Battle for Health

Extracts from A Political History of the Socialist Medical Association, 1930–51 by John Stewart, reproduced with permission

CHAPTER THREE The People’s Health

This chapter examines the founding of the Socialist Medical Association and its consequent organisational development in the 1930s, including affiliation to the Labour Party in 1931. It further analyses the principles on which the Association argued for a socialised medical service. Unsurprisingly, these built on the ideas put forward by medical reformers since the turn of the century. The great change in the 1930s, however, was that now an explicitly socialist medical organisation – the SMA – was in existence, and affiliated to the main opposition political party. The Association could anticipate, at some future point, a Labour administration in which its own ideas on health and health care might be highly influential. A sense of optimism and of urgency informed the SMA’s arguments in this period although it was, as shall become apparent, fully aware that its scheme was not the only proposed solution to the reconstruction of the health care system.

The founding of the Socialist Medical Association

Both Murray and Brook give accounts of the circumstances surrounding the SMA’s formation. In addition to the general context described in the last chapter, at least three immediate factors seem to have been involved. First, the question of a state medical service had again been under discussion by left-wing medical activists, both in the National Medical Service Association (successor to the SMSA) and, more specifically, as a result of an article by Hastings on the future of medical practice which appeared in the Lancet in 1928. Second, Brook, following a speech to an LCC meeting, had been contacted and visited by the Berlin dentist Ewald Fabian. Fabian was involved with the German socialist doctors’ organisation whose journal, “Der Sozialistische Arzt”, he also edited, and was keen that British socialist doctors set up a similar body. The SMA later repaid its debt to Fabian by sending funds in the summer of 1933 to help his journal out of its financial difficulties and by securing his release from a French internment camp at the beginning of the Second World War. Third, Brook was particularly incensed by a speech hostile to state medicine made by the Independent MP for London University, Sir Ernest Graham-Little MD. This prompted him to write to the Labour newspaper The Daily Herald proposing the setting up of an organisation of left-wing medical practitioners.1

Webster adds a further possible factor by suggesting that the creation of the SMA might have been in response to the BMA’s A General Medical Service for the Nation, first published in April 1930. There is no direct evidence of this in statements by Association founders. But certainly it would have been part of the general context described earlier, since at least one reason behind the BMA document was, as Peter Bartrip puts it, the desire to halt ‘local authority “encroachments” on private practice … and to pre-empt government plans for a service antipathetic to BMA priorities’.2 It is important to bear in mind here that in 1930 a minority Labour government was in power and, as we have seen, individuals and groups within the labour movement were already agitating for some form of state medical service.

A meeting was held in September 1930, attended by around 20 left-wing medical personnel. It was chaired by Esther Rickards, a Labour LCC member who had been, according to Brook, victimised ‘for her political views when she sought surgical appointments at London hospitals’. A sub-committee was formed to draft a constitution, and in this was aided by James Middleton, Acting Secretary of the Labour Party. The three principal aims of the new organisation (the name of which had been a matter of some debate) were to work for a socialised medical service, both preventive and curative, free and open to all; to secure the highest possible standard of health for the British people; and to propagandise for socialism within the medical and allied services. The proposed constitution was put to a further meeting in early November, and appointments to various offices agreed. The founding officials of the Association were Hastings (President); Alfred Welply, of the MPU (Treasurer); and Brook (Secretary). Brook, who was especially active in the early phase of Association history, also allowed his home to be used as its first office. Other members of the newly-created Executive Committee (EC) included Santo Jeger, soon to be an LCC member and later MP for South West St Pancras; and Alfred Salter and Robert Forgan – like Hastings at this time, MPs. Immediately after the first meeting, Brook told Fabian that: ‘Much notice is being taken of our new organisation in the English press and we are being attacked by the Capitalist newspapers’. None daunted, Brook was convinced that ‘ultimately we shall be very strong in numbers’.3

Because of its small membership, the Association initially decided to postpone applying for Labour Party affiliation. This did not mean, however, that it was inactive. The EC met regularly, and sub-committees on research and on education were set up. The secretary to the latter was the American doctor, Caroline Maule; and to the former G.R Blizard, an old associate of Hastings and also, once again, secretary to the PHAC. The research sub-committee was charged with devising ‘practical measures for a free socialised medical service’, and heard evidence from, among others, Henry Brackenbury of the BMA. As Brook points out, this was quite a coup for such a small and recently-formed organisation. A London and Home Counties branch was formed, a sub-committee of which prepared the document Labour’s Hospital Policy for London, the basis of Labour’s health policy in the 1931 LCC elections. London’s importance to the SMA is discussed in Chapter Five. Contact was also made with foreign socialist medical organisations. As Webster suggests, the founding of the Association ‘reversed the decline’ in Labour Party discussion of health issues which had taken place in the mid- to late 1920s, creating a ‘new forum for mobilising the expertise of socialist doctors’.4 How effective this was remains, however, rather more problematical.

The first annual general meeting (AGM) took place in May 1931. Resolutions were passed on the need to amend Neville Chamberlain’s 1929 Local Government Act to allow for free treatment in municipal hospitals; on health insurance; and, at Maule’s instigation, on the need for municipal hospitals to provide medical education to both men and women on an equal basis. The last was henceforth a consistent feature of the SMA’s programme. The meeting was addressed by Major Greenwood, Association member and Professor of Epidemiology at London University, who spoke on ‘The Municipal Hospitals, the University, and Research in London’. Greenwood, whose ‘profoundly social orientation’ to medicine led him to join the SMA, was to be an important influence on Richard Doll, later prominent both in his own field and in medical politics. However, two other features of the AGM stand out as especially noteworthy. First, on the EC’s recommendation the meeting agreed to seek Labour Party affiliation. Later in 1931 Brook and Hastings appeared before the party’s Organisation Sub-Committee, and the Association was duly affiliated.5 This political commitment distinguished it from earlier bodies such as the SMSA, and opened up the possibility that the SMA might have a real chance of seeing its programme put into action. The organisation’s first delegate – Hastings – attended party conference in 1932, and the significance of this will be discussed in the next chapter.

Second, Hastings gave a key-note speech, ‘The Medical Service of the Future’. This is worth analysing in some detail for the clues it affords as to what the SMA sought.6 Seven basic principles were identified:

1. a preventive service;
2. the end of economic barriers to medical care;
3. the importance of hospitals;
4. the centrality of teamwork;
5. the revised role of the general practitioner;
6. free choice of doctor; and
7. professional freedom.

The starting place here is Hastings’s notion of the ‘team’. However well-informed any individual doctor, he or she could not know everything about rapidly expanding medical science, so in the future ‘the team and not the individual doctor must be the unit’. The ‘medical centre’ (a synonym for ‘health centre’) would be the location of such teams, and would ‘bring together in closest possible cooperation all the several spheres of clinical activity’. These centres were to be linked to hospitals, reorganised into a ‘complete and coordinated … system’. All this would facilitate the already-existing trend towards preventive medicine, which in turn would yield ‘an increase in knowledge such as we have yet hardly dreamed of. This sense of optimism about the possibilities of medical science was, rather unthinkingly, a characteristic of Association attitudes throughout the period of this study. In terms of administration, for Hastings the key institution was to be local authorities and their health committees. Implicit in this, therefore, was democratic control of the health services. Any other consideration aside, this was obviously seen as a direct contrast to the unaccountable voluntary hospitals ruled by the medical elite.

So far, Hastings was expressing ideas which had been around in reforming medical circles for some time, and elements of which can be seen in his own proposals of the 1920s and earlier. In his speech he also began to address what was to be one of the most problematic issues for the SMA in the coming years, the role of the ‘independent’ doctor, and particularly the general practitioner. Inherent in the idea of teamwork was, consciously or otherwise, the notion of a full-time salaried service. This was something of which GPs in particular were well-known to be deeply suspicious, their argument being that such a service would, among other things, undermine clinical independence and reduce them to the medical equivalent of civil servants. Hastings approached this from a number of different angles. First, he maintained that even in a system based on health centres the GP would be the ‘most important link in the medical chain’. Second, there had to be ‘professional freedom’. In other words although health services were to be democratically controlled (with all that this implied for the role of medical practitioners), nonetheless the autonomy of clinical judgement should be safeguarded. There was a clear tension here, which was to prove consistently problematical for the Association. In 1933, for example, Hastings told an SMA meeting that there were four guiding principles in respect of doctors’ control in a state medical service. It was certainly the case that medical appointments should be made by the appropriate public body. But doctors should also have direct access to administrators and elected representatives, both to remedy their own grievances and to give advice. The first, and crucial, principle was that ‘medical staff must have the sole determining voice as to the type of medical treatment to be given to each individual patient’. Hastings had, at this point, a very low opinion of the average citizen’s medical knowledge. As he put it on one occasion, the general public were ‘extraordinarily bad judges of a doctor’s worth’.7

This was, of course, unsurprising, given that Hastings also argued that medicine was now so complex that individual doctors themselves had great difficulty in encompassing it. But as will subsequently be shown, particularly after the capture of the LCC by Labour in 1934 democratic control by local authorities was consistently pushed as the model for health service reorganisation. Even so, Hastings in 1938 still emphasised that it was ‘very difficult for the public to appreciate what is essential for the adequate treatment of disease’.8 In effect, what the Association was encountering was the classic political dilemma of the role of professional bodies in democratic societies characterised by a high division of labour and specialised knowledge. This was an issue never fully resolved by the SMA perhaps because it is, ultimately, irresolvable. It recurs at various points, and in various contexts, through­out this work.

The third way in which Hastings addressed the GP issue in his speech was through the economics of health care. From the patients’ point of view, he was clear that there should be no ‘economic barrier’ to the provision of medical services. Similarly, patients should have the right to choose which doctor they attended. Embryonically present here was another issue more explicitly dealt with in the debates of the 1940s, the citizen’s ‘right’ to health. But the existing economic relationship between doctor and patient did not, Hastings further argued, benefit doctors either. Indeed the relationship could be one of dependence on the practitioners’ part, ‘undesirable’ in a number of ways. These included the risk that the doctor might not give ‘wholesome but unpleasant advice’, and that he might become more concerned with ‘mere externals’ rather than an ‘intimate knowledge of the science of his profession’. In other words doctors were, under the present system wherein some patients held the economic advantage through direct payments or through private or even state insurance, being put into positions which might ethically compromise them and which did not allow for the full development of medical skills and understanding. Clinical independence would, consequently, be enhanced rather than diminished by the kind of system Hastings proposed. The significance of these ideas, as further expounded in two important documents – The People’s Health and A Socialised Medical Service – are returned to below.

Such arguments for a socialist medical system were, as will be evident, largely organisational. There was no questioning of the basis of scientific knowledge nor of the ability of doctors to employ such knowledge. Nonetheless, two points are worth emphasising about the ideas of its leading activists at the time of the Association’s creation. First, medical practice at its best could provide a model for socialism, and this underpins arguments on matters such as teamwork and health centres. As Hastings told (no doubt bemused) medical colleagues in 1932, in principle at least, ‘doctors more than any [other profession] practised socialism’.9 Second, and as we saw in the last chapter, the proposals of some of its founding members were underwritten by a philosophy which found cooperation and harmony in the natural world. This provided an organic model on which both a socialised medical service and a socialist society could be built. Medicine was not, moreover, seen in isolation. On the contrary, it was clearly felt that the capitalist system, and the social conditions and inequalities it generated, was the ultimate source of the vast majority of ill-health.

Nor was health simply an individual concern. Illness had an impact not only on the lives of the sufferers, but also on society as a whole, to the detriment of both. Hastings wrote to the Lancet in 1932 on the subject of unemployment and health. There could be no question, he claimed, that many of the unemployed experienced considerable difficulties in gaining an adequate diet, and that existing welfare measures were in themselves insufficient – hence the urgent need to combat the physical degeneration certain to result from a deficiency of the proper type of food. It was, he continued, ‘of the greatest importance that the standard of our national stock shall be maintained’. Nor did Association members doubt that the distribution of economic resources had a profound impact on individual and national well-being. As Stella Churchill remarked in 1935, it was ‘one of the great anomalies in our civilization that matters of health receive far less State support than do those of Defence … or business communications’. 10

Health was therefore identified as a total package, an integral part of the wider society and thereby bound up with prevailing socio-economic conditions and political structures. This in part explains the SMA’s continuous demand for a shift from curative to preventive medicine. Of course by this time there was nothing new, at least on the political left, in the idea that the capitalist system made you sick. Influential social democratic thinkers such as R.H. Tawney saw health inequalities as central to their moral condemnation of capitalism and possessive individualism.11 What socialist medical personnel were able to contribute, however, was first-hand, professional experience of contemporary health care provision and analyses from both left-wing and medical perspectives. They saw the anarchy, instability, and inequalities of contemporary capitalism reflected in medical organisation. Services were provided on the basis of patients’ income and the profit motive of independent contractors, distortions of medicine’s true aims and purposes. At its best, medicine was altruistic; internationalist; geared towards patients’ needs, not practitioners’ profits; and carried out by teams of professionals – doctors, nurses, social workers and so on – working cooperatively. Moreover, health services should be controlled by all citizens rather than by medical elites: the right to health, therefore, implicitly involved more than the passive receipt of welfare.

