Nursing at King’s College London, I set out what I saw as a consistent theme for the year: we could not rest on the advances made since 1997 but needed to drive a new agenda of personalisation in the delivery of public services. If the challenge since 1997 had been increasing capacity, the challenge now was improving quality. Instead of what were all too often run-of-the-mill public services – what some called ‘bog standard’ – impersonally delivered, I wanted all public services – the NHS, schooling, policing, welfare and housing – tailored to individual need, quick to respond, more professional in delivery, with, at all times, the focus on the requirements of those we served.
The priority of personalisation – as opposed to privatisation – was bound to be less exciting for the media, but I felt sure that public servants, most of whom were motivated to join up because they wanted to make a difference, would respond to this new agenda. It was radical because we were challenging the view that you had to go private if you wanted personal attention focused on your particular needs, with hands-on service tailored to your own individualised requirements.
In education, in particular, I was trying to find a way to ensure that the 93 per cent of children who were in state schools could enjoy the same educational advantages as the 7 per cent whose parents paid for schooling in the independent sector; and to do so without necessitating a huge increase in public spending. Our reforms to schools would include more emphasis on tutoring, mentoring and personalised learning. In housing, we would widen the range of individual choices available for buying, like shared equity mortgages, and offer new opportunities for those renting. In welfare – especially for the disabled – the emphasis would now be on the capabilities of the individual and the potential of each claimant. In policing, the general public, including victims of crime, would have more say in how policing and justice were carried out.
The agenda came alive in what we planned for health. In my January speech, I said the NHS had to be equipped to meet the higher individual expectations of the patient. With patients living longer, end-of-life care in need of expansion and higher expectations all round on the quality of care provided, we had to show how we could combine health and social care in a way that offered a service best suited to patients’ needs – whether it be home help once a week or twenty-four hours a day bedside care in a hospital. By giving greater attention to an individual’s diet, nutrition, exercise and habits like smoking and drinking, we could do more to prevent people from getting sick, rather than just treating them when they fell ill. And what seemed medical miracles accessible to only a few today should become medically routine and available to all who needed them tomorrow. Cutting-edge technologies, techniques from genetics to stem-cell therapy and life-saving drugs to prevent, alleviate or cure conditions like Alzheimer’s – which no one but the very wealthy could afford – reinforced the case for the insurance-based, tax-funded service we had.
Alan
Johnson and his deputy Ara Darzi proved effective partners in delivering health reform. My personal relationship with Ara got off to an unexpected start just before I became prime minister. One of his friends was my parliamentary private secretary, Ann Keen, a former nurse who as nursing minister chaired an excellent review of the profession. She told him of a cyst I had complained about on my back. Because I did not want questions to be asked about my health in the months leading up to entering No. 10, I wanted his confidential advice on what needed to be done. If the cyst was cancerous, I would of course have had to deal with it in a way that would become public. In any event, Ara agreed to operate. He came to my Downing Street flat one evening with his scalpels, needles and other surgical equipment, and for some reason the metal detector did not pick them up. I lay on the dining table and he gave me a local anaesthetic and removed the cyst. Ara soon reported back that the cyst, fortunately, was as benign as the metal detector.
Ara led the national review to plan the course of the NHS over the next decade. On his advice, GP practices and local health centres moved centre stage in the reformed NHS by expanding their range of health checks and screenings, ranging from blood tests to electrocardiography and ultrasound. 15 million people with a long-term condition, from asthma to diabetes, would have a personal care plan tailored to their needs and circumstances. Freely flowing information about results and league tables comparing performance would in future tell patients how hospitals, departments and doctors were performing and allow them to choose between them. The income of hospitals and GPs would in future depend on how much they improved their patients’ health.
The focus on outcomes rather than inputs was the right test. By 2010 Labour policy had helped the NHS achieve a 22 per cent fall in cancer deaths, a 52 per cent reduction in fatalities from circulatory diseases among men under seventy-five, the lowest infant mortality rate ever, and all our waiting-time targets – no more than four hours for treatment at A&E, forty-eight hours to see a GP, sixty-two days before cancer treatment and eighteen weeks prior to hospital operations – were being met. The NHS was never going to be perfect – as graphically illustrated by the failure of effective regulation and supervision at Mid-Staffordshire Foundation Trust – but it now stood in marked contrast to the dilapidated Victorian hospitals, demoralised staff and chronic underfunding we had inherited.
I was committed to do far more on public health, especially in narrowing the gap between rich and poor, and in November 2008 we asked Sir Michael Marmot, a leading expert in public health at University College London, to review inequalities in health with a view to introducing a new Equality Act. Earlier equalities legislation had created positive duties on public authorities to give due regard to promoting equality by sex, race and disability. The new Equality Act, passed just before the 2010 general election, put increased emphasis on rooting out deeper social and economic inequalities. It was pioneered by Harriet Harman, who had, more than anyone, put gender equality on the map. But still a manual worker in a city like Glasgow had a life expectancy of ten years less than a professional counterpart in Surrey or Sussex. Infant mortality was twice as high in poorer income groups. This arithmetic of deprivation in the Britain of the twenty-first century was a disgrace – and, if I had stayed in power, closing this unacceptable gap would have been one of my priorities.
