Treat with extreme caution

Homoeopathic medicine is founded on a bogus philosophy. Its continued use is a drain on NHS resource

Two years ago, a loose coalition of like-minded scientists wrote an open letter to chief executives of the National Health Service Trusts. The signatories simply stated that homoeopathy and other alternative therapies were unproven, and that the NHS should reserve its funds for treatments that had been shown to work. The letter marked an extraordinary downturn in the fortunes of homoeopathy in the UK over the following year, because the overwhelming majority of trusts either stopped sending patients to the four homoeopathic hospitals, or introduced measures to strictly limit referrals.

Consequently, the future of these hospitals is now in doubt. The Tunbridge Wells Homoeopathic Hospital is set to close next year and the Royal London Homoeopathic Hospital is likely to follow in its wake. Homoeo paths are now so worried about the collapse of their flagship hospitals that they are organising a march to deliver a petition to Downing Street on 22 June. Local campaign groups are being formed and patients are being urged to sign the petition.

Homoeopaths believe that the medical Establishment is crushing a valuable healing tradition that dates back more than two centuries and that still has much to offer patients. Homoeopaths are certainly passionate about the benefits of their treatment, but are their claims valid, or are they misguidedly promoting a bogus philosophy?

This is a question that I have been considering for the past two years, ever since I began co-authoring a book on the subject of alternative medicine with Professor Edzard Ernst. He was one of the signatories of the letter to the NHS trusts and is the world's first professor of complementary medicine. Before I present our conclusion, it is worth remembering why homoeo pathy has always existed beyond the borders of mainstream medicine.

Homoeopathy relies on two key principles, namely that like cures like, and that smaller doses deliver more powerful effects. In other words, if onions cause our eyes to stream, then a homoeopathic pill made from onion juice might be a potential cure for the eye irritation caused by hay fever. Crucially, the onion juice would need to be diluted repeatedly to produce the pill that can be administered to the patient, as homoeopaths believe that less is more.

Initially, this sounds attractive, and not dissimilar to the principle of vaccination, whereby a small amount of virus can be used to protect patients from viral infection. However, doctors use the principle of like cures like very selectively, whereas homoeopaths use it universally. Moreover, a vaccination always contains a measurable amount of active ingredient, whereas homoeopathic remedies are usually so dilute that they contain no active ingredient whatsoever.

A pill that contains no medicine is unlikely to be effective, but millions of patients swear by this treatment. From a scientific point of view, the obvious explanation is that any perceived benefit is purely a result of the placebo effect, because it is well established that any patient who believes in a remedy is likely to experience some improvement in their condition due to the psychological impact. Homoeopaths disagree, and claim that a "memory" of the homoeopathic ingredient has a profound physiological effect on the patient. So the key question is straightforward: is homoeopathy more than just a placebo treatment?

Fortunately, medical researchers have conducted more than 200 clinical trials to investigate the impact of homoeopathy on a whole range of conditions. Typically, one group of patients is given homoeopathic remedies and another group is given a known placebo, such as a sugar pill. Researchers then examine whether or not the homoeopathic group improves on average more than the placebo group. The overall conclusion from all this research is that homoeopathic remedies are indeed mere placebos.

In other words, their benefit is based on nothing more than wishful thinking. The latest and most definitive overview of the evidence was published in the Lancet in 2005 and was accompanied by an editorial entitled "The end of homoeopathy". It argued that ". . . doctors need to be bold and honest with their patients about homoeopathy's lack of benefit".

An unsound investment

However, even if homoeopathy is a placebo treatment, anybody working in health care will readily admit that the placebo effect can be a very powerful force for good. Therefore, it could be argued that homoeopaths should be allowed to flourish as they administer placebos that clearly appeal to patients. Despite the undoubted benefits of the placebo effect, however, there are numerous reasons why it is unjustifiable for the NHS to invest in homoeopathy.

First, it is important to recognise that money spent on homoeopathy means a lack of investment elsewhere in the NHS. It is estimated that the NHS spends £500m annually on alternative therapies, but instead of spending this money on unproven or disproven therapies it could be used to pay for 20,000 more nurses. Another way to appreciate the sum of money involved is to consider the recent refurbishment of the Royal Homoeopathic Hospital in London, which was completed in 2005 and cost £20m. The hospital is part of the University College London Hospitals NHS Foundation Trust, which contributed £10m to the refurbishment, even though it had to admit a deficit of £17.4m at the end of 2005. In other words, most of the overspend could have been avoided if the Trust had not spent so much money on refurbishing the spiritual home of homoeopathy.

Second, the placebo effect is real, but it can lull patients into a false sense of security by improving their sense of well-being without actually treating the underlying conditions. This might be all right for patients suffering from a cold or flu, which should clear up given time, but for more severe illnesses, homoeopathic treatment could lead to severe long-term problems. Because those who administer homoeopathic treatment are outside of conventional medicine and therefore largely unmonitored, it is impos sible to prove the damage caused by placebo. Never theless, there is plenty of anecdotal evidence to support this claim.