These arguments put forward by the Association also fit in with wider trends in social democracy’s history. In terms of policy formation the inter-war era was, Esping-Andersen suggests, the ‘historical watershed in which the struggle for social citizenship became the linchpin of social democratic polities’; and when, as Howell puts it in the specifically British context, the Labour Party adopted a ‘social democratic perspective’.12 This was, however, highly problematic in that social democracy always faces the dilemma of whether to prioritise welfare provision or economic reconstruction. The SMA was on occasions forced to acknowledge this strategic choice; and that the broader labour movement did not always accept the priority it accorded to health care reform, nor the organisational structures which it proposed. But this should also be put in the context of the organisation’s assertion that health was highly determined by social conditions and hence the need, for example, for a socialist government to devote significant resources to remedy poor housing conditions.

In 1931, however, when the central characteristics of the SMA programme were being put in place, these problems dwelt largely in the future. The Association had affiliated to the Labour Party – Brook’s ‘primary essential’ – and had thus avoided what its founders saw as the main drawback of bodies such as the SMSA. The SMA had, from the outset, members already well-known in left-wing medical politics. Hastings in particular was important, through his membership of parliament and of party bodies such as the PHAC; through, according to Murray, his contacts with leading Labour politicians such as Christopher Addison and Arthur Greenwood; and in his already-emerging role as a prominent medical figure in London politics.13 The Labour Party was, for the SMA, the vehicle for the achievement of socialism and, although it might not have yet recognized it, of a socialised medical service. What this might involve was laid down by Hastings at the first AGM. Before examining how the Association’s ideas on medical reorganisation developed during the rest of the 1930s, however, it is necessary to look in more detail at certain aspects of its organisation. In particular, attention will be paid to the size and nature of its membership; and to the founding and role of its associated publications.

Membership and propaganda

In 1930 the SMA consisted of only a handful of committed individuals. According to Labour Party annual conference reports, membership throughout the 1930s was consistently 240, remaining so until the rapid acceleration recorded from the early 1940s onwards, dealt with in a subsequent chapter. This suspiciously precise figure almost certainly relates to Labour’s requirement for minimum levels of affiliated membership so that an organisation be allowed a party conference delegate. Nonetheless the Association did expand in the course of the decade. The EC report for 1937-38, for example, noted the recruitment of 33 new members, thereby bringing the total to 190. The following year’s report claimed five branches (London, Glasgow, Bridgend, Birmingham, and Rotherham) and a total membership of 242. One further point needs to be made about these figures. As the 1937-38 report also recorded, of the total membership of 190, approximately 150 lived and worked in or around London.14 Having a membership concentrated in the capital had its advantages, particularly when it came to activities on the LCC. More generally, London is the location of national politics, and where pressure groups such as the SMA primarily conduct their business. Nonetheless, the low level of provincial membership was a clear Association weakness, and a hindrance in setting down deep roots in the labour movement as a whole.

If, concentration in London notwithstanding, the SMA was increasing in size by the late 1930s, there still remains the question of who made up the membership. There are two aspects to this, one political, the other occupational. In 1936 as a result of an EC-sponsored resolution to the AGM, the Association’s constitution was altered to allow full membership to any socialist who subscribed to the organisation’s aims; and who was a member of the medical or ‘allied Professions’, for example dentistry or nursing. Previously, only doctors accepting the rules of the Labour Party had been allowed full membership. The first of these changes effectively opened the door to members of the Communist Party. The timing here is significant for, as we shall see in Chapter Six, the Association was heavily involved in support for the Spanish Republic. It therefore became, both practically and politically, a ‘popular front’ body, adopting a notably left-wing stance on a number of issues. However the acceptance of communists was, as will become apparent, a significant problem for the Association in the longer term.15

The admittance of other professions into full membership is also worth discussion. As Brook noted, despite this change doctors ‘retained a controlling interest in the Association’s governing body’. The Executive Committee of 1942-43, for example, contained 34 members, of whom the majority were medical practitioners or medical scientists. All the leading offices were held by doctors, a situation which prevailed through to the 1970s.16 This hegemony had a further important dimension. In many ways, the SMA was keen to break down the middle class biases and prejudices of the profession, for instance in its campaign for a more broadly-based entry to medical education in terms of both gender and class. But it was also anxious to maintain professional standards and autonomy, and this attitude was clearly present in the potential tension between democratic control and professional rights.

Ultimately, though, and however much they agonised about it, the medical practitioners who led the SMA knew they were middle-class professionals. Hastings had issued a rallying cry to the middle classes in the early 1920s and in 1935 Brook invited Lawrence Benjamin to speak at the Association’s AGM. Benjamin was the author of a Labour Party pamphlet on the role of the middle class in the coming of socialism. This noted that socialism was the ‘scientific means’ of solving problems of distribution, and that professional workers – including doctors, dentists, and nurses – performed the ‘civilising work’ of society. The position of such workers under socialism would, therefore, be guaranteed by the state. Moreover it was necessary, under capitalism and socialism, for professionals to organise themselves in associations. Hence Benjamin’s urging of those suitably qualified to join bodies affiliated to Labour such as the SMA.17 It is easy to see the attractiveness of this to the Association, and its intellectual debt to the Webbs. The appeal to science, professionalism, the public spirit ethos, and state guarantees were all matters with which SMA members could empathise. Benjamin was unable to accept Brook’s invitation because of other commitments. He noted, however, that recruiting the middle class was of ‘first importance to the Movement and specially since the Socialist Medical Association has organised itself for this purpose’. The aim of his pamphlet, he suggested, was to ‘break down professional attitudes to Socialism’. This sort of approach is important in understanding the SMA. Its members were certainly socialists. But their aspirations were also motivated by professional ideals, as was the Association’s behaviour as a pressure group.18 This helps explain the continuing concern with clinical independence and the medical practitioners’ retention of control within the SMA despite the widening of its membership base.

An important way of keeping in touch with these members was through propaganda and publications. At Welply’s suggestion, the first edition of Socialist Doctor appeared in February 1932, taking on a new format in the summer of 1933. Its founding prompted a letter to Murray, installed as editor, from George Lansbury in which the Labour leader argued that state medical services were needed ‘more than ever’. Health care, he continued, was an area of social organisation which had to be removed ‘from the sphere of money-making’, very much the sentiments of the SMA itself. Socialist Doctor, the ‘official organ of the Socialist Medical Association’, ran until 1936. It carried a range of material although much was contributed by Hastings and, in various guises, Murray. But as Brook later pointed out, owing to ‘financial stringency … and, eventually, through lack of support, it eventually petered out’.19

The indefatigable Murray, however, was not inclined to let matters rest. At the 1937 AGM he proposed the publication of a new journal, to remain the SMA’s ‘official organ’ but widened to include ‘all kinds of progressive thought’. Thus was created Medicine Today and Tomorrow (MTT), which continued until 1965 when it was replaced by Socialism and Health. In March 1938 the EC agreed that MTT be formally separated from the Association so as to facilitate its broader approach, and to this end a limited liability company was set up. Murray remained editor with the assistance of a sympathetic journalist, L.C.J. McNae. The journal, which first appeared in October 1937, was initially monthly, but once again financial constraints led it to becoming quarterly in 1939.20

Administrative complications aside, what is perhaps most noticeable in this story is the new publication’s declared mission. As the MTT masthead put it, it provided a forum for expression of all forms of progressive thought within the medical profession, for discussion of the development of medical practice, and for focusing the attention on the place of the doctor in world affairs. This certainly seems to have worked in that, according to Murray, contributions ‘poured in’ from those involved in medical politics from a broad range of positions. The first edition also noted that it had received greetings from important individuals on the left such as Labour leader Clement Attlee, and the advocate of ‘social medicine’ John Ryle.21 Clearly, then, the journal sought to be a ‘popular front’ of medical opinion.

Medicine Today and Tomorrow was of prime importance to the Association, for two related reasons. First, it had an important role in,as Murray put it, keeping ‘the SMA programme in front of an expanding audience’. It was therefore a major outlet for Association ideas, both as expressed by individuals such as Hastings and by the organisation as a whole. As internal correspondence in early 1938 makes clear, although technically Murray’s responsibility as editor was to the publishing company’s shareholders and not to the SMA, in fact the majority of these belonged to the Association. Furthermore, members still received a copy of MTT as a part of their membership, and the Association held shares in the publishing company in its own right. The separation of the Association and the journal was thus more formal than actual.22

Second, there was the presence of Murray himself. Murray claimed editorial autonomy on MTT, and on the creation of the independent publishing company resigned as editor to the SMA and consequently as an EC member. He was, however, soon back on the Executive, and remained a leading figure in the organisation and an important participant in policy formulation. Moreover Murray did not simply edit MTT. He was also one of its most frequent contributors, sometimes under pseudonyms such as ‘Irwin Brown’. The central point here is that through MTT the SMA had the opportunity to thrash out, often in considerable detail, proposals for medical reorganisation. Murray was later to claim, ‘with certainty’, that ‘most of the ideas later incorporated in the NHS, and many still being discussed after twenty years of that service, first appeared in MTT’. This view was broadly shared, much earlier, by Brook.23 While an extravagant assertion, this did contain an element of truth. The journal also carried features on foreign health care systems; on issues such as nurses’ pay and conditions; on the importance of environmental factors in ill-health; on the use of film in health education; and on the architectural criteria for efficient medical buildings. All this emphasises the Association’s commitment to placing health in its broader social and political contexts.

Communication between the SMA leadership and members was further enhanced by the creation of the monthly Bulletin, first published in September 1938 with Dr Elizabeth Bunbury, the Association’s Propaganda Secretary, as editor. Bunbury clearly saw her function as educational. As she told the left-wing scientist J.B.S. Haldane shortly after the Bulletin’s launch, ‘I am trying gradually to introduce a more political and less exclusively medical attitude into the Association, on the basis that we are human beings before we are doctors’.24 This is an interesting comment on Bunbury’s view of her colleagues’ political awareness. It implies that while the SMA leadership was highly politicised, this may have been less true of its ordinary members, most of whom were already heavily committed through the demanding nature of their work. The possible differences between leadership and membership are returned to in Chapter Ten. From a rather different angle, Honigsbaum argues that Bunbury’s overtly political approach certainly tightened up the Association organisationally. But he also claims that it undermined the SMA’s influence on the broader health debate, a further instance of the way in which its left-wing tendencies were, in the long run, a source of weakness,25 For present purposes, what is important is that the Bulletin, like MTT, clearly saw itself as having a didactic role, and as dealing with medicine in its broadest possible sense. This is the context in which we now examine the issue which most preoccupied the Association in the 1930s: the need for, and proposed methods of, medical reorganisation.

The principles of socialised health care

The two key formulations of Association policy in the 1930s were The People’s Health and A Socialised Medical Service. Particular attention will be paid to these, and to how their arguments were built upon in further statements by the SMA and its leading members. First, however, it is necessary to say something about their origins and status. In fact the 1932 pamphlet The People’s Health was not an SMA publication. It was brought out by the Labour Party, with the disclaimer that it was not ‘in any way a statement of official … policy, and has not been examined or approved by the Labour Party as such’. Hastings was the principal author, assisted by J. Bacon, G.P. Blizard, Dr C. Parker, and Dr A. Salter, a ‘group of members of the Labour Party particularly interested in public health’. The disclaimer was reinforced by a statement at 1932 party conference which noted that a number of educational texts – including that of Hastings – had come out, but could not be considered policy statements as they had not been discussed by the Policy Committee. This followed on a decision by the Research and Publicity Committee in May when it was agreed to publish the pamphlet but with a ‘clear statement’ that it was not necessarily official policy.26 The party leadership’s approach here was an early indication of the caution with which it was, ultimately, to deal with the SMA, and particularly its more radical proposals.

A Socialised Medical Service, which appeared in 1933, was by contrast an explicitly SMA publication. It too was not an unequivocally supported document. A policy statement had originally been prepared by the Association’s research sub-committee and presented to the 1932 AGM, where it was the subject of a day-long debate. During this it ran into opposition from, especially, a dissenting member of the subcommittee, Dr Frank Bushnell. According to Murray and Brook, Bushnell objected to the document’s ‘reformist’ tendencies, particularly regarding the control of a socialised service. This is an interesting – if rather obscure – remark in that Bushnell, at the 1930 ILP conference, had proposed a resolution arguing that in a socialised system the ‘authority of medical science would be confined solely to its own sphere, where it would be unquestioned’. Wittingly or otherwise, he was raising an issue we have already noted, the tension between democratic control and professional autonomy. At the SMA meeting other members, less worried by reformism, expressed the need to proceed by stages towards a state medical service, particularly through extending health insurance. Despite these doubts and disagreements the document was subject to only minor modifications, and duly published.27

The wariness of the Labour Party leadership and the misgivings of some Association members are not without meaning. It is important to remember two broader issues. First, Labour had only recently suffered a catastrophic general election defeat. This was followed by a period of intense soul-searching and internal debate as to the way forward to a socialist society, with important sections of the party stressing the need to gain command of the economy as a first step. Ameliorative social reform was not necessarily precluded by such a strategy, but it was placed in an ambiguous position – the classic social democratic dilemma. Second, for its socialist critics at least the most obvious characteristic of the inter-war health care system was that it was hardly a ‘system’ at all. Rather, the provision of medical services was characterised by anarchy, inefficiency, and duplication. Although the SMA drew heavily on the ideas and experiences of earlier in the century, it still saw itself as, in effect, having to build from the foundations upwards. In such circumstances, it was the clarity and coherence of their vision which should be admired, rather than their disagreements and inconsistencies condemned. But what, more precisely, was this vision?

As Murray correctly points out, The People’s Health and A Socialised Medical Service were not identical. Rather enigmatically, he suggests that ‘there are just enough differences between the two to show that the author met some differences of opinion in one of the organizations to which the drafts were presented’.28 Presumably the ‘author’ here was Hastings, and the ‘differences of opinion’ those expressed at the 1932 AGM. These notwithstanding, and they are relatively minor, in what follows the two documents are taken together to illustrate SMA thinking on medical reorganisation in the 1930s. Where appropriate, this will be expanded upon or modified in the light of subsequent policy and other statements. The themes under which this discussion is organised are hospitals; teamwork and health centres; and funding and remuneration.

