Preparing for the worst: when the PM falls ill
Recent premiers have been a fairly hardy bunch, but what happens if the head of government succumbs to a physical frailty?
It seems a long time ago now, when Covid-19 and Brexit were challenges for the government—with its healthy majority—to address head on. On 31 January 2020, it was confirmed that the UK had seen its first cases of a new respiratory virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which became known simply as Covid-19. The spread of this new virus was swift and terrifying. Less than two months later, on 27 March, it was announced that the prime minister himself, Boris Johnson, had tested positive for the affliction. He tweeted that he was suffering “mild symptoms”, and would be self-isolating, but that he would “continue to lead the government’s response via video-conference as we fight this virus.” It was an optimistic, bantering reaction typical of Johnson, but it proved inaccurate. On 5 April, his symptoms persisting, he was admitted to St Thomas’ Hospital for more thorough tests, and the following day, with his condition worsening rapidly, he was admitted to intensive care.
The prime minister was in intensive care for only a few days, from 6 to 9 April, and left hospital altogether three days after that, heading to his official residence at Chequers in Buckinghamshire to recuperate. How ill had he been? Outwardly, his condition was downplayed: everything was routine, excessive caution was just a sensible approach, he would be back soon. He had been given oxygen, it was true, but that was not in itself a cause for anxiety: but he was not put on a ventilator or given continuous positive airway pressure (CPAP). Indeed, there were accusations that he was taking up an intensive care bed without really needing it.
We will not know all the details of those few days for years, until official papers are released. But we do know that, in Johnson’s inimitable words, “it was a tough old moment, I won’t deny it”. Asked, gently, if clinicians and officials had contemplated the worst outcome, his death, he agreed “they had a strategy to deal with a ‘death of Stalin’-type scenario”. His principal private secretary, Martin Reynolds, was in constant communication with the doctors. Dominic Raab, the first secretary of state, foreign secretary and de facto deputy prime minister, was nominated to act in Johnson’s stead as far as government business was concerned; this was important, for the administration was still in the early stages of fighting an unpredictable and formidable public health crisis. Letting matters slide was simply not an option.
Speaking to The Sun on Sunday afterwards, Johnson went on to concede that disaster planning had taken place. “The bad moment came when it was 50-50 whether they were going to have to put a tube down my windpipe. That was when it got a bit . . . they were starting to think about how to handle it presentationally.” Speaking later that year as he stepped down from his position as cabinet secretary and national security adviser, Sir Mark Sedwill confirmed that there had been a Plan B. While he was reluctant to talk about specific details, he admitted that “We have in place, particularly in national security area, well-established procedures for ensuring decisions are taken if the prime minister is indisposed or uncontactable.”
No prime minister has died in office since Lord Palmerston in October 1865. Generally in good health but aged nearly 81, he caught a chill which became a violent fever which was too much for him to resist. (Apocryphally, Palmerston’s last words were “Die, my dear doctor? That is the last thing I will do.” In reality, but less wittily, he actually said, his mind still on diplomatic treaties, “That’s Article 98; now go on to the next.”) Queen Victoria, as was the sovereign’s personal prerogative at that time, invited the foreign secretary, Earl Russell, to form a new government. The cold-voiced little peer (he was only 5’5”) was himself 73, but he had previously been prime minister from 1846 to 1852 and seemed the obvious choice.
The political landscape is now unrecognisable from that of 1865. The monarch has had no effective say in the succession to the premiership since at least 1963, when Harold Macmillan resigned and advised Elizabeth II to send for the Earl of Home. Downing Street officials and senior members of the Royal Household must have discussed what would have happened if Johnson had died. We know that Raab was acting in Johnson’s stead, and perhaps he would have been asked to become “interim” prime minister on a slightly longer term basis. Organising an election within the Conservative Party to choose a new leader during a pandemic would have been difficult, perhaps impossible. Certainly the official opposition would have been consulted, perhaps on Privy Council terms.
It may in fact have been the one set of circumstances in which public opinion would have accepted the sovereign taking a more proactive role: Dr Robert Saunders of Queen Mary University of London has written an article setting out some of the problems of a prime minister dying in office; I will come back to the issue more fully at another time. But it would have been a very challenging problem in constitutional, parliamentary and political terms. One issue is that our political system, unlike, say that in the US, has no formal line of succession. If a president dies, you can trace the person to take over down through dozens of different office-holders thanks to the Presidential Succession Act 1947, from the vice-president to the holder of the most junior cabinet position (currently Secretary of Homeland Security). We have no equivalent, nor, easily, could we introduce one without seriously rethinking the monarch’s theoretical prerogative to choose the first minister.