For example, in 2003 Professor Ernst was working with homoeopaths who were taking part in a study to see if they could treat asthma. Unknown to the professor or any of the other researchers, one of the homoeopaths had a brown spot on her arm, which was growing in size and changing in colour. Convinced that homoeopathy was genuinely effective, the homoeopath decided to treat it herself using her own remedies. Buoyed by the placebo effect, she continued her treatment for months, but the spot turned out to be a malignant melanoma. While she was still in the middle of treating asthma patients, the homoeopath died. Had she sought conventional treatment at an early stage, there would have been a 90 per cent chance that she would have survived for five years or more. By relying on homoeopathy, she had condemned herself to an inevitably early death.

The third problem is that anybody who is aware of the vast body of research and who still advises homoeopathy is misleading patients. In order to evoke the placebo effect, the patient has to be fooled into believing that homoeopathy is effective. In fact, bigger lies encourage bigger patient expectations and trigger bigger placebo effects, so exploiting the benefits of homoeopathy to the full would require homoeopaths to deliver the most fantastical justifications imaginable.

Over the past half-century, the trend has been towards a more open and honest relationship between doctor and patient, so homoeopaths who mislead patients flagrantly disregard ethical standards. Of course, many homoeopaths may be unaware of or may choose to disregard the vast body of scientific evidence against homoeo pathy, but arrogance and ignorance in health care are also unforgivable sins.

If it is justifiable for the manufacturers of homoeopathic remedies in effect to lie about the efficacy of their useless products in order to evoke a placebo benefit, then maybe the pharmaceutical companies could fairly argue that they ought to be allowed to sell sugar pills at high prices on the basis of the placebo effect as well. This would undermine the requirement for rigorous testing of drugs before they go on sale.

A fourth reason for spurning placebo-based medicines is that patients who use them for relatively mild conditions can later be led into dangerously inappropriate use of the same treatments. Imagine a patient with back pain who is referred to a homoeopath and who receives a moderate, short-term placebo effect. This might impress the patient, who then returns to the homoeopath for other advice. For example, it is known that homoeopaths offer alternatives to conventional vaccination - a 2002 survey of homoeopaths showed that only 3 per cent of them advised parents to give their baby the MMR vaccine. Hence, directing patients towards homoeo paths for back pain could encourage those patients not to have their children vaccinated against potentially dangerous diseases.

Killer cures

Such advice and treatment is irresponsible and dangerous. When I asked a young student to approach homoeopaths for advice on malaria prevention in 2006, ten out of ten homoeopaths were willing to sell their own remedies instead of telling the student to seek out expert advice and take the necessary drugs.

The student had explained that she would be spending ten weeks in West Africa; we had decided on this backstory because this region has the deadliest strain of malaria, which can kill within three days. Nevertheless, homoeopaths were willing to sell remedies that contained no active ingredient. Apparently, it was the memory of the ingredient that would protect the student, or, as one homoeopath put it: "The remedies should lower your susceptibility; because what they do is they make it so your energy - your living energy - doesn't have a kind of malaria-shaped hole in it. The malarial mosquitoes won't come along and fill that in. The remedies sort it out."

The homoeopathic industry likes to present itself as a caring, patient-centred alternative to conventional medicine, but in truth it offers disproven remedies and often makes scandalous and reckless claims. On World Aids Day 2007, the Society of Homoeopaths, which represents professional homoeopaths in the UK, organised an HIV/Aids symposium that promoted the outlandish ambitions of several speakers. For example, describing Harry van der Zee, editor of the International Journal for Classical Homoeo pathy, the society wrote: "Harry believes that, using the PC1 remedy, the Aids epidemic can be called to a halt, and that homoeopaths are the ones to do it."

There is one final reason for rejecting placebo-based medicines, perhaps the most important of all, which is that we do not actually need placebos to benefit from the placebo effect. A patient receiving proven treatments already receives the placebo effect, so to offer homoeopathy instead - which delivers only the placebo effect - would simply short-change the patient.

I do not expect that practising homoeopaths will accept any of my arguments above, because they are based on scientific evidence showing that homoeopathy is nothing more than a placebo. Even though this evidence is now indisputable, homoeopaths have, understandably, not shown any enthusiasm to acknowledge it.

For now, their campaign continues. Although it has not been updated for a while, the campaign website currently states that its petition has received only 382 signatures on paper, which means that there's a long way to go to reach the target of 250,000. But, of course, one of the central principles of homoeopathy is that less is more. Hence, in this case, a very small number of signatures may prove to be very effective. In fact, perhaps the Society of Homoeopaths should urge people to withdraw their names from the list, so that nobody at all signs the petition. Surely this would make it incredibly powerful and guaranteed to be effective.