SMA members had long had reservations about voluntary hospitals because they were autonomous and so not subject to planning or control, and because private philanthropy was thought an inefficient and inappropriate method of health care funding. The voluntary hospitals’ situation was highlighted by the 1929 Local Government Act which permitted, but did not compel, local authorities to take over Poor Law institutions, and thereby began to bring some measure of order by way of an expanded municipal hospital system. As both The People’s Health and A Socialised Medical Service argued, ‘the ideal medical service will need to have associated with it a complete and co-ordinated hospital system’, which was also ‘a single hospital system’. The 1929 Act’s significance was acknowledged, and it was proposed that a slight amendment would enable the full transference of Poor Law institutions to the local authorities which could then build a municipal system free from Poor Law stigma. This was to be a first step towards the abolition of all charges, a process which would be furthered by the repeal of clause 16 of the Act – ‘a particularly odious clause’ – which required authorities to pursue patients for payment. Municipal hospitals would thus become effectively free, and ‘if their efficiency is insisted on by an active Ministry of Health, they will be used by an increasing number of the population’. The potential of the 1929 Act was therefore huge – hence Hastings’s earlier noted admiration for Chamberlain’s tenure at the Health Ministry, and his claim in 1934 that the Act was a recognition by the Minister that private enterprise in health had failed.29

Here, then, were emerging what were to be a number of Association preoccupations, notably the ‘active’ Health Ministry with, nonetheless, local authorities carrying out the responsibility of hospital provision; and free services, part of a ‘complete and co-ordinated hospital system’. Where did these proposals leave the voluntary hospitals? In some respects, The People’s Health and A Socialised Medical Service were relatively moderate here, not least when compared with what Brian Abel-Smith describes as the ‘outspoken attack’ on them by Hastings in 1931. This had included the suggestion that voluntary institutions would soon have outlived their usefulness, and that their absorption into a ‘National or Municipal system seems … certain within a comparatively few years time’.30

Both documents found it ‘most undesirable’ that a voluntary hospital could be set up anywhere without ‘consideration of the existing facilities or the needs of the district’. Such institutions should therefore be licensed and registered, and no new ones founded without special need being demonstrated to the Health Ministry, Moreover the popularity of a free, expanded municipal service would almost certainly increase the charitable sector’s current financial problems. In such circumstances, those voluntary hospital governors with the ‘good of the community at heart’ would realise the need for greater cooperation with the municipal system, and allow local authority hospital committees to take over their institutions. These would then become part of the municipal system, with existing governors being allowed to form up to one-third of the boards of managements during their lifetimes.31 This was a gradualist approach, predicated on the increasing financial problems of the voluntary sector, with no implication of enforced takeover by local or central state. It is clear, though, that there was an inevitability to this gradualism, and no suggestion, for example, that the voluntary hospitals should be bailed out by government, national or local. Given the political circumstances of the 1930s, this gradualism is understandable enough. The National Government which took power in 1931 was disinclined, ideologically or for any other reason, to either challenge the position of the voluntary sector or to amend the 1929 Local Government Act in the ways suggested by the SMA.

Nonetheless the latter’s critique continued unabated. Hastings, Brook, Rickards, and H.B. Morgan gave evidence to the Sankey Commission on voluntary hospitals in 1936, confirming that the SMA’s ‘ultimate policy’ was for their absorption into a ‘complete, unified and co-ordinated service’. Pending this, central coordinating offices should be established as a matter of urgency in London and in large provincial centres ‘to facilitate speedy admission of emergency and urgent cases to all Hospitals irrespective of whether they are Voluntary or Municipal’. Specifically in the capital, this work should be handed over to the LCC, by 1936 an SMA stronghold. Brook saw their evidence as a ‘notable success’, with suggestions such as that for pooling beds in emergencies coming about with the wartime Emergency Bed Service for London.32 The SMA’s approach to the Sankey Commission was clearly to state its fundamental principles while pressing for immediate reforms which could, if implemented, bring the autonomous voluntary hospitals into something more resembling a planned system. The fundamental principles did, however, remain. As discussed in Chapter Five, Hastings and his LCC colleagues argued strongly against any council subsidy to the capital’s voluntary hospitals. Pressing this point home, an MTT editorial in late 1937 suggested that for ‘public money to be handed over to private enterprise’ – that is the voluntary hospitals – would be ‘the negation of democracy’.33 The tactic was thus financial attrition; the strategy the replacement of an inefficient, ill-coordinated, and undemocratic ‘system’ with a socialised and municipally controlled health service.

The hospital scheme being proposed was not an end in itself. It was to be part of a comprehensive, unified service covering all aspects of health care, curative and preventive. Furthermore, given the complexity of modern medical knowledge, ‘no one doctor, however clever he may be, can know all there is to be known about prevention, diagnosis, and treatment of all diseases’. Consequently, in the socialised medical service to come the basic unit must be the team rather than the individual doctor. Under the current state of affairs, as Murray further argued, it could not be suggested that ‘the organization of the medical profession has reached its optimum efficiency’. British doctors did remarkably well by individual patients, but ‘as a whole the work is unorganized, and the arrangements permit at one and the same time of much overlapping and of many gaps in the service’.34 What was therefore needed was team­work and integration, and the crucial institution which would ensure this was to be the health centre.

The idea of the health centre was embryonically present in the Edwardian era in the proposals of the SMSA and other left-wing reformers, and had also been part of the post-war Dawson Report. As we have seen, Murray was later to blame the decline of the SMSA partly on the mistaken belief of some of its members that the battle for health centres had, consequently, been won. This was despite the fact that, as far as Murray was concerned, the Dawson Report had not fully addressed the issue of what constituted a health centre. Moreover by the 1930s there continued to be widespread discussion of how, if at all, such institutions should be organised and controlled. The famous Peckham Health Centre, visited by Association members, provided one possible working model.35 So it became important for the SMA to define what was meant by the term, and to agitate for the introduction of what it saw as ‘true’ health centres.

Unsurprisingly, therefore, these were questions which both The People’s Health and A Socialised Medical Service addressed. In urban areas, the population was to be divided into units of around 60,000 people, each served by a health centre located, as far as possible, at the ‘obvious natural centre of each unit’. Every centre would have a team of general practitioners, each responsible for between 2000-2500 patients. Patients would be able to choose their own doctor, as long as the doctor still had room on his or her list, and would be seen ‘mainly by appointment’ at the centre. Although the stated purpose of the GPs was to practise curative medicine, it was also clearly intended that they should have a preventive role. It was to be their duty to ‘do their utmost to maintain and improve’ their patients’ health. General practitioners would therefore carry out periodic medical checks and various mechanisms were to be put in place to allow, for example, for the reporting of unhealthy domestic conditions. Finally, at least one of the GPs attached to each health centre was to be a woman.36

If, however, this was the sum of the SMA’s proposals they would amount to little more than an advocacy of group practice. But in a socialised medical service, health centres were to have a much broader and more important function. Qualified pharmacists would be available to dispense drugs, while there would be departments and clinics specifically geared to such health issues as child welfare and ‘the study and treatment of early mental disease’. Pathological laboratories were to be provided for it was important that ‘pathology should not be divorced from clinical medicine’, a proposal probably put forward by Murray, himself a pathologist. Centres would have an important role in record keeping, thereby enabling the maximum knowledge of each individual patient; and, again emphasising their preventive and didactic functions, would provide ‘health education by lecture and demonstration’. Similar, if slightly more modest, proposals were also made for health centres in rural areas.37

The health centre, then, was to provide a comprehensive, integrated service – both curative and preventive – to the citizens of its designated area, and so act as the focal point of health care. Importantly, there was also to be a close relationship with hospitals, general or local. These would take patients sent to them by GPs, who would be encouraged to remain in contact with their hospitalised charges. Once again, this was part of the SMA strategy for bringing general practitioners fully into the health care system, thereby ending their professional and intellectual isolation. Hospital specialists – for example in tuberculosis and venereal disease – would also be attached to centres and have patients referred to them by GPs. Patients could thus receive both primary and more specialist care at or through the centre. As far as the relationship between hospitals and health centres was concerned, integration was clearly to be a two-way process.38

Health centres were central to the SMA’s vision of a socialised medical service, although many of the details of their operation remained to be worked through. The Association did not have a totally static or fixed model, and matters such as the size of clientele and the precise nature of the services offered were to be the subject of considerable discussion and debate. The significance of health centres, however, was never in doubt, and it is clear that in their method of operation they were to embody the inherent socialism of medical practice. The idea of health centres continued to be pressed by the Association for the rest of the 1930s. In 1938, for example, in a piece devoted largely to a critique of the BMA’s plans for a reformed medical service, Hastings stressed the need for local authorities to be encouraged to ‘centralize in Health Centres in each locality their various clinical activities5.39 One of the most important functions of health centres for the Association was, as has been suggested, the merging of all medical personnel into a compre­hensive system. This was seen as particularly necessary in respect of general practitioners, as matters currently stood a highly autonomous and individualistic group. The integration of such medical workers in turn raised the issue of their conditions of service, including financial reward. This further raised questions as to how a socialised medical service was to be funded. As these matters were closely interlinked, they are dealt with together in the text.

One of the SMA’s principal aims was that the whole population should have access to free medical care, irrespective of age, gender, or employment status. The health insurance scheme as it currently stood provided no coverage for groups such as the dependants of insured workers, and even they gained only limited facilities. The Association clearly felt that this system could not be expanded in such a way as to achieve the desired universality and comprehensiveness. In The People’s Health and A Socialised Medical Service Hastings and his colleagues went into some detail in respect of the complexity of the issue, and the consequent need for a carefully planned transition to a socialised service. A shift away from insurance should be effected as ‘soon as national finances make this possible’, and medical services should be offered free to all who sought to take advantage of them. Hastings had gained considerable experience of the existing system through his part in drawing up Labour Party and TUC evidence to the Royal Commission on National Health Insurance in the mid-1920s. In 1939 he argued further that:

Dr Cox (former Secretary of the BMA) had come down on the side of insurance, but he had not said whether he wanted it to be compulsory or voluntary. If compulsory, what was the difference between that and payment through the rates? If voluntary, the people who needed medical service the most would not take the trouble to insure.40 In short, universality could not be guaranteed or effectively implemented by the existing, or even an extended, insurance system.

Hastings’s possible alternative of local taxation is also worth noting, for two reasons. First, the whole question of how to finance a state medical service was highly problematic given that, for example, the revenue derived from direct taxation was relatively small when compared with what it was to become during and after the Second World War. Raising funds locally, at least in part, may therefore have seemed an attractive option. Second, and rather more positively, Hastings and his colleagues assumed that any future socialised system would be administered primarily at local level. This issue had been made explicit in A Socialised Medical Service and The People’s Health, both of which affirmed that the ‘Health Service of the future will be administered by local authorities’, although this was to take place under the general supervision of an enhanced Ministry of Health, with the latter having the power to compel ‘reactionary local authorities to carry out their statutory duties’.41 If, however, local authorities were to be given a substantial measure of control in a socialised service, this posed the dilemma of how doctors could be reconciled to such a system. Not only were GPs in particular hostile to the idea of a salaried service, they were also deeply antipathetic to any hint of supervision by local government bodies. How, with this tangle of issues in mind, did the SMA approach the matter of medical remuneration?

In the 1930s general practitioners were, effectively, independent entrepreneurs. They held property in the form of their medical practices, which could be bought and sold, and derived their income from a variety of sources. These included a combination of some or all of their fees from private practice; capitation fees from the health insurance system (the ‘panel’); and fees for work undertaken for public bodies such as the school medical service. One effect of this was to institutionalise an inherent conflict between improving medical care and maintaining doctors’ living standards. There was a further twist in that GPs, in the years before the Second World War, developed a strong sense of grievance over both their own income levels and the wide disparities in medical remuneration. They would therefore have been unlikely to welcome changes perceived, rightly or wrongly, as eroding their standard of living and economic autonomy. This was particularly so in the case of one crucial part of their earnings, that from panel patients.42 This situation, whereby the nation’s health was apparently being sacrificed to individual interests, was for the SMA a prime example of what was wrong with British health provision. It therefore argued that all medical personnel in a socialised health system, including doctors of all types, should ideally be salaried employees of the state. At least some of its members were uneasy about what was perceived as, in the words of one correspondent to Brook, the organisation’s ‘tendency to show a none too friendly attitude to the general practitioner’.43 But the Association did realise the importance of not alienating GPs, many of whom were already feeling beleaguered, any more than was necessary. It was therefore anxious to stress the positive aspects of a particular form of relationship between doctors and the state.