With more than 150 years having passed since the situation last arose, are we to conclude that our prime ministers have been a hardy bunch? Recently, that has been true. Although Theresa May manages type-1 diabetes, this had no discernible effect on her fitness for office. David Cameron was fit and healthy. Gordon Brown suffers from severe limitations on his eyesight after a rugby accident at school but was in good health during his three-year tenure (though very speculative rumours flew around in 2009 that he was struck by severe depression for which he was taking medication, but this suggestion was widely given short shrift). Sir Tony Blair was twice treated for a heart condition but there was never a sense that his health was in serious danger.
John Major never had any major health issues in Downing Street; though in his final days as chancellor of the exchequer in November 1990, as Margaret Thatcher fought for her leadership, he was able to go conveniently missing, thereby unable to help or hinder her, for an operation on his wisdom teeth. Before that, shortly after the 1983 general election, Thatcher was admitted to hospital for an operation on her right eye to repair a detached retina. She remained in contact with officials and stayed in control of her government, although Viscount Whitelaw, her deputy, was ready to take over if anything unexpected took place.
The most serious illness to be suffered by a sitting prime minister was that which afflicted Sir Anthony Eden towards the end of 1956. He had been in poor health since 1953 (we shall come to this in a moment) and was susceptible to recurring infections, biliary obstruction and, potentially, liver failure. In October, under extraordinary pressure because of the unfolding disaster of the Suez crisis, he developed a fever of 104°F and was admitted to hospital overnight. Further fevers plagued him in December. It was clear that the political pressure on him over his foreign policy mistake, combined with continuing poor health, made his continuing in office impossible. He was already taking high doses of Benzadrine, a pharmaceutical amphetamine, Promazine, a strongly sedative antipsychotic, sodium amytal and Secobarbital, also sedatives, and Pethidine, a strong opioid painkiller believed (wrongly) to relax the bile duct. His resignation statement to the cabinet, issued on 9 January 1957, said “I have been obliged to increase the drugs [taken after his 1953 operation] considerably and also increase the stimulants necessary to counteract the drugs. This has finally had an adverse effect on my precarious inside.” It was an understatement. Eden was highly strung at the best of times: it was a wonder he was able to function at all.
In November 1956, Eden and his wife Clarissa had travelled to Jamaica for three weeks to offer the ailing prime minister a chance to rest and recuperate. They stayed with the writer Ian Fleming at his villa, Goldeneye, on the north coast. Fleming moved in glamorous circles and was well-connected; his wife Ann was having an affair with the leader of the opposition, Hugh Gaitskell, and had also had a liaison with Roy Jenkins. The Edens returned to the UK on 12 December. The prime minister was impressively suntanned, noticeable in 1950s Britain, but was very thin and looked frail. A week later he appeared in the House of Commons and MPs were shocked by his appearance. It was over, and his resignation was announced on 10 January.
Anthony Eden’s health leads us to a story perhaps not well known outside the circles of political connoisseurs. From 1951 to 1955, he was foreign secretary (for the third time after 1935-38 and 1940-45), effective deputy prime minister and impatient heir apparent to the ageing occupant of 10 Downing Street, Sir Winston Churchill. That Eden would be the next premier was unquestioned (though Churchill would say grimly to his private secretary just before he retired in 1955, “I don’t believe Anthony can do it”), but Churchill was addicted to office and kept finding reasons to stay on a little longer. He was old (77 when he returned to power in 1951) and increasingly deaf, but he was powered by determination.
A crisis came in 1953. On 23 June, not long after Elizabeth II’s coronation, he suffered an acute stroke which caused left hemiparesis. He had suffered similar cerebrovascular incidents in 1949 and 1950-52. This was, like Boris Johnson’s illness in 2020, the obvious opportunity for the foreign secretary and designated number two to step up and take control, even if only temporarily. But there was a problem. Eden was not there.
On 12 April, Eden had undergone an operation in Boston to remove gallstones. In what would become, in retrospect, the defining tragedy of his career, the procedure went wrong, and the surgeon damaged his bile duct, which would compromise his health (as mentioned above) for the rest of his life. He had a second operation on 29 April, and a third on 10 June, still in Boston. He was not well enough to return to the UK until 30 July, while Churchill was unable to undertake government business in any meaningful sense until the end of August. What was the ship of state to do?