"Trick or Treatment? Alternative Medicine on Trial" (Bantam Press, £16.99) by Simon Singh and Edzard Ernst is published on 21 April

Homoeopathy by numbers

3,000 registered homoeopaths in the UK

1 in 3 British people use alternative therapies such as homoeopathy

42% of GPs refer patients to homoeopaths

0 molecules of an active ingredient in a typical "30c" homoeopathic solution

$1m reward offered by James Randi for proof that homoeopathy works

This article first appeared in the 21 April 2008 issue of the New Statesman, Food crisis

TOM EVANS/MOD
Show Hide image

The May Doctrine

The Prime Minister on Brexit, Trump, the return of the state and enticing Labour supporters to vote Tory.

1. The Smart State

Quiet resolve: if you read Theresa May’s speeches carefully, you will notice that it’s a recurring phrase she uses when explaining the motivation for Brexit. With “quiet resolve”, the Prime Minister likes to say, the British people voted to leave the European Union. It’s also a phrase that could characterise her unflashy approach to politics and, more specifically, to the premiership-making-or-breaking task of delivering Brexit. Talk to May – perhaps the most inscrutable politician to reach 10 Downing Street in modern times and the first sitting home secretary to become prime minister since Lord Palmerston in 1855 – and certain words and phrases repeat in her conversation: civic duty, responsibility, playing by the rules, the common good.

In May’s speech to the 2002 Conservative party conference – through which she first came to national prominence – she called her party “nasty” and complained that Tony Blair’s Labour government, which had won its second landslide election victory the year before, had borrowed “some of our rhetoric”. Something similar could be said in reverse of May’s discourse since becoming prime minister – because, with its echoes of some of the pro-state interventionist rhetoric of Ed Miliband and Vince Cable, it is strikingly different from what we have come to expect from the Conservatives.

David Cameron came to the leadership eager to soften the image of the Tories. In his early tree-hugging, hoody-embracing, Notting Hill-inflected phase, he announced with considerable banality that there was such a thing as society, as if anyone doubted it, but: “It’s just not the same thing as the state.” For all its soft-focus social liberalism, Cameron’s government was resolutely “neo­liberal”, determined to cut back the state and reduce public spending to 35 per cent of GDP. In power, bolstered by the Liberal Democrats, he and his chancellor, George Osborne, were doctrinaire austerians but also liberal globalisers, with an open immigration policy and mercantilist foreign policy. Osborne was also a self-described “liberal interventionist”.

May is moving the Tories in a different direction, and the public and her party are warming to her in a way they never did with Cameron. Tory MPs say that, unlike her predecessor, she has a “people” and she is far more at ease with the average Tory activist than the Cameroons were (one could always imagine them muttering about “swivel-eyed loons” as they left a village fete). It was emblematic that, when May sacked George Osborne at the start of her premiership, she is reported to have told him to get to know the party better.

The vote for Brexit has unlocked possibilities for her and created an opportunity, she believes, for a new political economy. It was Brexit that opened the door of 10 Downing Street to her, not least because the alternatives – Boris Johnson, Andrea Leadsom, Michael Gove – were so wayward and divisive.

Unlike Boris Johnson, who seems to have no consistent or coherent world-view, Theresa May believes in an interventionist, even moral, state. “The key thing about her is her belief in the efficacy and, so to speak, compensatory function of the state, the important positive functions – you might even say the moral functions of the state,” said the philosopher John Gray, whose recent New Statesman essays have been read with interest in No 10.

 

***

 

When I visited Theresa May one recent morning in her office in Downing Street, we discussed her trip to Davos, Switzerland, in January. In an address to the World Economic Forum, she told the citizens of the world gathered high in the Alps that “those on modest-to-low incomes living in relatively rich countries around the West” feel that the forces of globalisation are not working for them, hence the “quiet resolve” protest vote for Brexit.

I asked what she meant by the phrase, which carries an implicit suggestion of approval, as if people had risen up against those who would suppress or deceive them. Indeed, I asked her, given the resilience of the British economy, which according to the Bank of England’s revised forecasts is expected to grow by 2 per cent this year, whether she regretted not voting for Brexit, so completely had she embraced it. She smiled and said she never answered “hypothetical questions like that” but conceded that, much to the irritation of the liberal wing of her party and the 48 per cent of Britons who voted for the status quo, a “clean” Brexit was necessary and irreversible. There would be no turning back.

May referred to a speech she gave in April 2016, at the start of the referendum campaign. “What I said was, ‘This is a balanced judgement.’ The sky will not fall in if we leave the European Union, and it hasn’t. And this is where the ‘resolve’ comes in, the sense that a lot of people voted for Brexit because they believed in this, they wanted us to feel that we were a sovereign, independent nation, not dependent on decisions taken elsewhere, and they felt that that might bring some problems, but that we would get over them. And that was, if you like, that – and that we would come through stronger. That’s what I’m trying to capture in how we look at this. And the overwhelming view I get from the public, from business, is that, whichever side of the debate people were on before 23 June, the decision’s been made, so let’s get on with it. This is what I meant by the phrase ‘Brexit means Brexit’.”