This question was hardly a new one. It had been the subject of discussion by, among others, the Webbs and the SMSA in the Edwardian period, while the PHAC had called for doctors to work in teams, and for the funding of a state medical service through general taxation rather than insurance. Crucially, Hastings had, as we have seen, addressed the implications of the economic relationship between doctor and patient in his speech to the Association’s 1931 AGM. Here he stressed the ‘dependence’ of many medical practitioners on their patients and, by contrast, the professional benefits which payment by salary could bring to doctors themselves. This idea that doctors would actually be liberated by a salaried service – for example through the economic security of a pension scheme, the true independence which an end to the cash nexus would bring, and the opportunity to pursue further medical education – became a central strand in the SMA’s argument and an appeal to both the altruism and the self-interest of its fellow professionals. In turn such a rejection of individualism was part of a broader historical change. As Hastings again put it in 1931, in health private enterprise had failed ‘lamentably’. The ‘spirit of the age demanded collective action’, and he therefore had no doubt that the already existing trend away from the family doctor to state medicine would continue.44

Consequently, these issues were very much the concerns of The People’s Health and A Socialised Medical Service. Both emphasised that there should be no ‘economic barrier between the doctor and his patient’. Both repeated, verbatim, Hastings’s remarks about economic dependence, and stressed that a free and comprehensive state service must necessarily be staffed by full-time, salaried medical practitioners. Team work too was emphasised, again in terms very similar to those of 1931, for ‘lacking in our health services to-day is above all else organisation and cooperation’. In short, the doctor was to be ‘at the service of his patients’. Patients had, or ought to have, rights by virtue of being citizens in a democratic society. These rights were to include not only free access to medical care but also the right to have a say in how medical services were to be run, although once again the question of possible tension between this democratic right and doctors’ professional rights remained unresolved. The overall message, however, was clear. A socialised service should be free to all patients, and doctors should be salaried employees of the state to the benefit of both themselves and society as a whole.45

The international character of medicine

So far we have traced both the organisation and ideas of the SMA as they developed from its foundation in 1930, focusing in particular on two early policy statements. Before placing these in the broader context of labour and medical politics in the 1930s attention needs to be paid to one further important influence on the Association’s thought. The SMA was firmly committed to internationalism: medical knowl­edge was shared across national boundaries, and socialism was, by definition, internationalist. Part of the impetus for the Association’s creation had come from a German colleague. In 1931 it sent delegates — Hastings and Dr V.H. Rutherford – to the first congress of the Interna­tional Socialist Medical Association in Carlsbad, and Hastings and Brook became the British representatives on its Executive Committee. Hastings later recalled that he brought home a photograph of the participants in the Carlsbad conference which allowed him to identify refugee doctors in the years before the outbreak of war. When invasion of England seemed imminent, he took the sensible precaution of burying this photograph and accompanying documents in his garden, from whence he was able to retrieve them unharmed a few years later.46 Chapter Six shows some of the practical implications of SMA internationalism, but here the influence of ideas from other medical systems is considered.

The Association had an ongoing interest in the health service provision of other nations – hence the regular MTT column, ‘Medical News of the World’. In the 1930s Hastings in particular also visited various foreign countries. In 1931, for example, he and Salter travelled to the Soviet Union. Hastings subsequently praised that country’s ‘prophylactoria’, or health centres, commending especially their apparent efficiency, medical division of labour, and preventive as well as curative functions. Despite the scepticism of some Association members about the Bolshevik regime, Soviet health care was often held up by the left as an example of what could be achieved in a socialised system -hence Harold Laski’s invitation to Hastings, in the immediate aftermath of his journey, to join a Fabian Research Bureau committee on the USSR.47

Murray had no doubt that in qualitative terms British doctors were at least the equal of their Russian counterparts. But, he went on, the Soviet Union could ‘teach us something of organisation and give us new ideas to ponder over’. In particular, it had shown that when doctors were ‘freed from financial anxiety’ and integrated into a comprehensive and free service, then they were able to give to patients the full benefits of modern medicine. Like Hastings and Salter, Elizabeth Bunbury visited the USSR. While finding it a ‘paradoxical country’, she was nonetheless impressed by a society where medicine was not seen as isolated, but as part of the ‘social complex’. In England, doctors were continually hampered by the ‘economic system’, among the consequences of which were lack of income on the part of patients and lack of coordination and research on the part of doctors. In the Soviet Union, by contrast, there was ‘a general plan for public health in which all forms of activity are correlated’. All medical workers could thus justifiably feel they were contributing to the general good.48 Here Murray and Bunbury were clearly stressing the positive impact on both doctors and patients of a salaried service, as did Hastings.

Another important aspect of the Soviet system for Association members was its method of recruitment. The SMA, quite rightly, saw the British medical profession as being drawn largely from the middle classes, in part at least because of the expense of medical education. In the USSR, Hastings told an Association meeting in 1932, the full costs of education were met by the state, and students were ‘for the most part recruited from the factories and collective farms’. Drawing trainee doctors from all parts of society meant, he continued, that students came to their studies ‘with some knowledge and experience of the world as it really is’. This contrasted with the British situation, where the outlook of doctors was largely shaped by ‘the nursery and public school’. It was clear from all this which system Hastings – a public school product himself – preferred.49

Idealised (and misguided) as such analyses of Soviet health care undoubtedly were, they clearly played a part in reinforcing SMA policy on socialised medicine. This process was almost certainly furthered by the publication in 1937 of Henry Sigerist’s book on medicine in the USSR, the subject of a favourable review in MTT. Sigerist’s work provided, for example, a detailed and generally positive description of health centres, and was dedicated to the ‘young medical workers in whose hands the future of medicine lies’. It is perhaps from Sigerist that Murray took the title for one of his own books, The Future of Medicine, published in 1942. On the other hand, and as Honigsbaum again points out, the enthusiasm of certain leading members for the USSR would have done nothing to enhance the Association’s reputation with the Labour leadership.50

But the USSR was not the only foreign country from which the Association could derive inspiration. Certain characteristics of social democratic Sweden’s health provision were also much admired. Hastings visited Sweden in the early 1930s and reported that in terms of organisation and equipment its hospitals were ‘the best in the world’. He was inspired enough by what he had seen to claim that at least in the sphere of health Sweden was ‘solving to some extent the difficult problem of the transition from Capitalism to Socialism’. It seems likely that Hastings was particularly won over by the fact the Swedish hospi­tals were run by local authorities, another possible source of SMA inspiration on this issue. And as with the Soviet Union, he was also taken by the availability of a scholarship scheme for medical school.51 In short, the SMA was internationalist in outlook, and prepared to draw lessons from the health systems of other countries and apply these to the British situation. As Hastings put it in 1933,

What we want … is a State Medical Service providing at the cost of the rates and taxes, the best that medical services can give for rich and poor alike. There is nothing unusual or extraordinary in such a service. They have it in Russia and they have it in Sweden. I have seen it working in both countries … ,52

This was a brief, but accurate, statement of the Association position. We will now examine the wider context in which the organisation operated, and the extent to which its proposals were gaining influence.

Notes

• 1.Murray, Why a National Health Service?, p. 17ff; Brook, Making Medical History, p. Iff; DSM 1/1, EC Report, AGM 1934; and DSM 1/1, Report of the EC, May 1939-April 1940. The Hastings article was The Future of Medical Practice in England‘, Lancet, 1928,1, pp. 67-9.
• 2.Webster, ‘Labour and the Origins of the National Health Service’, p. 187; Peter Bartrip, Themselves Writ Large: the British Medical Association 1832-1966, BMJ Publishing Group, 1996, p. 215.
• 3.Brook, Making Medical History, pp. 3-4; Murray, Why a National Health Service?, pp. 21-2; DSM (2) 5, ‘International SMA’, Brook to Fabian 24 September 1930.
• 3.DSM 1/1, Report of the EC, 1930-31; Brown, Back-Room Boys of State Medicine-, Brook, Making Medical History, pp. 5-6; Webster, ‘Labour and the Origins of the National Health Service’, p. 187.
• 4.DSM 1/1, Minutes of the First AGM, 10 May 1931; Report of the EC, 1931-32; Milton Terris, ‘Epidemiology and the Public Health Movement’, journal of Chronic Diseases, 1986, 39, 12, p. 958.
• 5.Lancet, 1931,1, pp. 1115ff.
• 6.Lancet, 1933,1, p. 1324, and II, p. 1459.
• 7.Somerville Hastings, The First Steps towards a Socialized Medical Service’, MTT, July 1938, p. 4.
• 8.Lancet, 1932,1, p. 838.
• 9.Lancet, 1932, II, p. 1185; Stella Churchill, ‘Socialisation of the Medical Services’, Fabian Quarterly, no.5, March 1935, p. 16.
• 11.Geoffrey Foote, The Labour Party’s Political Thought, 2nd edn, Croom Helm, 1986, pp. 77-8.
• 12.Esping-Andersen, ‘Citizenship and Socialism’, p. 83; David Howell, British Social Democracy, Croom Helm, 1976, p. 47.
• 13.Brook, Making Medical History, p. 3; Brown, Back-Room Boys of State Medicine; Stewart, ‘”For a Healthy London”‘, pp. 419-20.
• 14.DSM 1/1, Report of the EC, 1937-38; and Report of the EC, 1938-39.
• 15.DSM (2) 65 document for 1936 AGM, ‘Proposed Changes in the Constitution’; DSM 1/1, Minutes of the Sixth AGM, 24 May 1936. See also Honigsbaum, Division in British Medicine, pp. 259-60; and Brook, Making Medical History, p. 3.
• 16.Brook, Making Medical History, p. 3; DSM 4/2, Members of the Executive Committee 1942/3; Watkins, Medicine and Labour, p. 61, where it is also noted that the shift to a predominantly non-medical membership resulted in the change of name to ‘Socialist Health Association’.
• 17.Lawrence Benjamin, The Position of the Middle-Class Worker in the Transition to Socialism, Labour Party, 1935, pp. 11, 16, 17, 22.
• 18.DSM (3)/3, item 2; on the whole issue of professionalisation see Harold Perkin, The Rise of Professional Society, Routledge, 1989, passim.
• 19.DSM 1/1, Report of the EC, 1931/2; Report of the EC, 1932/3; AGM 1934, EC Report; DSM (2) 7, item g), Lansbury to David Stark Murray, 7 July 1933; Brook, Making Medical History, p. 7.
• 20.DSM 1/1, Minutes of the Seventh AGM, 9 May 1937; Report of the EC, 1937/8; and Murray, Why a National Health Service?, pp. 36—7.
• 21.MTT, no. 1, October 1937, p. 13.
• 22.Murray, Why a National Health Service?, p. 37; DSM (3) 14/25; DSM I/ 1, Minutes of the Eighth AGM, 22 May 1938.
• 23.On Murray’s life and ideas, see Stewart, The “Back-Room Boys of State Medicine”‘, passim; idem, ‘David Stark Murray’, in the forthcoming New Dictionary of National Biography, London and Oxford, British Academy/Oxford University Press, 2004; Murray, Why a National Health Service?, p. 38; Brook, Making Medical History, p. 7.
• 24.Murray, Why a National Health Service?, pp. 40, 46; DSM (3) 14/30.
• 25.Honigsbaum, Division in British Medicine, pp. 261-2.
• 26.Somerville Hastings, The People’s Health, Labour Party, 1932, p. 2; Labour Party, Report of the Thirty-Second Annual Conference, Labour Party, 1932, p. 64; Minutes of a Meeting of the Labour Party Research and Publicity Committee, 18 May 1932, p. 2.
• 27.SMA, A Socialised Medical Service, SMA, 1933; DSM 1/1, Report of the EC 1931/2; Report of the EC 1932/3; and Brook, Making Medical History, p. 6; Murray, Why a National Health Service?, p. 26; DSM 4/1, ‘Socialisation of Medicine: Independent Labour Party Resolution’, by EG. Bushnell.
• 28.Murray, Why a National Health Service?, p. 26.
• 29.Hastings, The People’s Health, pp. 10, 18-19; SMA, A Socialised Medical Service, pp. 11,18-19; Somerville Hastings, ‘Socialism and Public Health’, Socialist Doctor, vol. II, no. 3, May 1934, p. 12.
• 30.Abel-Smith, The Hospitals, 1800-1948, pp. 365-6.
• 31.Hastings, The People’s Health, pp. 18-19; SMA, A Socialised Medical Service, pp. 18-19.
• 32.’Submission to the Voluntary Hospitals Commission of the Socialist Medical Association of Great Britain’, DSM (2) 5; also, Lancet, 1936, II, p. 353; Brook, Making Medical History, p. 10.
• 33.MTT, no. 3, December 1937, p. 13.
• 34.Hastings, The People’s Health, p. 5; SMA, A Socialised Medical Service, p. 5; David Stark Murray, Science Fights Death, Watts and Co., 1936, p. 9.
• 35 Phoebe Hall, The Development of Health Centres’, in Hall, Phoebe, Land, Hilary, Parker, Roy and Webb, Adrian (eds), Change, Choice and Conflict in Social Policy, Heinemann, 1975, pp. 279-80; Jane Lewis and Barbara Brookes, The Peckham Health Centre, “PEP”, and the Concept of General Practice during the 1930s and 1940s’, Medical History, 27, 1983; DSM 1/1, Report of the EC, 1935-36.
• 36. Hastings, The People’s Health, p. 9; SMA, A Socialised Medical Service, p. 9. The two disagree about the number of patients per doctor, the former arguing for 1:2000, the latter for 1:2500. This is one of the modifications alluded to by Murray, Why a National Health Service?, p. 26.
• 37.Hastings, The People’s Health, pp. 9-10, 13; SMA, A Socialised Medical Service, pp. 9-10, 14. With respect to rural areas, the two works once again disagree slightly on the ratio of doctors to patients.
• 38.Hastings, The People’s Health, p. 11; SMA, A Socialised Medical Service, P. 11.
• 39.Somerville Hastings, ‘The First Steps Towards a Socialized Medical Service’, MTT, no. 10, July 1938, p. 5.
• 40.Hastings, The People’s Health, pp. 16-17; SMA, A Socialised Medical Service, pp. 17-18; BMJ, 1939,1, pp. 451-2; Earwicker, thesis, p. 177.
• 41.SMA, A Socialised Medical Service, p. 7; Hastings, The People’s Health, p. 7.
• 42.Anne Digby and Nick Bosanquet, ‘Doctors and Patients in an Era of National Health Insurance and Private Practice, 1913-1938’, Economic History Review, 1988, 2nd series, 41, 1; Charles Webster, ‘Doctors, Public Service and Profit: General Practitioners and the National Health Service’, Transactions of the Royal Historical Society, 1990, 5th series, 40.
• 43.DSM (2) 6, E. Fairfield Thomas to Brook, 19 October 1936. Thomas in fact resigned over this issue. 80.Somerville Hastings, ‘Can We Afford to Leave the Nation’s Health to Private Enterprise‘, Labour Magazine, April 1931, p. 545; and BMJ,1931,1, p. 470.
• 44.Hastings, The People’s Health, pp. 4-5, 6; SMA, A Socialised Medical Service, pp. 4-5, 6.
• 45.Murray, Why a National Health Service?, p. 24; SMA Bulletin, no. 5, January 1939, pp. 1-2; DSH, File 3, ‘International Socialist Medical Association’, memo by Hastings on ‘A New International Socialist Medical Association’, 1948.
• 46.There are accounts of the Russian trip in Brockway, The Bermondsey Story, pp. 155-61; and in Somerville Hastings, Medicine in Soviet Russia, n.p. , 1932(?), reprinted from Medical World, January 1932; DSH, Bundle 1, General: Laski to Hastings, 6 January 1932.
• 47.David Stark Murray, ‘Should Medicine be Just a Trade?’, Reynolds Illustrated News, 26 December 1937, cutting in DSM (2) 4; Elizabeth Bunbury, ‘An English Doctor in Russia’, MTT, no. 7, April 1938, pp. 15-16.
• 48.Lancet, 1932,1, p. 1213.
• 49.Henry E. Sigerist, Socialised Medicine in the Soviet Union, Victor Gollancz, 1937, pp. 289-96, and dedication; review, by Philip Wiles, in MTT, no. 4, January 1938, pp. 5-6; Honigsbaum, Division in British Medicine, pp. 261-2.
• 50.Somerville Hastings, ‘The People’s Health in Sweden’, Socialist Doctor, vol. II, no. 2, November 1933, pp. 2-3.
• 51.Somerville Hastings, ‘When Sickness Comes’, The Chingford Advertiser, October 1933, cutting in DSH, File 2, ‘Articles’.

