In 1985 Clive Smee, who had recently been appointed chief economic adviser to the Department of Health and Social Security, commissioned two studies. The first concluded that, despite the controversially high expense of heart transplants, they might be cost effective and were therefore worth pursuing. The second used international evidence to make the case for the UK to adopt breast cancer screening. Both recommendations were acted on, saving many lives.
Those two breakthrough studies – both of which had a real impact on policy – were just the start of almost two decades’ worth of health policy development in which Smee, who has died from motor neurone disease aged 77, played a key role. His lasting contribution was, first, to help develop the idea of the economic evaluation of health services and, then, to inject the findings into government decisions, often in turbulent times.
In his senior roles at the Department of Health and Social Security and then the Department of Health from 1984 to 2002, Smee was there for the political storm that surrounded the Thatcher government’s initial introduction of more market-like mechanisms into the NHS in 1991, and for the policy whirlwind that came after Tony Blair’s landslide victory in 1997.
The team of analysts he built up, both within the department but also externally, played a key part in at least an element of evidence-based policy being adopted for the NHS. As he said in his 2005 memoir, Speaking Truth to Power, “today it would be a brave or foolhardy policy lead who would put forward a major policy proposal without any reference to cost-effectiveness”.
Smee also had an important hand in the development of Nice, the National Institute for Health and Care Excellence, which helps to decide what the NHS should – and should not – fund. Additionally he is credited by ministers with assembling the evidence for the progressive ban on tobacco advertising, and he produced a beds inquiry in the early 2000s showing that the NHS had been closing too many too fast, and in fact that it needed more.
While he had a superb brain, Smee’s distinctive style was a big element of his efficacy as a senior civil servant. Though tall at 6ft 4in, he had an unassuming presence with a slow winning smile (his children’s friends dubbed him the Big Friendly Giant) and a quizzically dry sense of humour allied to good communication skills. All of this helped to steer the eight health secretaries for whom he worked towards the right decisions and away from the worst, without any of them ever feeling patronised.
Born in Gerrards Cross, Buckinghamshire, the son of Victor Smee, a greengrocer, and Leila (nee Harrod), a nurse, he was one of the big beneficiaries of a post-1945 welfare state that he greatly valued.
A peripatetic childhood led him to the Royal Grammar school in Guildford and an economics degree at the London School of Economics. There, in the early 1960s, an American tutor encouraged him to take an MBA at a time when the UK had not developed such courses; Clive chose to do so at the University of Indiana.
He worked for the British Council in Nigeria (1966-68) during the civil war there, before returning to the UK and starting with the civil service as an economics adviser at the Overseas Development Ministry.
A travelling fellowship to the US and Canada was followed in the early 80s by a spell first as an adviser on the Central Policy Review Staff at No 10 Downing Street – the first proper central government policy unit, which gave him his first encounters with Margaret Thatcher – and then as a senior adviser at the Treasury.
Those early experiences at the centre of government helped Smee to understand how to build the bridges that are needed if the findings of research and analysis are to become policy action. After he became chief economic adviser at the DHSS in 1984, successive prime ministers – Thatcher, John Major and Blair – much valued him in that role over the next 18 years, as did most health secretaries across the political divide.
Virginia Bottomley (now Lady Bottomley of Nettlestone), the Conservative health secretary during the 90s, said he was “as good as they come: a man of total integrity and ability, and I always wanted him there even when some of the policy officials were a bit obstructive to him being at so many meetings”.
Alan Milburn, who was in charge of health for Labour between 1999 and 2003, said Smee provided much of the evidence for the huge commitments in the NHS Plan of 2000 and “was very much part of the reset of health policy post-1997”.
Sometimes that meant helping the government to operate by the seat of its pants. In his memoir Smee gave a self-effacing account of the Sunday morning in January 2000 when Blair went on the Breakfast with Frost TV programme and announced, pretty much out of the blue, that Labour would get NHS expenditure up to the European Union average over five years.
Given that it was a weekend, only Smee had the international health spending data to hand. A panic-stricken phone call from No 10 saw him charged with working out how much that huge commitment would cost over time, and whether it was achievable.
Smee recalled that, as he worked out the implications of what became dubbed “the most expensive breakfast in history”, most of the complicated calculations were done by his daughter’s boyfriend because he was the only one who knew how to work the compound interest function on his calculator.
It was under Blair that Smee finally relinquished his senior role at the Department of Health by moving to become a senior policy adviser to the New Zealand Treasury (2002-04), just part of his international influence, which included chairing the health committee of the OECD.
Later he returned to the UK to sit on the economics advisory panel at the Home Office (2006–08) and on various other committees and bodies, including the Department for International Development’s independent advisory committee on development impact (2007–10).
In 1975 he had married Denise Sell, a maths teacher whom he had met at a development aid conference. Together they enjoyed international travel, walking, cycling and charity work.
He is survived by Denise, their three children, Anna, David and Elizabeth, and three grandchildren.
• Clive Harrod Smee, civil servant, born 29 April 1942; died 26 December 2019