My meeting with Theresa May took place a few days after she had returned from her trip to visit Donald Trump in the White House and just as she was preparing to leave for an informal EU summit in Malta. She considers her trip to the US to have been a resounding success, despite Trump’s best attempts to undermine it with the timing of his nefarious executive order seeking to ban refugees and citizens of seven Muslim-majority countries from entering America. At a press conference in Ankara, Turkey, on the way back from the US, May equivocated when she was asked about the so-called Muslim ban, as if the question had surprised her.

“From memory, I was specifically asked about the refugees,” she told me. “I made the point but in a slightly different way, which is: we have a different approach to this, which, if you like, is saying we don’t do it like that! And we’re not going to do it like that. We do it the way the UK does.”

To many Britons, May’s visit to Trump so soon after his inauguration and the sight of them walking hand in hand were distasteful. Tens of thousands of people marched in London and elsewhere to protest against Trump’s ban and his planned trip to the UK.  But May reaffirmed that the president’s state visit would go ahead. “The invitation has been given and accepted. The relationship we have with the US is very important. And it’s partly because of the nature of the relationship that we can say to them if we don’t agree with something, we can say that openly to them.”

She had not met Trump before the visit and had no prior expectations, despite the many severe doubts expressed by others about his temperament and character. “I’d only seen him on television. Somebody asked me this [if he had lived up to expectations] the other day and I said I’m not the sort of person who thinks, ‘Well, I’m going to meet X and they’re going to be A, B, C, D and E, and how am I going to react?’ I just meet them and take them as I find them.”

May is too cautious and pragmatic to condemn the US president, but nor will she commend him. Her approach to Trump’s White House should surely be the same as her approach to Vladimir Putin’s Russia, on which she said she “wants sanctions to remain”: engage but beware.

 

This is the cover story from this week's New Statesman, on sale from 9 February. For access to the full issue, subscribe here.

 

***

Since the start of the year, when she was mocked on the cover of the Economist as “Theresa Maybe”, Britain’s “indecisive premier”, May has delivered three major speeches – at Lancaster House in London, in Davos and in Philadelphia – which, read together, offer a coherent exposition of what is an emerging May Doctrine. The May Doctrine has three pillars: a new realism in foreign policy; the return of the state in domestic affairs; and social and economic reform leading to a renewed commitment to social cohesion and the common good.

In the Lancaster House speech on 17 January, the Prime Minister confirmed to her audience of diplomats and journalists (I was present) that Britain would leave the European single market and the customs union and take back control of its borders. The speech was praised by Brexiteers, and also in Brussels, where diplomats liked its clarity and the fact that she wasn’t asking for something complicated. How­ever, May has also faced strong criticism over her Brexit strategy, some of it from within her party. On 1 February, in the Commons debate on Article 50, George Osborne suggested that the government had chosen “not to make the economy the priority”. Instead, he said, “They have prioritised immigration control.”

I read the former chancellor’s remarks to May when we met but she pushed back against them. “One of the problems with this debate about Brexit is that people look at too many aspects of it in a binary way,” she said. “They are thinking about this in terms of the power that we’ve had as a member of the EU.”

What is required is a different approach, she told me.

“What we say is: what is the outcome that we want to achieve? And it is possible to achieve an outcome which is both a good result for the economy and is a good result for people who want us to control immigration – to be able to set our own rules on the immigration of people coming from the European Union. It is perfectly possible to find an arrangement and a partnership with the EU which does that.”

Charles Grant, the director of the Centre for European Reform, believes that rather than choosing a “hard” – the Prime Minister prefers “clean” – Brexit, May should have tilted more towards those who voted Remain. She should have pursued what he calls “an economically optimal deal, something like Norway but a bit different, where we would more or less have been in the single market with a little bit of restriction on free movement”.

Grant told me that the Prime Minister might have failed, but at least she would have tried. “She didn’t want to invest any political capital in an economically optimal outcome because she might have failed and it would have been embarrassing. So she has gone for a hard Brexit, which she knows is not really good for our economy but the politics come first. But Britain is in a very weak position. As soon as you activate Article 50, the clock is ticking. Therefore diplomacy matters. To get a half-decent deal, you need the goodwill of your partners.”

It is said in Brussels that Theresa May is not a natural diplomat. In meetings and phone conversations with European partners, she is reported to stick rigidly to her speaking notes. “She may not realise how weak her hand is,” Grant said.