After he took over as Health Secretary in 2009, Andy Burnham and I discussed how we could take the next bold step in health modernisation: integrating health and social care. Colin Currie, who had joined as an adviser on health in No. 10, proved to me that the only way forward was to bring the two services together and expand their range. In 2010, we stood on an election manifesto that guaranteed to elderly citizens – no matter the state of their finances – a minimum level of care available to all. This, we knew, would not be easy or cost-free. But neither had been our transformation of the NHS after 2002. While we expected people to continue to pay for accommodation costs in residential care if able to do so, Labour’s plan was a universal deferred-payment system. No one would have had to sell their home during their lifetime to pay for residential care.
The NHS should have been an important reason for voting Labour in 2010. But many had forgotten the pre-1997 NHS and did not fear a return to those dark days. While in the run-up to the 2010 election the Conservatives proclaimed they accepted our health settlement, the NHS is at the time of writing two-thirds of the way through the most austere decade in its history. Whereas health spending grew by an annual average in real terms of 4.5 per cent in the three years that I was in No. 10, average annual growth this decade has been only 1 per cent; and, with many health trusts in deficit, 4 million on waiting lists, targets on waiting times and A&E treatment missed, a £10 billion maintenance backlog, social care in crisis and staff morale lower than ever, many NHS services are close to breaking point. The issue today is not just how we improve performance through reform: it is how much we are prepared to pay for a good NHS. In future we will need to spend far more than we do currently – and we now need a similar kind of refinancing to the 1 per cent rise in employees’ and employers’ National Insurance of 2002. Once again, we have to explain what any new funding is for, why other ways of funding do not work and what it can achieve for British families.
The NHS has been a cause throughout my life and time in government. So, when Sarah encouraged me to join an online campaign when it was under attack, this time from opponents of Obamacare in America, I sent my first ever tweet to say what I had learned from my own life and believed heart and soul: ‘The NHS makes the difference between pain and comfort, despair and hope, life and death. Thanks for always being there.’
Reform was even more central to our agenda on education. I wanted to prove that state schools could be as good, pioneering and geared to personalised learning as independent schools, giving each pupil as much individual attention as parents bought when they took their children into the private sector. Opportunity for all also meant supporting every part of a young life – from nursery and playgroups upwards right across to child health, youth crime and poverty prevention. Before I became prime minister, Ed Balls and I had thought through an innovation that would break down what we saw as self-defeating divisions between schools and other children’s services. This led to our creation of the Department for Children, Schools and Families, which Ed led with enthusiasm and distinction. The aim was, as Ed said, to remove every barrier that prevented a child making the most of their abilities.
I was in no doubt that we could not create a modern egalitarian Britain without investing in the potential of every child. But if education is a moral imperative, it is also an economic necessity: we had to draw on the widest pool of talent.
In the past, countries in possession of raw materials enjoyed competitive advantage. Now what mattered most were skills, ideas, innovation and creativity. The old argument was that room at the top was limited so there was no point in educating everyone as far as their talents would take them: the economy didn’t require it. This was encapsulated by Kingsley Amis’s condescending notion that ‘more means worse’. I believed Britain had been held back by this prejudiced way of thinking, whose arguments had since been decisively defeated by a fast-changing, knowledge-based global economy in which people continuously had to be trained and retrained. The rallying call for a successful modern economy could not be ‘no room at the top’; it had to be ‘no room at the bottom’.
Under Ed’s predecesssors as Education Secretary – David Blunkett, Estelle Morris, Charles Clarke, Ruth Kelly and Alan Johnson – we had moved Britain from an education system which was below average to one that was above average, but as prime minister I wanted us to do much more. Our ambition, I believed, had to be nothing less than coming top of the global education league. While we had made major structural changes (academies being the most controversial) accompanied by huge new investments, our priority – indeed our stated mission – was always raising standards for all. That meant we could no longe
r accept any child nor any school falling behind. We had to aim high but also eliminate failure, thus Ed’s controversial declaration that each failing school had no more than five years to prove themselves or be taken over.
As with the NHS and children’s services, all of this required a more personalised kind of support. As I told the Labour conference in 2007, ‘learning personal to each pupil – education available to all’ was our mantra, ‘not one size fits all, but responding to individual needs’. Our reforms included individual tutoring, customised teaching, personalised learning plans and where we could afford it one-to-one lessons for children falling behind.
At one of our events to make ‘every child a reader’, I read to a six-year-old at a school in Tower Hamlets who had been unable to make any progress until he had been given a personal tutor. He told me he wanted to be the best reader in Britain – reminding me that if we can capture the imagination of a child, anything is possible. These reforms went hand in hand with the early opening of 400 academies and more encouragement for universities to open them in deprived areas; the extension of Teach First, an American-born scheme that brought the best graduates into teaching within the inner cities; and the expansion of both the numbers and quality of teachers. By 2010, there were 50,000 more teachers than in 1997, now backed up by 190,000 support staff. Over 150 new schools were built with many more planned. Even after taking inflation into account we had nearly doubled total spending on education from just over £50 billion when we came into office to just under £90 billion when we left. In addition, as well as providing free nursery education for three- and four-year-olds we delivered by 2010 an amazingly successful innovation: Sure Start centres in every community – 3,500 in all – that combined health and educational services for the very young (all like the one I visited in May 2009, mentioned in the Introduction).