CHAPTER FOUR The SMA, the Labour Party, and Medical Politics in the 1930s

The SMA’s founders had come to view the State Medical Service Association’s lack of political focus and identification as one of its principal weaknesses. Affiliation to the Labour Party was therefore perceived as a major breakthrough in left-wing medical politics, not least because it gave the Association a platform – the annual party conference – from which to address the wider labour movement. Hastings was conference delegate for most of the 1930s, and he and his organisation achieved their first major success in 1932. Hastings proposed a motion – seconded by Rickards, one of the London Labour Party delegates – seeking the introduction of a state medical service. As Hastings put it, the country’s health needs can only be effectively provided by the establishment of a complete State Medical Service, giving everything necessary for the prevention and treatment of disease, free and open to all. An investigation into the issue was also demanded of the party executive, and the resolution as a whole duly agreed.1 The Association could therefore feel justifiably pleased at having made such an impact at the first conference at which it was represented in its own right.

But this was not an unequivocal triumph, and in this we can see once more the circumscribed place which the SMA held in the contemporary labour movement. In the wake of the electoral disaster of 1931 the Labour leadership was cautious about immediately committing itself to any specific policy until all options had been fully considered. As George Latham, conference chairman and NEC member, told delegates in 1932, he did not wish to be seen as offering any objection to the Association’s motion. But, he continued, he would be failing in his duty if he did not point out that its implications were very far reaching’. The executive would examine the matter, and consult not only with the SMA but with ‘everybody concerned’,2 Such official caution was also, as we saw in the last chapter, evident in contemporaneous publication of The People’s Health.

Consequently the Association was moved to write to party headquarters in mid-1933 asking what had become of the proposed inquiry into a state medical service, and in response was told that nothing could be done about this prior to annual conference. At this meeting Hastings further questioned why the previous year’s resolution had not been acted upon. Herbert Morrison, a colleague of Hastings on the LCC and a leading figure in both London and national Labour politics, replied that it had been a busy year and that the NEC would address the issue as soon as possible. Hastings was careful to acknowledge that other socio-economic matters, for example bank nationalisation, might have to be considered first. But he argued that while a state medical service could not be achieved immediately, nonetheless ‘we must have a mental picture of the service we want to develop’. To this end, and perhaps explaining Hastings’s conciliatory tone, the party set up a Medical Services Committee which, as Murray suggests, was largely composed of representatives from the SMA. This body, which met four times in the course of the following year, was chaired by Association member and TUC medical advisor H.B. Morgan. Other SMA participants, of whom there were around eight out of the committee total of fifteen, included Hastings, Brook, and Rickards.3

The Medical Services Committee presented its report, A State Health Service, to 1934 party conference. The document acknowledged the complexity of the subject under discussion, as a result of which the committee had felt it best to raise the general issues at conference before going any further with its work. Nonetheless specific policy proposals were made, and a number of these clearly coincided with those of the SMA. It was suggested, for example, that a state service could be built in one of two ways: through an extension of health insurance, or through local authority health services. The latter was deemed ‘the proper course’. This meant, effectively, that the existing panel system should come to an end, something to be welcomed given its ‘very grave deficiencies’. The ‘ultimate aim’ was a unified service providing, through local authorities, universal, comprehensive, and free care. This could, however, only be achieved in stages, for ‘financial and other reasons’.4 Such arguments echoed very closely those put forward in documents such as The People’s Health and A Socialised Medical Service. Similarly, A State Health Service identified three prerequisites for the development of a socialised service: the consolidation of all existing local authority medical services outside the Poor Law; the ending of local authority dealings with voluntary agencies, including voluntary hospitals, which ideally should be taken over; and the provision of a service under such a scheme at least as good as that provided to those covered by the insurance system. Suggestions were made as to the timing and prioritising of the transitional arrangements, although it was recognised that even before this much work had to be done, especially by local government. Emphasis was also laid on the need to develop health centres, designed not to replace the domiciliary service but rather to become ‘the centre round which such attendance and the other facilities of the Public Health Service should evolve’.5

Finally, the report turned its attention to the medical profession itself. The panel system had created Vested interests’, in that panels were in effect a form of property which could be bought or sold. It should therefore be transformed as soon as possible into a non-transferable institution, effectively being absorbed into the public scheme to which doctors would be contracted on a part-time basis. In the longer term, the document continued, the ‘aim would be to amalgamate part-time appointments into full-time public appointments’.6 This was a rather convoluted way of proposing something approaching a full-time salaried service, but the general message was clear enough. The concept of Vested interests’, which we have already encountered in the writings of Edwardian reformers and which was consistently advanced by the SMA, is also worth noting. It encompassed the commercial insurance companies and, in particular, the organised medical profession as represented by the BMA. These, it was argued, had an interest in promoting sickness rather than health, and were thereby a block on medical progress. The rhetoric of Vested interests’ was to become especially pronounced in the 1940s.

The SMA’s success in strongly influencing the form and content of this report should not be undervalued. However, while A State Health Service pressed some central Association preoccupations, unsurprisingly given the composition of the committee which produced it, it was also a deliberately cautious document. This was pointed out forcefully in the journal Socialist Doctor. An article, unsigned but almost certainly by Murray, welcomed the emphasis on the local authority model of administration. This was especially important for, as we shall see in the next chapter, by this time Labour had gained control of the LCC and Association members been given considerable powers over the capital’s health services. But as a whole, the piece continued, A State Health Service would ‘do nothing to further the case for a State Health Service’. It showed ‘no comprehension of the whole problem’ – for example in its lack of clarity ‘as to how much of the wasteful voluntary system should be allowed to continue’. The exercise had been valuable, however, in prompting a critical reappraisal of the SMA programme.7 This last comment is especially interesting, suggesting as it does the fluidity and complexity of the debates and discussions inside the organisation, as well as within the broader labour movement.

The report was discussed by conference itself. Hastings, again Association delegate, agreed that it was only a ‘first step’ and that he and the SMA would continue to fight for a free and comprehensive service, curative and preventive. He admitted that devising a socialised medical service was a difficult task, but pointed out that Labour was now ‘getting hold of the local authorities’ – undoubtedly a reference to the LCC – and that some sort of plan was necessary for advances to be made. These remarks should be seen in the broader context of Labour’s tactic of seeking to undermine the National Government through the capturing of local institutions. Hastings was also at pains to stress the need for health centres; and to suggest that while patients should have a free choice of doctor, this was something which did not need overemphasis. The report, and the associated passage in the policy statement For Socialism and Peace, were duly adopted. The Labour leadership, however, remained cautious. The Annual Report noted that the Medical Committee’s proposals were ‘preliminary’. Moving their acceptance on the NEC’s behalf, Barbara Ayrton Gould also drew attention to the provisional nature of the committee’s findings, and suggested that a more detailed document would be forthcoming the following year.8

The Public Health Advisory Committee

Nothing, however, came of this, at least in the form promised. Once again, therefore, the SMA can be regarded as having experienced mixed fortunes in its attempts to push the Labour Party towards its vision of a socialised service. It had clearly made the running in health terms from 1932 to 1934, both in its own right and through its influence on an official party committee. The 1935 EC Report remarked that the events of this period were ‘an achievement of which the Association may be particularly proud’, and its members were later to look back on the 1934 conference as the first major step in the creation of the National Health Service.9 When added to SMA activities on the LCC, all this seems highly positive. On the other hand, the Labour leadership was clearly keeping its options open and not, as yet, committing itself to any specific form of health service reorganisation, and this must be seen as a qualification on the Association’s successes. However, before suggesting what further constraints were operating on the SMA, both inside the labour movement and in the wider medico-political sphere, attention should be drawn to one of its most important domestic political achievements of the 1930s.

We have noted that the Labour Party’s Public Health Advisory Committee, following a spasmodic existence after the First World War, finally expired in the early 1930s. This was despite offers of help from Brook, on behalf of the SMA, in late 1930. Although Hastings and his Association colleague Dr R.A. Lyster were coopted to the Local Government and Social Services Sub-Committee specifically to help prepare a report on the ‘Development of Public Health Services’, the mid-1930s were a period of anti-climax for the SMA in respect of overt influence on the Labour Party, at least at national leveL After the satisfaction in 1935 with the course of events inside the party, by the following year the EC was noting the failure of its conference resolutions to be taken on two consecutive occasions (on health matters at least, this was to continue to be the case at subsequent pre-war conferences); and suggesting the need, as a matter of urgency, for a reorganisation of conference machinery so that more resolutions could be dealt with.10 Such complaints about conference organisation re-emerged in the late 1940s, suggesting that over the long term the Association did not feel that it had been especially well served by participation in these events. More generally, Labour itself was under the control of moderates anxious that the electoral gains of 1935 should not be jeopardised in the next general election, due in 1940, by any over-ambitious plans or rhetoric.11

However 1937 did see a significant development of the SMA’s role within the Labour Party. At a meeting of the newly-created Home Policy Committee in November it was agreed to reappoint a number of subsidiary bodies. These included the Local Government Committee, one of whose own advisory sub-groups was to be the Public Health Committee whose purpose was the preparation of a ‘comprehensive statement of public health policy’. It took a full year for the reconstituted PHAC to meet for the first time, but when it did it had a strong SMA presence. Of its sixteen members, at least half belonged also to the Association. These included Brook, Murray, Rickards, Lyster, Amy Sayle, and, in the crucial position of chairman, Hastings. Although the inaugural meeting made it clear that committee members were to act as individuals, not as representatives of any organisation, nonetheless the size of the SMA contingent must be viewed as a clear recognition of its place within the labour movement in devising plans for a reconstructed health service.12 It was certainly the case that by the late 1930s the Association was becoming increasingly determined that greater stress should be placed by Labour on this issue. As an MTT editorial of January 1938 put it, the SMA had some years ago put forward what was in many ways a ‘good plan’ for medical reorganisation, but since then things had moved on, especially in local government. It was therefore necessary to devise plans for a full and complete State Medical Service, not a sketchy outline of hopes and aspirations to serve as policy, but a scheme complete in all its administrative details, ready for adoption by the first Administration with sufficient vision to put it into operation.

This was clearly a call to action for both the SMA and the Labour Party. The former had proposals for a socialised scheme which it was adapting in the light of experience, especially that of the LCC. The latter, however, was much less focused in its ideas, hence the need for enhanced Association input to party deliberations. Furthermore, as an article in the same edition put it, any new scheme should not be built on health insurance, ‘that idol with the feet of clay’.13 Much hope must, therefore, have been invested in the SMA’s strength on the reconstituted PHAC, and in its various guises this body was to play an important role in the ensuing years in debating and formulating Labour’s health policy.

However, one of the first issues the PHAC faced highlighted the complexities of creating a socialised system of health care, and the contested area in which the SMA was operating. In 1936 a Joint Committee on Medical Questions was set up by the TUC and the BMA, and its principal outcome in the pre-war era was suggestions for a national maternity scheme. The maternal mortality rate remained stubbornly high in the 1930s, and was thus in itself extremely important in driving health discussions. This was particularly so in the labour movement, and Labour Party policy statements frequently highlighted its significance. Furthermore, there was an ongoing debate over the respective merits of hospital and home deliveries; and the role to be played by specialists, midwives, and general practitioners. The Joint Committee scheme rested on the three related ideas of the primacy of GP care; a domiciliary service; and funding through an extension of insurance. As Earwicker points out, the acceptance of these principles was a ‘complete capitulation by the TUC to the BMA point of view’. Considerable disquiet was voiced in the labour movement about these proposals, for example over the suggested control of such a service by the medical profession, with SMA members prominent in the objections.14 The whole episode throws light on the kind of problems faced by the Association, even allowing for its influence on official Labour committees, and this is further illustrated by a brief account of the critique offered by its members.