May does not accept that her negotiating position is weak. Yet, even if she did, she wouldn’t say so. “The reason I don’t feel I have a weak hand is because this isn’t just about us, it’s also about the remaining member states of the European Union. If you look at the issues around trade, they will have interests in that, as well. If you look around some of the other aspects of the strategic partnership we want and the co-operation we want, they will have interests in this, as well. This isn’t just about the UK as a supplicant to the EU, it’s about arranging a partnership that works for all of us.”

Perhaps May under-appreciates just how embattled the remaining 27 EU member states are feeling. Not only has the bloc been destabilised by the eurozone and refugee crises and by the vote for Brexit, anti-immigrant populist and ethnic nationalist movements are also sweeping the continent. President Trump, who leads what the conservative American commentator David Brooks describes as not a Republican but an ethnic nationalist administration, unapologetically wants the European project to fail.

In this context, agreeing a mutually beneficial free trade deal with the British might be in the best economic interests of the EU27, but would it be in their political interest? Why should they make it easy for the British, who by leaving the EU are, in the view of the Brussels elites, wilfully weakening the rules-based liberal order?

Worse still, the British have rushed to embrace Trump. According to Emmanuel Macron, the independent centrist challenger for the French presidency, Britain is becoming a “vassal state”. In such circumstances, why wouldn’t the EU punish us?

“Well, there has been some language of punishment,” May said, her tone unvaryingly measured and cautious. “But what I’m seeing is, over time, a slightly different approach is being taken . . . There is an issue for the European Union [in relation to its disintegration]. We want to see it remain strong. It’s in our interest to continue to have a good strategic relationship with a strong European Union. And as I also hinted in my Lancaster House speech, the members do need, perhaps, to look at the Brexit vote and think about whether they need to reform the way they approach things. You mentioned the issue of what people often call the populist parties. This is about people saying that there are issues for them that they want their politicians to respond to. It’s so important for mainstream politicians to recognise that and to respond.”

I suggested that these issues are to do with identity, belonging and security.

“Yes, those issues,” May said. “And also the economic impact, of what’s happened in terms of the way the world operates economically these days, people feeling that somehow they’ve been left behind.”

May is committed to reducing the UK’s annual net migration from more than 330,000 to the tens of thousands, which is why her desire to restrict intra-European migration is so fundamental. “We have always been a welcoming country,” she said, “but we want to bring immigration down to sustainable levels. There is evidence – I know people argue about this – but there is a displacement of jobs, and you can see an impact on people, particularly at the lower end of the income scale.

“The Labour Party has abandoned many people who have traditionally supported it. Because it hasn’t responded to their concerns on things like the impact of immigration on lower income levels.”

***

Many people I know were offended when, in her conference speech last year, May said: “If you’re a citizen of the world, you’re a citizen of nowhere.” Was this an attack on deracinated cosmopolitans, on those whom the writer Pico Iyer calls “global souls”?

“What I was saying was more about [how] people should have a root in a community, should have a feeling that they are part of a community and that they have responsibilities in a community,” May told me. “I was talking about the concept that you can be around the whole world and not have those responsibilities anywhere. I wasn’t getting at a particular grouping or individual . . . Recently there’s been a sense that all that matters is the individual, rather than their responsibilities to other people. I think we need to redress that balance.”

Some of May’s closest aides call her “a new model conservative”. She is neither a Thatcherite nor an old-style One Nation Macmillanite Tory. Her cabinet is more meritocratic than Cameron’s (it is the most state-educated since the Attlee government), older and more serious-minded. She does not tolerate fools or frivolity, though she does have a nicely modulated sense of humour. She said she would not call an early general election and she did not – a notable contrast with the game-playing of Gordon Brown when he became prime minister.

May is not an ideologue but she aspires to be a consensus-breaker, as Margaret Thatcher was before her. In many ways, she is our first post-Thatcherite prime minister, even a post-liberal, but not an anti-liberal: she embraces the liberal reforms of the past two decades, such as gay marriage, and has never said a word against them. To the bewilderment of many on both the left and the right, she is intent on breaking with the orthodoxies of neoliberalism, but
from the right.

“To me, May is a communitarian,” said Ryan Shorthouse, the director of the right-leaning think tank Bright Blue. “She has moved left economically and to the right socially. She doesn’t like excessive individualism and is putting the state central in reforming society. She recognises that globalisation and liberalism have downsides.”

Elected to the House of Commons in 1997, May, the grammar-school-educated daughter of a vicar who grew up in an Oxfordshire vicarage and who was an only child, is not considered to be clubbable in the way that Cameron and Osborne were, with their gilded extended network of like-minded, well-born friends in politics and the media: the so-called chumocracy. “May won the leadership race by not being close to anyone or any faction,” Shorthouse told me. “She isn’t part of any tribe. Cameron had his think tanks, like Policy Exchange, and his journalists, and those who were ideologically loyal to him. But May is an independent figure. There are no Mayites. She’s hard to pin down. As home secretary, she took on the police but also wants to cut down on immigration. She gives a bit to every wing of the party. It makes her vulnerable if the heat is on.”

