A New Look at Medicine and Politics

J Enoch Powell 1966

1. The Ministry of Health

I WAS Minister of Health for three years and three months. That is not a long period, as time goes in professional life; but it is longish in comparison with the average occupancy of a particular office by a politician. In fact, since the Ministry of Health assumed its present identity in 1950, only one Minister, Iain Macleod, has had a longer tenure, and that was longer by only a few months.

A politician should never use the word ‘never’, and there are instances, even instances within living memory, of politicians who have given the lie to Heraclitus’ dictum that no man goes down into the same river twice. However, I suppose the chances against my ever returning to this particular office must be rated pretty high. I can, therefore, even at a distance of less than three years, look back with some detachment upon my time at the Ministry of Health, and try to draw from my experiences there, while they are still relatively fresh in the mind, some reflections on the subject of Medicine and Politics. It is, at any rate, only on the basis of those experiences that I can have anything of use or interest to offer.

Perhaps I may preface one or two general observations about the relationship between a Ministry and its political head.


Only during the last year and a quarter of my own tenure has the Minister of Health, in the post-1950 meaning of the term, been a member of the Cabinet. When, in July 1962, Mr. Macmillan gave me one of the seats at his Cabinet table that had become vacant by what has gone down in political nomenclature as ‘the night of the long knives’, I was struck, and could not help being gratified, by the satisfaction this seemed to give to people throughout the health services. ‘Hoorah,’ they said, ‘our Minister is in the Cabinet; this is as it should be.’

I am afraid this reaction was due to a misconception that is widely held. It is commonly believed that a department or service whose political head is not in the Cabinet gets short shrift, and that only if a Minister is able to fight the Chancellor of the Exchequer across the Cabinet table and wrangle on equal terms with his colleagues about their respective shares of finance or legislative time will the department concerned get a fair crack of the whip. I must say that, so far as my personal experience and observation go, there is no substance in this notion. On the contrary, from the narrow interest of a department or service, especially at a period or in circumstances where the continuous and detailed attention of its ministerial head is beneficial, I would say that the balance of advantage lies decidedly the other way.

The idea that members of a government extort by their weight and personal influence a larger or smaller share of national resources for their respective charges is grotesquely unreal. The complex balance of pressures— electoral, social, practical— that determine the rate at which a branch of public expenditure grows are little accessible to individual sway; and even if one individual could, by force of personality and advocacy, present the claims of his department to his colleagues with more emphasis and advocacy than another, that result would still not depend on whether he was ‘called in’ to Cabinet for the items in question or sat there as of right throughout.

I believe this to be true generally. In my own particular case the question hardly arose; for to the best of my recollection I was never at variance on any departmental issue with either of the Chancellors of the Exchequer with whom I served.

Incidentally, it can also sometimes happen that a departmental minister fails to carry his colleagues with him on a proposal toreduce expenditure on his ministry or service, which illustrates how far from the truth is the popular picture of ministers engaged in nothing but ‘fighting their own corner’, and how powerfully electoral or political considerations can predominate over personal factors.

On the other hand, it is easy to overlook the claim which membership of the Cabinet makes on a minister’s time and energy, and how it carries his mind and interest away at a tangent from the concerns of his department unless that department, like Foreign Affairs, or Defence, or the Exchequer, is one whose work forms a large part of the stuff of Cabinet deliberation itself. The mere extraction, from the working week of a minister, of five hours in conclave, plus time to read the Cabinet papers, is no small interruption to the smooth flow of administration and application of the ministerial mind. It is more than propor­tionately severe because of the overriding priority of the Cabinet’s claims and, for those who enjoy it, the absorbing interest of the fascinating but mostly insoluble problems that engage a Cabinet’s attention, and of the endlessly varied interplay of a score of personalities at grips with those problems. A minister without a seat in the Cabinet is therefore better placed to give his mind and his heart to the affairs of a service such as the National Health Service.

It is perfectly true that the civil servants, especially the senior civil servants in a department, prefer, other things being equal, that their minister should be in the Cabinet— automatically if possible, or in a personal capacity if not. The reasons for this are not easy to define precisely. There is a certain status the department shares with its departmental head. There is also the unseen, unofficial channel of communications between per­manent heads of departments, which operates more freely and actively between those whose ministers have a seat in the Cabinet. It is easier for the senior officials in a department to gauge ‘what is really going on’ if they serve a Cabinet minister; and this is both interesting in itself and, to some degree perhaps, relevant to the departmental advice they may have to tender. However, all this is very much a matter of nuance and quite marginal in its effect.


Another popular fallacy is the expectation that a minister should either have a deep knowledge of the subject-matter of his depart­ment or at least remain there long enough to acquire it. ‘There they go’, the cry arises from the personnel of a service, ‘shuffling the Minister away, just as we are getting to know him and he is picking up the rudiments of what our service is all about.’ Hence the complaints that the Ministry of Health, for example, is treated ‘just as a stepping-stone to higher office’, with the implication that Prime Ministers and others are indifferent to its interests and requirements.

Admittedly there is a minimum length of time below which a minister could hardly be in a position to make a distinctive con­tribution to a department or service. Perhaps this period could very roughly, and on average, be set at about eighteen months, though at certain junctures that figure could well be even lower. But there is also very definitely a maximum period after which a minister ceases to be capable of contributing significantly. How long this maximum is will again differ greatly with the nature of the department. The more general the department’s concerns, and the larger the sector of political life they subtend, the longer will be the maximum period, until one reaches the limiting case, that of the prime ministerial office itself, where the bounds are set by other factors altogether. Where, however, the subject matter is restricted to a single service ;or aspect of the economy or society, the average maximum is probably in the region of three years or so for most individuals in most circumstances.