The SMA attacked the BMA-TUC scheme through a number of routes: by its meetings and propaganda; on the PHAC; and, as Earwicker has shown, as individuals (notably Hastings and Sayle) in Labour Party delegations. In so doing, it drew on its own existing plans for enhanced maternity provision. These had been worked out in 1933-34, primarily by Rickards and Edith Summerskill, and despite differences – notably over home versus hospital deliveries – consensus had been reached on two vital issues. First, any maternity scheme should be part of, and integrated with, a more general state medical service, supervised nationally by the Ministry of Health and locally by local authorities. Second, and irrespective of whether delivery took place at home or in the hospital, the primary responsibility should rest with midwives. This was designed to move maternity care out of the hands of GPs and into those of specialists. In turn, this was a critique of GP skills, greed, and commitment to an essential public service. As Summerskill put it, the ‘time has come when we must recognise only one interest – one that has been largely ignored – the interest of the expectant mother’. Brook was later to claim the Association’s role in highlighting the problems of maternal mortality as the beginning of ‘the campaign for safer motherhood in Britain’. The SMA had also, by the mid-1930s, direct experience of the administration of maternity services through its activities on the LCC, especially in the wake of the 1936 Midwives Act.15

Drawing on these analyses and experience, the July 1938 edition of MTT described the BMA-TUC scheme as a ‘negation of progress’, and denounced the TUC for supporting the BMA’s ‘backward step’. In an internal Association document prepared primarily by Hastings it was pointed out that, contrary to the claims of the BMA and the TUC, many GPs disliked providing maternity services, were incompetent at such provision, and did so only in order to maximise their incomes. Explicitly on this last point, it was argued that

so long as doctoring remains a trade in a capitalist society, very many other factors beside the best interest of the patient are bound to enter in, little as the doctor himself may be conscious of the fact.

Furthermore, the conditions under which GPs worked had in themselves contributed to the high levels of maternal mortality.16 Here, then, were further instances of the economic barrier to health which disadvantaged the patient and compromised the doctor, and of Association scepticism about current GP expertise.

The proposed scheme was also debated on Labour Party bodies. The Home Policy Committee noted its deviation from official party policy, and that it was to be discussed by the PHAC. These discussions, which took place at two meetings in November 1938, illustrate both the role being played by Association members in official party deliberations on health and the potential for dissension on such issues inside the broader labour movement. At the first meeting, the view was initially expressed (it is not clear from the records by whom, but very probably the committee chairman, Hastings) that the BMA-TUC proposals were contrary to party policy as laid down in 1934, in particular because they would take away important functions from local authority clinics and hand them back to private practitioners. This would create – in a familiar phrase – ‘enormous vested interests’ which would be difficult to displace, but which would have to be destroyed with the coming of a state medical service. Nonetheless the scheme had its defenders, specifically in the persons of TUC medical advisor H.B. Morgan (also, of course, an SMA member) and J.L. Smyth, Secretary of the TUC’s Social Insurance Committee, the two principal labour movement initiators of the Joint Committee. Among their arguments was that GPs should be given facilities to attend their patients while in hospital. This effectively meant that one doctor – the GP – should be solely responsible for the whole course of a woman’s pregnancy. If implemented, this would institutionalise and consolidate the general practitioner’s position, and thereby his income.17 This position was attacked by, among others, Esther Rickards. She (reluctantly) agreed that Morgan and Smyth’s argument might apply to rural districts, but claimed that it was ‘undesirable and unworkable’ elsewhere. In most big maternity units in modern hospitals, she continued, ‘there was complete coordination and continuity of knowledge of a patient but not one doctor responsible for the case’. This was, she implied, the most efficient means of care in virtually all circumstances. The second meeting a week later equally failed to reach a consensus. Criticisms were raised over the lack of consultation with the Labour Party on the proposed scheme, and Lyster made the not especially helpful, but almost certainly heartfelt, point that ‘the BMA represented the great vested interests of disease’.18

This was the last, inconclusive, discussion of the issue on the PHAC, although not entirely the end of the affair. The Home Policy Committee recorded in December 1938 that the Health Committee had debated the proposed maternity scheme on two occasions, and that ‘negotiations with the TUC were under way’. A number of meetings, at which SMA members such as Sayle and Hastings were present as Labour Party representatives, duly took place. In the face of mounting criticism, and aided by the interruption of war, the BMA-TUC scheme went quietly to its grave. The PHAC itself lapsed into relative inactivity, apart from producing a rather vague document on Labour and the Hospitals.19 The maternity episode provides, however, a useful way into assessing the SMA’s position as the 1930s drew to a close.

The SMA and the wider labour movement

The first point is to re-emphasise the Association’s success in gaining, in a short space of time, access to and influence on the Labour Party as a whole. It was affiliated to the party, the Fabian Society, and its London branch to the London Labour Party. The SMA had played an important part in driving Labour’s discussions of health policy, initially through party conference, and had gained an important foothold on the PHAC.’

It had also set up a ‘memorandum of agreement’ with another left-wing medical organisation, the Inter-Hospitals Socialist Society, whereby each body had two members who sat on the executive committee of the other.20 To all this should be added the Association’s position on the LCC, very much Labour’s ‘flagship’ in the 1930s. Furthermore it was able to put forward a relatively coherent vision of what it wanted from a state medical service, and the method of its achievement. This was no mean feat, given the anarchy, overlap, entrepreneurialism, and lack of coordination of the existing health care ‘system’. But, as will already be evident, it was certainly not the case that the SMA was the only player in this complicated game.

The Medical Practitioners Union, for example, was also part of the labour movement through its affiliation to the TUC in 1934. Two years later it too entered the maternity care debate. The MPU’s policy statement was described by Brook to a correspondent as ‘a most reactionary and in my opinion inconceivably stupid Memorandum’. The recipient of this letter was a St Helens councillor, Alderman Taylor. Taylor had sought Brook’s advice on a forthcoming MPU delegation taking up the cause of local GPs who had been excluded from maternity provision, presumably in the municipal hospital. Brook commended the council on its stand; argued that the ‘only proper method’ for deliveries was attendance by specialists; and so suggested that the council not bother seeing the MPU deputation. Brook’s hostility to the MPU proposals was based on factors such as its proposed expansion of opportunities for GPs to take on maternity cases, a point it had in common with the BMA-TUC plan. On the other hand, the MPU – unlike the Joint Committee — favoured a nationally rather than locally organised maternity scheme. This reflected the deep hostility which GPs, and an organisation of GPs such as the MPU, felt towards any move towards local authority, lay control. More generally, MPU ideas on a reformed health care system centred largely on an extension of insurance.21

What is important here is less the formal aspect of the MPU’s affiliation to the TUC – the former was often ignored or treated brusquely by the latter, for example through exclusion from the Joint Committee -than the actual existence of a trade union oriented organisation concerned to promote its own ideas for a reconstructed health care system. Initially, relations between the SMA and the MPU were reasonably good, and throughout the period of this study there were overlaps in membership between the two organisations. As we have seen, Alfred Welply was a founder and first treasurer of the Association. Brook was elected to the MPU Executive Committee in 1929, a post he retained for at least five years, and was the first MPU delegate to TUC conference in 1935. He also wrote to SMA members urging them to join the MPU in early 1935, that is immediately after the latter had affiliated to the TUC. Even at this stage, however, not all Association members were as enamoured of the MPU and Brook records that he was effectively censured by the SMA leadership for his activities in 1935.22

Relations between the two organisations continued to deteriorate, for a number of reasons. First, as we shall see in Chapter Six, the Association was extremely hostile to the MPU’s stand on medical refugees. Second, its EC passed a resolution in early 1936 recommending that SMA members not join the MPU, a decision Brook then communicated to the Labour Party secretary James Middleton. This resulted from MPU support for an ‘anti-Labour’ candidate in the Swansea municipal elections. Shortly afterwards Welply – who had resigned as Association treasurer in late 1935 – protested to Hastings about the Association’s activities, claiming that the MPU’s policy had always been ‘non-party political’, not a stance likely to endear it to the SMA.23 Most importantly of all, however, were the different ways in which the two organisations saw the future of medicine. Brook’s outburst over the MPU’s maternity plans signals a number of the problems. Its proposals regarding general practitioner autonomy and a health system based on insurance, for example, were diametrically opposed to key SMA demands. Such differences also further highlighted another feature of the Association, namely the low opinion which many of its leaders held of GPs. As private contractors, these doctors had little time or incentive to acquire more specialised medical knowledge. To critics such as the SMA, GPs were also obsessed with economic issues such as the size of their ‘panel’ and with the right to sell their practices on retirement, the latter being viewed by individuals such as Hastings as especially morally repugnant.24 Here, then, was another instance of ‘vested interests’ operating to the detriment of national health. These reservations may also have been an unconscious reflection of what was seen as a contrast between the political, and metropolitan, sophistication of Association members and the political, and provincial, backwardness of many Gps.

Of particular significance for this study, however, is the MPU’s hostility to local authority control. The strategy of the SMA, by contrast, was to argue for reconstructed health care provision administered through local government, with the LCC’s achievements being held up as an example of the efficacy of municipal socialism. As will become apparent, this was to prove a highly divisive issue in the labour movement. Indeed some SMA members, often those with some sort of relationship with the MPU such as Brook, were to break ranks with the Association’s advocacy of the local authority model, partly on the pragmatic basis of its unacceptability to the mass of GPs. The MPU was not, furthermore, the only labour movement body sceptical of locally run health services. While this issue is dealt with more fully in later chapters, it is worth noting here a Fabian Society document produced in 1939. This argued that while the intention of the 1929 Local Government Act had been to leave local authorities ‘as free as possible’, this had in fact resulted in wide disparities in the level of services provided. These were caused not by the needs of the inhabitants, but rather by the rateable value of local property. The Ministry of Health had not taken on a positive role, for example through promoting the ‘regional grouping of local authorities where they are individually too small to carry out particular schemes effectively’. It was thus concluded that such ‘central planning will become an absolute essential when the hospital services are organised … ‘.25 In short, explicit and implicit criticism was being made of the local variations, and thereby lack of uniformity of provision, which came with administrative devolution. Even in the 1930s, therefore, there were differences inside the labour movement over the structure of socialised health service. This in turn suggests, at the very least, constraining factors on SMA power and influence.

A number of other organisational and historical factors exacerbated this situation. First, we have observed that the SMA was at this stage very much a small London-based organisation, which meant that its impact in the provinces, both on its potential political allies and more generally, was strictly limited. Second, the Association had a difficult relationship with one of the most important sections of the labour movement, the trade unions. In 1937, for example, a delegate to TUC conference suggested its inclusion on the BMA-TUC Joint Committee, to counterbalance BMA influence. He could, however, find no seconder for his motion. In such circumstances it is not surprising that, as Brooke puts it, the ‘SMA was not yet completely convinced that Transport House supported a radical health policy’, and that it was concerned that the TUC was being seduced by the BMA’s proposals. As Hastings wrote to Brook in the summer of 1937, he found a recent speech by union leader Ernest Bevin favouring improvements in the panel system ‘very serious. It looks as if the BMA were getting their tentacles into the TUC very strongly’.26 From the other side, it seems likely that the Association’s criticisms of the TUC-BMA maternity plan would have done little to recommend it to the leaders of organised labour. The strained relations between the SMA and the TUC were to continue in the 1940s, when the latter proved more accommodating to the sensitivities of the medical profession than to the Association’s radical ideas. Overall, this tension must be seen as a serious hindrance to the SMA’s ambitions, and will be the subject of further comment in subsequent chapters.

In fact, in the 1930s the Association was already aware of the problem of its standing with the industrial wing of the labour movement. In 1938 it sought affiliation to the London Trades Council, only to be rejected on the grounds that only trades unions were eligible. The following year, Brook wrote to TUC Council member George Gibson expressing the hope that one day members of the medical profession might have a ‘proper Trade Union’ affiliated to the Labour Party and to the TUC. Of the two main doctors’ organisations, the BMA was powerful but hostile to the idea of trades unionism. The MPU, on the other hand, was a registered union but ‘so reactionary and incidentally so weak in its influence that little can be hoped from it’. The position of most of the MPU on the question of a state medical service, moreover, was ‘definitely more reactionary than the BMA’. Of course militant doctors alone would not be enough to constitute a powerful union body, so what was really needed was a federation of health workers. The SMA, while ‘purely a political and propagandist organisation’, had at least made some steps in the right direction, almost certainly a reference to the decision to expand its membership base.27

The third factor relates to the more general historical position and condition of the labour movement in the mid- to late 1930s. It is clear that the Association was making considerable advances in Labour policy and policy making on health matters. Nonetheless it remained the case that the party as a whole was, understandably given the circumstances of the 1930s, more concerned with economic planning and foreign affairs than with the complexities of health care provision. Labour had a general commitment, from 1934, to a state medical service, but continued to prioritise other issues. Thus while A State Health Service was duly passed by the 1934 conference, one of the decade’s key policy statements, Labour’s Immediate Programme, limited its remarks in this area to: ‘Health Services will be extended and special measures will be taken to reduce maternal mortality’. The predominant emphasis in the Labour Party’s strategy can be inferred from the Report for 1935, which noted that educational conferences had been held on Industry, Finance, and Foreign Affairs, with no mention made of health matters.28

On the level of ideas, the model of health care reform which the Association offered fitted in with a particular, and undoubtedly influential, ideological strand in contemporary Labour thought. This stressed popular democratic control, especially at local level and hence an activist, participating citizenry. Devolution of power and the accountability of social services were regarded by thinkers such as Tawney and G.D.H. Cole as necessary safeguards against an over-centralised and bureaucratic state, as well as being in themselves integral components of a socially responsible society. Intellectuals such as Tawney further stressed the need for professions to behave in a public spirited way, rather than simply to pursue pure self-interest.29 Or, to put it in a slightly different way, the Association adopted in the 1930s what Peter Clarke describes as a ‘moral’ rather than a ‘mechanical’ reform strategy, based on the ‘free will, spontaneous endeavours and democratic efforts of the citizens’. The ‘irreducibility of the distinction between moral and mechanical means of change’ is for Clarke a variant of the observation by Cole -which again bears strongly on the kind of programme being put forward by the SMA – that socialist thought was fundamentally divided in two ways: not only between reformers and revolutionaries, but also between ‘centralisers and federalists’.30 Cole’s distinction thus reminds us that the labour movement contained not only proponents of devolved, democratic power such as Hastings and his colleagues. It also contained planners and ‘centralisers’, proponents of efficiency and uniformity who saw central government, with expert advice, as the best way of achieving such ends.31 This was true in the 1930s and, as will become apparent, a case can be made that in the longer term it was the latter type of socialist who won out over the former in the creation of welfare institutions such as the NHS.