Because of her relative isolation, May’s closest aides are extraordinarily loyal to and protective of her, and their loyalty – one of them told me that he would “run through a brick wall for her” – is fundamental to understanding her style.

If May, who is 60, succeeds in creating a new political economy combining greater social mobility with enhanced social justice, she will condemn Jeremy Corbyn’s party to electoral oblivion, because, as she told me several times, she intends directly to appeal to disillusioned Labour voters, those who feel let down or abandoned by the party’s turn to the radical left. The Tories are expected to win the Copeland by-election on 23 February, which would be the first time the governing party has a gained a seat in a by-election since 1982.

“I hope there are Labour voters out there who will now look at us afresh and say, ‘Labour hasn’t responded to our concerns, it hasn’t recognised what matters to us, but the Conservatives have seen that and are responding to it.’ I want our greater prosperity not to be confined to particular groups of people or a single part of the country.”

Listening to May, who delights in reminding Labour that the Tories have had two women prime ministers, speak about the need to create a society “that works for everyone, not just the few”, is to understand that her threat to turn Britain into an offshore tax haven if the EU seeks to “punish” her government for opting for a hard Brexit is no more than a transparent negotiating gambit. Although many on the right yearn for such an outcome, she does not.

“I don’t think we will get there [Britain becoming an offshore tax haven], but I think it needs to be clear: if it [a lack of a deal] did happen, this is what we would do. But I don’t think we’ll get to that point because I think it is in everybody’s interest to find an arrangement, to find a partnership between us that actually meets the needs on both sides. Because there are two sides to this. It isn’t just about what happens to the UK but also about what happens in terms  of economics and manufacturers and others in the European Union.”

2. The Common Good

So far, the rhetorical positioning has been matched by policy initiatives that the Prime Minister’s critics say are modest and incremental at best. She seemed irritated to hear this. “I don’t know which particular policies they’re thinking about, but they’re not modest or incremental,” she said. “Look at the industrial strategy. There have always been industrial policies, but this is an industrial strategy that says, ‘This is about a whole government approach, about looking across the whole country to ensure that we’re making the best of the expertise and the advantages that different parts of the country have, but ensuring that we are seeing that growth spread.”

May believes not that government is the problem, as Ronald Reagan once declared, heralding the neoliberal era, but that it is and should be a force for the common good. In her 2016 conference speech in Birmingham, she denounced the templates of both the socialist left and the libertarian right. I asked what it was about the libertarian right that bothered her. “I suppose it’s the concept that it’s only the individual who matters, that there is no common good, if you like. To me, conservatives have always believed in the common good.”

John Bew, the author of Citizen Clem, an acclaimed biography of Clement Attlee, believes that May is closer to offering “some kind of Attleeite new deal for Britain” than any Labour leader for a generation. (May is an admirer of Attlee and referenced him in her 2016 conference speech, but doesn’t think in such terms.) “Her cool-headed realism now as Brexit hysteria dies down,” Bew told me, “chimes with the mood of Britain, which is why she is doing so well in the polls. Some of it has landed accidentally in her lap . . . But she appeals to a fair-minded, moderate majority. Her vision does not require great virtue from the private citizen like the ‘big society’ – she wants to let people get on with their lives but for the powerful to play by the rules, too. All this is very British in spirit. But is this new credo fit for purpose in this changing world?”

Too often, during the last Conservative government, it seemed as if the poorest were carrying the greatest burden of austerity, as well as being penalised and harassed for minor benefit infringements, while the wealthiest operated by different rules, indifferent to the struggles of the majority. Yet for May, if the common good means anything, it means business recognising its sense of responsibility to wider society.

“There has been a breakdown in trust,” she said. “Wages have been stagnant but there are other aspects to it, too. There’s been a breakdown in trust in institutions that have always formed the core of our society. There’s a sense that business somehow has been playing by a different set of rules, which is unfair. Tax avoidance is one of the issues. I’m trying to show business the importance of recognising the roots in community and the impact that decisions have on a community. What I’m talking about is a wider sharing and signs of solidarity. I don’t tend to think about terms like a new social contract between the state and the citizen, but I do speak about responsibilities. There needs to be a new recognition of the role that the state can play. And the separate responsibilities of the different players that make up our whole society and our economy and the role they have to play in forging a new and different future.”

Her instincts are classically Tory on defence and security issues but no one close to her doubts her sincerity in wanting improved corporate governance and a fairer deal for the ordinary worker, for those who are “just about managing”. As it happens, she did not use this phrase once during our conversation, and I’ve heard that she was furious when, early in her premiership, a civil servant referred to this group by the acronym “Jam” in a written report. May crossed it out and instructed that the acronym should not be used again. Unfortunately for her, it is now in wide circulation.