The laity or, as the case may be, the professions, find this idea startling, if not shocking. ‘Do you not find it galling,’ they ask, ‘to have to move before you can see your ideas and policies at least begin to come to fruition ? It must be bitter to sow but never reap, despite the occasional compensation of reaping what one has not sown.’ This sentiment betokens a complete misconcep­tion of the politician’s job. His job, as his description denotes, is politics. Placed in charge of a service or department, he will make it his duty, and often find it some satisfaction, to administer it efficiently and well, even in those aspects in which no element of politics enters into the decisions. But his specific function is to handle the issues, be they major or minute, that are political in character, where the management of public opinion and the interpretation of actions and events in a political sense is involved.

These issues he handles as his peculiar province, and his skill or lack of it, his seriousness or levity—in short, his qualities as a politician—will be in evidence whether the subject matter is pensions or prisoners or practitioners. This is his business in life, and he moves from one field to another as a barrister will put down one case and take up another. True, some departments at some times will throw up relatively little political work: but it is surprising how much of a minister’s work, be he Postmaster-General or Chancellor of the Exchequer, is in this sense truly political. As I shall argue at greater length later, whatever is entrusted to politicians becomes political even if it is not political anyhow.

Since the politician’s business is politics he will, as part of his career, aspire to move around the offices of state, learning how his craft applies in different departments and acquiring the breadth of view and experience that makes a man a more useful member of a Cabinet and government and nourishes the reservoir of papabili who, under the British system, so unlike the American in this respect, can be drawn on to fill the highest places of responsibility.

But this is only one of the causes that sets a relatively short time limit to the utility of a political head in charge of one department of state. His specific political function actually demands for its satisfactory performance a certain detachment and even strangeness vis-a-vis his department and his service. This is lost as he becomes more familiar with its subject matter and immersed in it. I remember being shocked when, after I had been little more than two years at the Ministry of Health, a new Parliamentary Secretary asked me to explain certain terms I was using that he found unintelligible. I realised I had absorbed the departmental jargon to the extent of being unconscious that it was jargon. When a minister begins to think like his officials and understands before they explain, his work in that office is done: he is losing the power to see the issues in a political light from the outside, which alone is what he is there for.

A fortiori a minister is under a grave disadvantage if he is a professional in the subject matter of his department. If that is so, he can never bring to it the outside view, but starts out psycho­logically enmeshed in that from which he ought to be detached, bringing with him all kinds of preconceived ideas that will militate against his political assessment. Under the British system at least, this is a severe objection to a doctor being Minister of Health. In fact, to date, since the department took its present form, none has been.


It is not possible to be so dogmatic about the advantage or disadvantage of a prior non-professional interest. On the whole, my inclination would be towards the view that such a prior interest, if it has been at all detailed or personal, is usually a disadvantage. It may seem harsh to say that it is, on the whole, no gain that the person appointed political head of a department such as Health should never have been previously concerned in hospitals or mental health or care of the disabled or whatever it might be. Certainly such a previous concern can supply enthusiasm and secure the initial goodwill of those through whom the new minister will have to work. Yet the fact is that he will bring two disabilities under which someone without prior interest would not labour. One is a modified form of the professional’s disability— to be involved, rather than to stand aloof. The other is the besetting danger of the amateur, summed up in the ‘little learning’ which is ‘a dangerous thing’. Better have all to learn, than some things to unlearn and others that ought to be unlearnt but in practice never are. I hope I am not biased by the fact that in my own personal case any previous interest in the affairs of the Ministry of Health had been on a political level, and that not profound, and that I had no practical knowledge of any branch of the department’s concerns.

There is one remaining, important consideration that tends to fix a low limit to the useful life of a minister in a department. This is that the power of initiative is early lost. The political head, though he must cope with everything that events throw in his path, can only take personal control and initiative on very few fronts at once. He must select his points of attack and throw all his available weight and attention there. By the time this initiative has attained its objects, even its preliminary objects, it will usually be too late to recommence the same process elsewhere. The essence of a minister’s initiative is to alter what wouldotherwise have happened—to upset, in a word. This is relatively easy to do when he comes fresh and strange, is expected to innovate, and is also expected (on an actuarial calculation) to be able to see his initiative some distance through. Once that phase is past, any new initiative will be directed against what has been happening under his own administration, and therefore ex hypo-thesi with his approval, or at least acquiescence. He therefore runs into a certain personal contradiction, which becomes severer as time passes. He also presents his department with that administratively most unmanageable thing, inconsistent instructions: ‘Minister, we don’t know where we are. Last year you approved this; now, with no change in circumstances, you suddenly say it must all be altered.’ Those who thus remonstrate, like everyone else concerned, also know that with every month that goes by, the present incumbent’s tenure hastens to its end. And who knows what view, if any, the successor will take?

I have laid stress thus at the outset upon these arcana of ministerial life because failure to understand them sometimes leads observers to attribute to trivial and transient causes what are really the deep-seated effects of the association between politics and a profession such as medicine, and so to expect that these effects could be removed with corresponding ease. ‘If only the Minister of Health were more versed in the subject.’ ‘If only Ministers of Health could be allowed to do a good long stint at the job.’ ‘If only Ministers of Health were always in the Cabinet and could get what they want out of the Chancellor of the Exchequer.’ All these ‘if only’s’ and others like them are mere distractions from serious attention to the subject of Medicine and Politics. If a service is administered by a department of state, neither the personality nor the stint nor the status of the individual minister is going to vary very much, or make, in principle, much difference.