Other aspects of the Association’s political views posed more immediate problems. We have already remarked upon the admittance of communists to membership in the mid-1930s, and the organisation’s generally radical stance. Further instances of this came in 1937 when a resolution was passed objecting to the expulsion of the left-wing Socialist League from the Labour Party; and two years later when both the EC and the AGM protested at the expulsion of Stafford Cripps, the motion at the latter being proposed by Richard Doll.32 In short, the Association was well to the political left, as its policies, actions, and the composition of its membership testify. At a time when the party and trades union leaderships were highly suspicious of any hint of communist penetration, this was hardly a point in its favour. The SMA’s left-wing attitudes were to continue to put a distance between itself and the Labour Party and the TUC. For all these reasons, the Association had by no means a clear run inside the labour movement, despite its undoubted role in Labour’s health policy formation.

The SMA and medical politics in the 1930s

Of course, the Association was operating and competing not only within the labour movement, but also in the broader medico-political arena. Here, once again, it had some positive achievements. The 1930s saw an intense debate about nutritional standards and the impact upon them of high levels of unemployment. Association activists played a prominent part in these discussions. A Scientific Committee was set up in 1933/34 to examine the effects of malnutrition, and more generally to consider all diseases seen as having socio-economic bases. These included tuberculosis, conventionally viewed on the political left as an illness exemplifying poverty and thereby the failings of the capitalist system. This committee subsequently produced a memorandum on The Assessment of Adequate Nutrition’.33

Particular concern was expressed over the impact of poor feeding on children, and not simply for altruistic or humanitarian reasons. As Leslie Haden-Guest, a doctor and MP associated with the SMA,34 told the Commons in June 1938, malnutrition, which was related to unemployment and low levels of welfare benefits, was especially damaging to the young. There resulted a permanent injury, a permanent handicap, a reduction in their productive capacity, in their intelligence, and in their nervous stability, and a reduction in the most vital asset of the nation, which is, the children of the nation. Haden-Guest concluded, very much in the spirit of the times, that if it was possible to have a five-year plan for rearmament, then the same could be done to ‘improve the nutrition of the children of this country’.35

The idea of ‘nervous stability’ had already been picked up by Hastings, as previously observed a lifelong advocate of child welfare measures. In 1934 he argued that the present manifestations of ‘mass-hysteria’ in Germany were at least in part attributable to the ‘mental and psychological effects of under-feeding during the war’. The message here was clear. A degraded, demoralised, and undernourished population, particularly a child population, resulted in a deformed and degenerate political system – hence the need for, as he put it, a ‘national physiological minimum’ and for the full exploitation of all existing social welfare measures to ensure adequate nutrition. The level of interest and expertise the SMA was able to bring to this issue resulted in its participation in labour movement investigations into health standards. It was asked, for example, to prepare a Labour Party leaflet on ‘Nutrition’, and Hastings, Salter, and Maule were invited to join a sub-committee on school meals for children of the unemployed set up by the party’s women’s section.36

Association members also became involved with non-labour movement pressure groups such as the Campaign Against Malnutrition, and Hastings, in part because of his experience as a school medical officer, was asked to chair the medical sub-committee of the Children’s Minimum Organising Committee. The SMA’s demand for adequate nutritional standards also led it to ridicule the National Government’s ‘fitness campaign’ of the late 1930s, which it argued was a farce in the absence of proper feeding, especially of children; and to stress that modern medical knowledge now allowed that the ‘science of dietics has become part of the science of preventive medicine’. The Association’s emphasis on preventive medicine was thus further justified by the growth in scientific understanding itself.37 SMA members therefore intervened to some effect in the nutrition debates of the 1930s, just as its views on the need for reconstruction of the health services were being brought to the attention of the wider medico-political world through, for example, its use of the Sankey Commission as a platform from which to broadcast its ideas.

Nonetheless, the SMA had rivals in the field of health care reform. One of the most famous, and subsequently influential, surveys of health provision in the inter-war period was that of the research group Political and Economic Planning (PEP). PEP was part of a more general movement concerned with ‘planning’ in the 1930s and which sought to create what Marwick describes as a ‘middle opinion’ located between the perceived extremes of unbridled capitalism and socialism. The PEP report on health was published in 1937 and was, it was later claimed, the subject of an ‘extraordinarily favourable reception’ from leading articles and commentary in national and provincial newspapers; professional journals such as the Lancet and the BM/; and the BMA. Consequently, it was further claimed, the paperback edition had run into 25 000 copies by 1939 and the report itself was ‘a sort of Bible at the Ministry of Health’. It was its health report which gave PEP, Daniel Fox suggests, ‘for the first time, national status’.38

Although ambiguous in a number of areas, PEP’s health strategy stressed the need for improvements in general practice and the greater planning and coordination of services, ideas with which the SMA could certainly empathise. The Association also picked up very explicitly on a particularly important aspect of the PEP analysis: the cost of the current health services. As MTT pointed out, a ‘serious argument’ against a socialised service would be removed if it could be shown that it would not cost more than at present, and the case for such a service would be strengthened if the possibility of a saving could be demonstrated. This was, the article continued, exactly what PEP had uncovered. Estimated current expenditure of around £400 million was not being properly spent. On the contrary, the picture was one of ‘overlapping, redundancy, and at the same time complete inadequacy’. The report also showed, MIT suggested, the wastefulness of the voluntary hospital system, and the impact on health of environmental conditions. Consequently much of the illness that doctors were called upon to treat was ’caused by conditions which can and must be changed’. A socialised medical system would thus be more economically efficient than capitalistic anarchy, while a socialist society would tackle the socio-economic conditions which led to ill-health in the first place.39

The PEP report was an extremely useful tool for the SMA, in at least two ways. First, the quantitative approach to health service provision was one which the Association would draw upon and develop as it began, during the Second World War, to bring forward more detailed estimates of the cost of a socialised scheme. Second, the PEP findings appeared, from a politically ‘neutral’ point of view, to bear out many of the points which the SMA had been arguing for a number of years. However the report also showed up weaknesses in the Association’s position. For one thing, PEP was able to call upon considerably more financial and other resources than the Association, whose members were trying to devise plans for a socialised health service while, in the vast majority of cases, holding down demanding full-time medical posts. The amount of publicity the PEP report engendered must have been the source of some envy to SMA members.

Moreover PEP was determinedly ‘non-political’. Its aim was not that of the Association, a socialised service as part of the transition to a socialist society. PEP had no real quarrel with the capitalist system; rather, it wanted the more efficient allocation of resources and services. This ‘non-political’ stance was part of its broader appeal and gave authority to its pronouncements in a way less open to an overtly political body such as the SMA. Furthermore, in collecting its evidence PEP approached, according to Fox, ‘members of every faction in medical politics except … the Socialist Medical Association’. Nor, it transpired, did it seek the views of any other section of the labour movement. While it may have been that PEP was seeking to maintain its ‘non-political’ stance, it could also be that it thought the Association either too controversial or too marginal to the mainstream debate to be considered. Whatever the reason, this was a snub to the SMA. It is notable that Brook does not mention PEP in his history of the Association, and Murray does so only in passing, despite its report’s undoubted significance.40

If – its failure to be consulted notwithstanding – the Association could at least draw some positive messages from the PEP report, this was much less so in respect of another significant health policy statement of the late 1930s. This was the BMA’s revised A General Medical Service for the Nation, published in 1938. We have already noted that the publication of the first edition, in 1930, may have been one of the factors which prompted the SMA’s creation, and that by the late 1930s the Association was deeply concerned about the relationship between the BMA and the TUC. There is no doubt that the SMA saw A General Medical Service for the Nation as a dangerous and reactionary text, exhibiting a number of the same erroneous arguments as were employed in the contemporaneous BMA-TUC ideas on maternity care.

An early response came in an MTT article which denounced the BMA statement as ‘out of touch with both public and professional opinion’. The BMA sought to perpetuate the existing form of private practice, despite the fact that the public were becoming increasingly unhappy with treatment by an ‘isolated “family doctor”*. The emphasis on the expansion of the insurance system was at odds with ‘modern thought’, which sought a service freely available to all. The document as a whole showed the BMA’s determination to ‘get its ideas accepted before anyone had time to consider them, and to make as few changes as possible’. It had therefore not taken the opportunity to put forward a ‘revolutionary scheme designed primarily to serve the sick’.41 This was all good knockabout stuff illustrating, among other things, the SMA’s view of the BMA (and by implication the bulk of general practitioners) as at this stage profoundly conservative.

But this should not disguise the seriousness with which the BMA plan was treated as is witnessed by, first, an internal SMA document; second, the interventions of Association members at a New Fabian Research Bureau conference in late 1938; and, third, the publication of H.H. Mac William’s ‘Walton Plan’. The internal document was written by Hastings, and analysed the BMA plans in some detail. He first pointed out that the proposals under review were simply an updated version of those of 1930. While the kind of service recommended might have been acceptable a century ago, it was now ‘completely out of touch with modern medical thought’ which, Hastings suggested, stressed the need for specialisation and for teamwork. The BMA was further out of touch because of its failure to take into account the 1929 Local Government Act’s impact on hospitals.

Hastings, like the MTT article, opposed any expansion of the insurance and panel system. Rather, what was required was a system controlled and directed by public representatives. Indeed, Hastings emphasised the idea of popular control more forcibly than had usually been the case previously. The profession should not be allowed to regulate itself, nor should advisory committees composed of doctors be set up, for these would act as a brake on the local authorities which should have the responsibility for health matters. This was not because doctors were inherently self-seeking or dishonest. Nonetheless, the medical profession was almost entirely middle class in origin, and had a ‘predominantly conservative’ outlook. In a socialised service, by contrast, the doctor must have a responsibility to the nation and must understand it. He must be something more than a tradesman whose sole duty is to please his customers, and whose practice and remuneration depend almost entirely on the way in which he succeeds in this.42 This was a further example of the ‘economic dependency’ argument noted in the previous chapter.

Similar themes were picked up shortly afterwards at the Fabian conference on the health services, another instance of the Association using all possible labour movement platforms to propagate its views. Murray, as usual pulling no punches, thought the BMA proposals ‘a typical product of a conservative body … not concerned with the interests of the mass of the population’. Brook, rather more positively, claimed that he could agree with many aspects of the scheme, but acknowledged its failure to address the question of which bodies controlled the hospitals. It was in fact, he continued, a plan concerned only with general practice, with little to say about hospitals despite the example set by an authority like London through its full use of the 1929 Act. Brook also found fault with the BMA’s ‘commercial spirit’ and with any attempt to extend the insurance scheme. The arguments for this, he suggested, were the same as ‘those used in the nineteenth century against the provision of free education’.43

The third notable response by the Association came with the so-called ‘Walton Plan for a National Medical Service’. The Walton Plan -an historic document, according to Murray, and certainly a significant example of the sharpening of focus of plans for a socialised service -was devised by H.H. MacWilliam and published in MTT in March 1939. MacWilliam, Medical Superintendent of Liverpool’s Walton Hospital, had been influenced early in his career by Benjamin Moore of the SMSA. This had been supplemented by 20 years at Walton Hospital, during which time he had ample opportunity to observe the workings of the hospital system.44

One of MacWilliam’s initial points was that the BMA’s advocacy of extended health insurance derived from its ‘natural conservatism’. However, he continued, nowadays ‘everyone knows that efficient modern medicine is the work of a team and the BMA plan has the fatal defect that it is founded on the solitary individual practitioner” (emphasis in the original). This led him into criticisms of the current form of primary care and of what he saw as the trend towards bureaucratisation in the existing municipal services. To this MacWilliam counterposed a national medical service based on the general hospital; or, as he put it, the ‘real’ general hospital. All services, including domiciliary care, were to be focused on this institution and detailed attention was given to the requirements of all departments. The emphasis throughout was to be on teamwork, with all staff having a say in the running and administration of the hospital. Medical practitioners were to be salaried, with a suggested upper limit of £1500 per annum. MacWilliam agreed that this was a low figure compared with the income of many men in practice now’, but a salaried system would have important compensating advantages such as pensions, sick pay, and family allowances. He further expanded on one particular aspect of his scheme, maternity services, a few months later, again going into considerable detail over matters such as staff salaries and the ratio of health personnel to patients. Here MacWilliam was making a further contribution to the debate over the proper system of maternity care while re-emphasising the centrality of the hospital to his proposals.45

The Walton Plan explicitly restated a number of central SMA preoc­cupations, for example the hostility to the insurance system and the security for doctors of a salaried service. It did not entirely conform to the emphases of existing Association policy statements in that it did not, for instance, deal in any detail with how democratic control was to be exerted over the medical system, although MacWilliam did approach this obliquely by suggesting the need for local government reorganisation. Similarly, he was ambiguous about the extent to which the service was to be free to the consumer. Nonetheless his scheme was very obviously, and very deliberately, different from that of the BMA. And it was certainly the case that the Association saw the Walton Plan as yet another nail in the coffin of the existing system, and of the BMA proposals for health service reform. As Murray put it in 1939, the ‘germ’ of any socialised health service was to be found in MacWilliam’s work which contained ‘on close examination the … only basis on which a socialized service can be built, the basis of the general hospitals’.46 This was slightly misleading, in that the SMA had always tried to see a socialised health service as a totally integrated system, and not just a reformed hospital system, although it was clearly intended to counter what was viewed as the BMA’s obsession with the general practitioner. Nonetheless Murray’s comment is an indication of the Walton Plan’s place in Association thinking on the eve of the Second World War.