May is interested in the primacy of social cohesion, John Gray told me. “Of all of the things I note in everything she says – if you think of not just those liberal philosophers like Rawls, but even people like David Cameron – the key thing that they want to deliver is greater consumer choice or greater choice. What she seems to want to deliver is greater opportunities for the good life. And she’s not representing the good life as just increased consumer choice.”

Essential to May’s conception of the common good is the preservation of the Union. “We get so much benefit from being together,” she said. “Look at Scotland and the position it would be in because of what has happened to the oil price, for example, after the referendum. Look at the current polling evidence in Scotland. It shows that the Scottish people don’t want a referendum. And they don’t want independence.”

Should Nicola Sturgeon stop threatening a second referendum? “The vote took place in 2014, which I seem to recall everybody including the SNP said was a ‘once in a generation’ vote. It was clear that Scotland wanted to remain part of the United Kingdom. I want to negotiate a deal that is good for all parts of the United Kingdom. Further powers have been devolved. One of the decisions we’ll have to take as part of the Brexit work is where there are currently decisions being made in Brussels, should those return to the UK or be further devolved.”

3. The New Realism

Theresa May’s Philadelphia speech was the most significant on foreign policy by a British prime minister since Tony Blair’s Chicago speech in April 1999, in which in the aftermath of the Nato intervention in Kosovo he fervently defended Western values and made the “moral” case for remaking the world and becoming “actively involved in other people’s conflicts”.

But in Philadelphia, May emphatically broke with liberal interventionism, saying that we should not “attempt to remake the world in our own image”. The speech was misread by some at first as a statement of classic Tory foreign policy restraint and retreat. It was not. The speech made clear that her foreign policy would not be amoral or ethically neutral. Nor would it be “idealist” or universalist, as Blair’s was. Rather, it would be cautiously “realist”: the Prime Minister reaffirmed her commitment to free trade, to multilateral institutions such as Nato and to the rules-based liberal world order, but conceded the limits of Western liberalism, which, she said, cannot be exported or imposed by military intervention.

May and her advisers understand that liberal values are not absolutes but practices that evolve over a long time and can easily be disrupted, as is happening in Donald Trump’s America. These values cannot be merely dropped like bombs on foreign lands, as Blair and Cameron seemed to believe. May is not an advocate of a Pax Americana that is forced on the world by war.

But nor does May rule out military intervention if it should be in the national interest. “We need to put Britain’s interests first but mustn’t just assume there’s a sort of natural thing for the UK to intervene in order to change places in the way we think they should be changed,” she told me. “I’m not saying that we don’t believe that we would like to see more democratic countries, with a very clear [commitment to the] rule of law, but I think there are different ways of achieving that. I’m not ruling out the possibility of
intervention, but we do need to be very clear about when it is in British interests to do that.”

What is the UK’s role in the world? It’s a question that May believes Brexit has brought into “sharper focus”. She said: “As we leave the European Union but remain in close partnership with Europe . . . there is a role for the UK, and the US, to show leadership in the world. There is a real point of change at the moment. That was what the vote on 23 June was about. It was about leaving the EU, but there was a deeper call for change. As mainstream politicians, we need to recognise that and respond to that.”

She believes the UK should stand up for Western values of democracy and the rule of law, for the international rules-based order. “Internationally, there is a turn towards protectionism and isolationism. That is not what we want to see in the UK. We want to be outward-looking. There is a job for us in promoting free trade, to be able to show people what the benefits of that are. And, of course, it is about linking what we do in the world with how we as a government behave here in domestic policy terms.”

I discussed with Theresa May President Obama’s doctrine of “tragic realism” and his belief, influenced by the philosopher-theologian Reinhold Niebuhr, that there is evil in the world about which sometimes nothing can be done. In a recent interview with the New York Times book critic Michiko Kakutani, Obama cited the celebrated opening to V S Naipaul’s novel A Bend in the River, which is set in what is today the Democratic Republic of Congo: “The world is what it is; men who are nothing, who allow themselves to become nothing, have no place in it.”

Obama said that he thought about that line and Naipaul’s novel when “thinking about the hardness of the world sometimes, particularly in foreign policy, and I resist and fight against sometimes that very cynical, more realistic view of the world. And yet, there are times where it feels as if  that may be true.”

“I don’t think I’d put it in the same way,” Theresa May said of the notion of tragic realism. “But we have to recognise that there are threats out there in the world that we have to deal with.” She then spoke at length about the malignancy of Isis and of Islamist terrorism more generally.

For all the criticism of her trip to Washington, DC – the historian Simon Schama called her “Theresa Appeaser” for meeting Trump – the Prime Minister was delighted that she received from the new president a renewed commitment to Nato. “When President Trump spoke particularly during the election campaign about his attitude to Nato, a lot of people started to worry about what that means: is America going to withdraw? But I got a 100 per cent commitment from him to Nato.”