Neither parliament nor the public was informed of Churchill’s illness. Indeed, he had managed to chair a cabinet meeting the morning after his stroke without anyone noticing. But his condition got worse. The prime minister retreated to his country home, Chartwell, and was said to be suffering from “exhaustion”, hardly surprising for a man approaching 80. The original draft of a medical statement read:
The prime minister has had no respite for a long time from his arduous duties and there has developed a disturbance of the cerebral circulation which has resulted in attacks and giddiness.
This was seen, however, by the chancellor of the exchequer, Rab Butler, and the leader of the House of Lords, Lord Salisbury, who regarded it as too explicit and likely to cause alarm. A revised version was issued instead: “The prime minister has had no respite for a long time from his arduous duties and is in need of a complete rest.” Even other members of the cabinet were not told the truth.
A few days afterwards, Churchill’s press secretary, Fife Clark, told reporters that “there is no suggestion the prime minister is suffering from any specific ailment”. It was an absolute and unapologetic lie. But there was already a process underway to manage the prime minister’s illness in the hope (fulfilled, to some extent) that he would recover.
One of the key members of what became, without doubt, a conspiracy to conceal Churchill’s illness was his joint principal private secretary, Jock Colville. He has served in the prime minister’s private office during the war and was a close family friend; perhaps more importantly, he was experienced enough to be able to draft in Churchill’s florid style. Colville knew that a complete press black-out was not practical. So he invited three leading newspaper owners, Viscount Camrose (The Daily Telegraph), Lord Beaverbrook (The Daily Express and The Evening Standard) and Viscount Bracken (The Financial Times), to Chartwell to brief them confidentially. All were to some degree old cronies of Churchill; Bracken was practically a surrogate son. They agreed to report nothing except the official communiqué which described the prime minister’s need for “a complete rest”.
Churchill had instructed Colville to carry on the business of government as if nothing was amiss. He had defied his chief by briefing the press barons, but otherwise he pushed on, though he was uncomfortable at what he knew were exceptional constitutional actions. Butler and Salisbury were kept in the loop, which eased some of the stress. The palace was certainly told of some kind of illness, since on 26 June the Queen wrote by hand to Churchill:
My dear Prime Minister, I’m so sorry to hear from Tommy Lascelles that you have not been feeling too well these last few days. I do hope it is not serious and that you will be quite recovered in a very short time. Our visit here is going very well and Edinburgh is thrilled by all the pageantry. We have been lucky in having fine weather, but I fear that it is now raining after a thunderstorm.
With all good wishes
Yours very sincerely
Elizabeth R
The other important figure was Christopher Soames, Conservative MP for Bedford and Churchill’s parliamentary private secretary. He was also the prime minister’s son-in-law, having married his youngest daughter Mary. Colville remarked later that “the shrewdness of his comments, combined with his ability to differentiate between what mattered and what did not, was of invaluable help in difficult days”.
At first, the intention was to hold the fort until Eden could recover and, it was assumed, take over as prime minister in the autumn. But, remarkably, the aged premier slowly started to recover. Meanwhile, on 29 June, Butler chaired a meeting of the cabinet and at last informed them of Churchill’s condition, though the impression was somewhat toned down. They were shocked, many in tears, but some of them must have entertained the idea at some point that their leader would fall ill. Again, there was a feeling that the prime minister was winding down and should be given a little leeway to choose the time of his departure.
But, stubbornly, Churchill was improving. On 8 August, he chaired his first meeting since his stroke, with Butler, Salisbury and Lord Strang, permanent secretary at the Foreign Office, to discuss a letter from the Soviet leadership. Colville noted in his diary, “Apart from his unsteady walk, the appearances left by his stroke have vanished, though he still tires quickly.” It looked as if the matter of resignation was fading into the distance.
By the end of August, Churchill was well enough to chair the cabinet. It had been an extraordinary summer. For two months, the government had effectively been directed by Butler and Salisbury on the political side, and Colville and Soames acting on Churchill’s behalf. Salisbury, perhaps Eden’s closest friend, had also run the Foreign Office. It was lucky that the stroke had hit in late June, as Parliament approached its summer recess and the pace of business had slowed as it always does. But there had been a kind of a coup, if a benevolent one. The public and even members of the government had been given no idea that the prime minister was not only out of action but perhaps fatally ill.
This sort of thing could not happen now, in the age of instant news and maximum publicity. Perhaps Downing Street officials looked back enviously to the summer of 1953 when Boris Johnson fell ill in April 2020. It is not unfair to observe that Johnson is no Churchill, despite his pretensions, and Raab no Butler or Salisbury. But in a more deferential age, starved of information, the government machine was able, just, to get by until the prime minister could recover.