The re-publication of A General Medical Service for the Nation was an important event in the SMA’s early history. Although, rather surprisingly, Murray was later to say that it showed how the BMA ‘had moved forward quite a long way’, there is no doubt that at the time both that body and its plan were seen in almost wholly negative terms by the Association. Three related points in particular had been raised which were of concern to the SMA. These were, first, the failure of the BMA to address the central questions of control of the system and the place in it of hospitals. Second, the BMA’s preoccupation with general practice, which was to continue in its present form in according to GPs sole and independent contractor status. In turn, this involved an ongoing emphasis on curative rather than preventive medicine. And, third, the BMA’s commitment to the insurance system. Each of these was largely or totally incompatible with SMA demands or strategy.47 As Chapter Six shows, the BMA was also at this time taking what the Association considered to be a highly reactionary stand on medical refugees and on the National Government’s preparations for war. Nonetheless it was an inescapable fact that the BMA was a powerful organisation in its own right, which in addition had contacts with important sections of the labour movement. Of course some, although by no means all, SMA activists were eligible to join branches of the BMA through which they might seek to change its policy. But in the late 1930s hopes were not high. The British Medical Association was, therefore, a formidable opponent in both medical and political circles, and A General Medical Service for the Nation brought home very clearly its commitment to a certain kind of medical practice and organisation. The SMA’s fight against what it saw as ‘medical reaction’ will be one central concern of the remainder of this book. What the present and previous chapters have endeavoured to show is that, on the one hand, the SMA was a forceful body which was developing clear and well thought out proposals for a particular form of socialised medical service. On the other hand, it was a small organisation in what was becoming, by the late 1930s, an increasingly crowded field, both in the labour movement and more generally. Rudolf Klein suggests, in a musical analogy, that the SMA had a ‘radical treble’ in contrast to the BMA’s ‘conservative bass drum’.48 Having its voice heard at a volume it considered appropriate was a persistent Association preoccupation. We now go on to consider one area where it did enjoy considerable success in the inter-war period, the London County Council.

Notes

• 1.Labour Party, Report of the Thirty-Second Annual Conference, LabourParty, 1932, p. 269.
• 2.Ibid., p. 270.
• 3.Minutes of the Labour Party Finance and General Purposes Committee, 26 June 1933, p. 57; Labour Party, Report of the Thirty-Third Annual Conference, Labour Party, 1933, p. 141; DSM 1/1, AGM 1934, EC Report; Murray, Why a National Health Service?, p. 25; Labour Party, Report of the Thirty-Fourth Annual Conference, Labour Party, 1934, p. 7.
• 4.Labour Party, Report of the Thirty-Fourth Annual Conference, Labour Party, 1934, Appendix VI, ‘A State Health Service’, pp. 256-7.
• 5.Ibid., pp. 257-8.
• 6.Ibid., p. 258.
• 7.Socialist Doctor, vol. II, no. 4, p. 1.
• 8.Labour Party, Report of the Thirty-Fourth Annual Conference, pp. 214-15,9.
• 9.DSM 1/1, Report of the EC, 1934-35.
• 10.DSM (2) 5, ‘Labour Party’, correspondence between Brook and G.P. Blizard, October and November 1930; Minutes of the Labour Party Local Government and Social Services Committee, 14 July 1936; DSM 1/1, Report of the EC, 1935-36.
• 11.Martin Pugh, The Making of Modern British Politics, Oxford, Blackwell, 2nd edn, 1993, Ch. 13. I am grateful to John Macnicol for this point.
• 12.Labour Party Home Policy Committee, Minutes (unclassified material, Labour Party archives): Minutes of the Policy Committee, 15 November 1937; Public Health Advisory Committee Minutes, 1938-44 (unclassified material in three files, Labour Party archives): file 1, Minutes of the Public Health Advisory Committee, 23 November 1938.
• 13.M7T, no. 4, January 1938, pp. 12, 3.
• 14.Ray Earwicker, ‘A Study of the BMA-TUC Joint Committee on Medical Questions, 1935-1939’, journal of Social Policy, 8, 1979, pp. 344, 347, and passim-, for the development of the TUC’s views on health policy, see Earwicker, thesis, Ch. 7. I am grateful to both Stephen Brooke and John Macnicol for reminding me of the nature and significance of maternal mortality.
• 15.DSM 1/1, AGM 1934, EC Report; Esther Rickards, ‘A National Maternity Service’, and Edith Summerskill, ‘Hospitalisation as the Basis of a Maternity Service’, Socialist Doctor, vol. II, no. 2, November 1933, pp. 4—7; ‘Supplement: A National Maternity Service’, Socialist Doctor, vol. II, no. 4, November 1934, pp. 9-12; Murray, Why a National Health Service?, pp. 27-8; and Brook, Making Medical History, p. 7; Stewart, ‘”For a Healthy London”‘, pp. 427-30. On the wider issue of maternal care, see Irvine Loudon, ‘Deaths in childbed from the eighteenth century to 1935’, Medical History, 1986, 30, 1-41.
• 16.MTT, July 1938, p. 7; DSM 4/1, ‘Comments by Dr Somerville Hastings and Others on the TUC and BMA National Maternity Scheme’, pp. 1-2.
• 17.Labour Party Home Policy Committee Minutes (unclassified material, Labour Party archives): Minutes of the Policy Sub-Committee, 5 November 1938; Public Health Advisory Committee Minutes, 1938-1944 (unclassified material in three files, Labour Party Archives): file 1, Minutes of the Public Health Advisory Committee, 23 November 1938; Earwicker, ‘A Study of the BMA-TUC Joint Committee on Medical Questions, 1935-1939’, pp. 338-40.
• 18.Public Health Advisory Committee, Minutes 1938-1944 (unclassified material in three files, Labour Party archives): file 1, Minutes of the Public Health Advisory Committee, 23 and 30 November 1938.
• 19.Labour Party Home Policy Committee Minutes (unclassified material, Labour Party archives): Minutes of the Policy Sub-Committee, 13 December 1938; Earwicker, ‘A Study of the BMA-TUC Joint Committee on Medical Questions, 1935-1939’, pp. 349-56; Brooke, Labour’s War, p. 137.
• 20.DSM 1/1, Report of the EC, 1938-39; DSM (2) 5, ‘Inter-Hospitals Socialist Society’, memorandum 24 May 1936.
• 21.DSM (2) 5, ‘Labour Party’, Charles Brook to Alderman R. Taylor, 20 April 1936; Earwicker, ‘A Study of the BMA-TUC Joint Committee on Medical Questions, 1935-1939’, pp. 348-50, 338.
• 22.MSS.79/MPU/1/2/1, Minutes of Council, 18 July 1929; Brook, Making Medical History, p. 8; DSM (2) 5, ‘MPU’, Brook to SMA members, 2 January 1935.
• 23.DSM 1/1, Report of the Executive Committee, 1935-36; DSM (2) 6, Brook to Middleton, 9 January 1936; DSM (2) 5, ‘MPU’, Welply to Hastings, 21 January 1936; Honigsbaum, Division in British Medicine, p. 261.
• 24.See, for Hastings on the class composition of the medical profession and on the sale of practices, Stewart, ‘Socialist Proposals’, pp. 341, 345.
• 25.Fabian Society Papers, J41/2, memorandum on ‘National Health Insurance’ by the Health Services Sub-Committee of the Social Services Committee, pp. 9-10.
• 26.Earwicker, ‘A Study of the BMA-TUC Joint Committee on Medical Questions 1935-1939’, pp. 340-341; Brooke, Labour’s War, pp. 136-7; DSM (2) 6, Hastings to Brook, 29 July 1937.
• 27.DSM (2) 5, ‘Trade Unions’, London Trades Council to Buckle, 6 September 1938; and Brook to George Gibson, undated but 1939.
• 28.Labour Party, Report of the Thirty-Seventh Annual Conference, Labour Party, 1937, Appendix X, ‘Labour’s Immediate Programme’, p. 279; Labour Party, Report of the Thirty-Fifth Annual Conference, Labour Party, 1935, p. 25.
• 29.On the labour movement and active citizenship, see Steven Fielding, Peter Thompson and Nick Tiratsoo, ‘England Arise’: the Labour Party and Popular Politics in 1940s Britain, Manchester, Manchester University Press, 1995, Chs. 4 and 5; and Abigail Beach, ‘The Labour Party and the Idea of Citizenship, unpublished PhD thesis, University of London, 1996, passim-, Nicholas Deakin and Anthony Wright, ‘Tawney’, in George, Vic and Page, Robert (eds), Modern Thinkers on Welfare, Hemel Hempstead, Prentice Hall/Harvester Wheatsheaf, 1995.
• 30.Peter Clarke, Liberals and Social Democrats, Cambridge, Cambridge University Press, 1978, pp. 5, 15, 65; idem, The Social Democratic Theory of the Class Struggle’, in Winter, Jay (ed.) The Working Class in Modern British History, Cambridge, Cambridge University Press, 1983, p. 13 and pp. 262-3, note 23.
• 31.See, on economic policy, Elizabeth Durbin, New Jerusalems: the Labour Party and the Economics of Democratic Socialism, Routledge and Kegan Paul, 1985.
• 32.DSM 1/1, Minutes of the Seventh AGM, 9 May 1937; Report of the EC, 1938-39; and Minutes of the AGM, 14 May 1939.
• 33.DSM 1/1, AGM 1934, EC Report; and Report of the EC, 1935-36.
• 34.Frank Honigsbaum, Health, Happiness and Security: the Creation of the National Health Service, Routledge, 1989, p. 18.
• 35.Parliamentary Debates, 5th series, vol. 337, col. 1443ff.
• 36.Stewart, ‘Socialist Proposals’, pp. 349-53; and idem, ‘”The Children’s Party, therefore the Women’s Party”‘, pp. 176-80; Somerville Hastings, A National Physiological Minimum: Fabian Tract 241, Fabian Society, 1934,p. 8; DSM 1/1, Report of the EC, 1937-38, and Report of the EC, 1935-36; Minutes of the General Purposes Committee of the SJCIWO, 8 December 1932, p. 2, and Minutes of the SJCIWO, 12 January 1933.
• 37.DSH, File 9, ‘School Medical Service’, Marjorie Green to Hastings, 1November 1934; MTT, no. 3, December 1937, pp. 14-15.
• 38.On planning, see Arthur Marwick, ‘Middle Opinion in the Thirties: Planning, Progress and Political Agreement’, English Historical Review, LXXLX, 1964; for the PEP report, see S.M. Herbert, Britain’s Health, Harmondsworth, Penguin, 1937; Max Nicholson, ‘PEP through the 1930s: Growth, Thinking, Performance’, and Kenneth Lindsay, ‘PEP through the 1930s: Organisation, Structure, People’, both in Pinder, John (ed.), Fifty Years of Political and Economic Planning, Heinemann, 1981, pp. 45, 27; Fox, Health Policies, Health Politics, p. 68.
• 39.MTT, no. 4, January 1938, pp. 1-2.
• 40.Fox, Health Policies, Health Politics, p. 65; Murray, Why a National Health Service?, p. 35.
• 41.MTT, no. 2, November 1937, pp. 1-2.
• 42.DSM 4/1, ‘Some Notes on the BMA Scheme For a General Medical Service For the Nation’, by Dr Somerville Hastings, 18 October 1938.
• 43.DSM 4/1, New Fabian Research Bureau, ‘Report of a Conference on the Health Services, held at the Royal Star Hotel, Maidstone, on October 22—3, 1938’, pp. 12, 5-6.
• 44.Murray, Why a National Health Service?, pp. 7, 38—9.
• 45.’The Walton Plan for a National Medical Service’, MTT, vol. 2, no. 1 (New Series), March Quarter 1939, pp. 2-12; ‘A Model Maternity Scheme’, MTT, vol. 2, no. 3 (New Series), September Quarter 1939, pp. 3-7.
• 46.The Walton Plan for a National Medical Service’, pp. 4, 12; MTT, vol. 2, no. 2 (New Series), June Quarter 1939, p. 20.
• 47.Murray, Why a National Health Service?, p. 39.
• 48.Klein, The New Politics of the NHS, p. 4.