She said the commitment was made from the president in private as well as at the White House press conference. “It was absolutely yes, there’s an absolute commitment there . . . I didn’t surprise him by it, no. He did say yes into the microphone when I said it. But what he explained . . . is that he’d used some phrases about Nato in the past but what he actually wanted to ensure was that Nato was shaping itself up for the future. And we agree that it needs to do more to ensure that it is able to deal with terrorism and cyber warfare, as well as conventional warfare. I agree with him that we want to see all members of Nato [honouring] their commitment to spend 2 per cent of GDP [on defence].”

How toxic is Donald Trump, and how wary should the British be of him? “What I was saying to the Americans is about two things,” the Prime Minister said. “One was about the relationship between the UK and US and the strength that gives us in being able to take that leadership role and that responsibility to lead.”

Does being close to Trump’s White House mean turning away from China? “No, I don’t think so,” said May, who was encouraged by President Xi Jinping’s Davos speech, in which he defended the virtues of free trade, unsurprisingly since globalisation has helped lift 700 million Chinese out of poverty. “Obviously the White House has made certain comments about their future relationship with China, but that will be a matter for the United States. We will continue to build on the strength of our relationship that we have with China.”

May reiterated that the commitment she received on the special relationship and on Nato from President Trump was “very important, not just for our future, but the future of Europe, the security of Europe and indeed the West”.

***

Theresa May speaks of “my method”, by which she means her approach to politics, the way she likes to keep her strategic options open for as long as possible. She weighs and balances the evidence and consults with her closest advisers before acting. She considers it wise to make haste slowly and, I was told, allows the “logic of the situation” to dictate her actions. She chooses the outcome she wants and works backwards from there.

Her aides say that she is anything but indecisive, but she is deliberative: from the beginning, she understood that the referendum result was a mandate not merely to leave the EU but to reshape the economy and society. And she knew what she wanted from Brexit and that it would require Britain leaving the single market and ending freedom of movement. It was just that people refused to listen to what she was saying, or did not read her speeches attentively enough.

May aspires to create a Great Meritocracy and would be delighted if the first of the new grammar schools that she hopes to establish opened in one of the poorest areas in the country, rather than in one of the most affluent. But can her vision of a new, more equitable Britain, in which traditional Labour supporters are enticed into voting Tory, as many were in the Thatcher years, survive the strategic logic of Brexit, with its inevitable fractures and disruptions? The Prime Minister is wagering much on the goodwill of her negotiating partners. She hopes that economic self-interest will prevail over the politics of resentment.

May has a nuanced sense of the British national interest and accepts that she can’t simply have a narrow, trade-based, mercantilist approach to foreign policy. Values also matter, as her campaign against modern slavery demonstrates. In Philadelphia, she appealed directly to the better instincts of the Republican Party because, although she won’t say so, she understands how erratic and unpredictable the Trump White House is as it goads the Chinese, sweet-talks Putin, embraces protectionism and moves remorselessly towards authoritarianism.

Asked about the appointment of a senior general, Napoleon is reported to have said: “Is he lucky?” One should never underplay the role of luck in politics as in life. Theresa May is certainly fortunate in facing such a divided and demoralised opposition. But the last three Conservative prime ministers before her were, in their different ways, all ultimately brought down by Europe. Is it to be May’s destiny to settle the European question once and for all, and thus bring peace to her fractious party, or will the combined forces of Trump and Brexit destabilise the European continent and the fragile British state in ways as yet unimagined?

In his counterfactual novel The Plot Against America (2004), in which the pioneering aviator and America First nationalist Charles Lindbergh wins the presidency and begins to turn the country towards fascism, Philip Roth writes about the “terror of the unforeseen”: the unexpected event, the chance occurrence, the unimagined catastrophe that can transform all our lives.

As soon as Theresa May invokes Article 50, she will lose control of an essential aspect of her foreign policy. She will be at the mercy of events and have to rely on the pragmatic good sense and the kindness of others, by which I mean the spurned EU27. We all live with a sense of the terror of the unforeseen. Theresa May believes in the “quiet resolve” of her fellow Britons. She is optimistic about our future prosperity. She has a clear sense of the direction in which she wants to take the country and how she wishes to transform it. She knows the outcome she wants from Brexit and, after her Lancaster House speech, so does everyone else. Her competence, steeliness and method have taken her a long way, from the vicarage in Oxfordshire to 10 Downing Street. But is she lucky? And given the epic challenge of EU withdrawal, can she be more than the Brexit PM? 

Now read our quickfire questions with the Prime Minister, where she opens up on cooking, Jane Austen, and who she'd spend her last supper with.

Jason Cowley is editor of the New Statesman. He has been the editor of Granta, a senior editor at the Observer and a staff writer at the Times.

This article first appeared in the 09 February 2016 issue of the New Statesman, The May Doctrine