THE EARLY BEGINNINGS
WHY HAS GREAT BRITAIN a National Health Service, and why is it firmly based on socialist principles? The short answer is because there came into existence at a crucial political moment, a Socialist Medical Association; the longer answer lies in the history of medico-political thought which led to the examination of certain principles of medical service which could be realized only in socialist political action. Medicine and the way in which medical attention is given have been evolving for a very long time but whenever a doctor-philosopher sat down to think of the best way of attending to the health and the illnesses of mankind, he reached similar conclusions. Allowing for the vastly different circumstances, Hippocrates, 2,400 years ago, was saying the same as the SMA was to say in 1930, as Aneurin Bevan and a Labour Government were to say in 1946. All declared that the physician should do his work without any reference to the social, financial or racial position of the patient and that the necessary medical attention, preventive or curative, should be given without any question of fees arising.
The National Health Service Act crystallizes in legal language what the SMA had said was necessary, that the service should be preventive, curative and educative, that it should be universally available. These are monumental principles departing completely from the language of free enterprise, self-seeking and unprincipled money-making which are the mark of capitalist society. Insofar as they have not been completely translated into action and services we are still short of the ideal, but the foundations for further evolution have been soundly based.
These principles are soundly based both medically and politically. Medically they ‘take medicine out of the market place’ and elevate it to a social service in which the skilled doctor can apply all his knowledge to the care of both the individual patient and the community without any reference to cost, or the financial and social standing of the sick person. For the doctor who has any sense of vocation this is a great freedom far above all other freedoms to which he might aspire, and places the physician or surgeon in a unique position exceeded only by his unique part in matters of life and death.
Politically these principles are those of socialism and so set the scene for the next step to a socialist society. They placed upon a Minister of Health, answerable to Parliament and so to the people, the responsibility for the quantity and quality of services to be supplied. It was to be comprehensive and available to all citizens and so, by implication, of top quality: and was to provide for the prevention of disease, for the treatment of all diseases, for rehabilitation and for the education of the people in matters of health. It was to be paid for out of general national income although for a time part of the cost was to be met from the weekly contributions of those in employment.
To reach these conclusions and to translate them into legislation had been a long process. The whole nineteenth century was occupied with slow moves away from all the horrors and disease associated with the poverty and degradation of child labour, of long working hours, of intense hardship in factories and mines. In the second half of the century the discovery of the part played by bacteria in disease, especially typhoid, cholera and tuberculosis led to further schemes to control such conditions.
What is seldom noticed is how large a part the combination of disease with poverty played in the origins and growth of the Labour Movement which was to culminate in the National Health Service. From Robert Owen through Keir Hardie to Beatrice and Sydney Webb and on to Aneurin Bevan, the ill health associated with working class poverty was a great spur to the development of their socialist views. Hardie indeed saw socialism as the cure for the physical ills of his own class as well as the basic faults of capitalism and the British Labour Party’s origin lies in this and not in Marxist or other economic theories. By the beginning of this century we had made a start on public health measures but the Webbs clearly stated that this was not enough: a state medical service would be essential to establish a healthy nation.
Health has been a subject much discussed down the ages and attempts to provide medical care had been made in many places at various times. The Churches had played a very big part in providing some kind of charity for the poor leading to poor-law systems in many countries. By the middle of the nineteenth century the great political minds began to cogitate on the subject and writers began to put forward new ideas. Samuel Butler in Erewhon shocked many Victorians into asking if health was a right or a duty, if illness was a departure from duty or an act of God; and if medical care was to be regarded as a privilege or something to be denied to those wicked enough to become ill.
In most utopian writings health was assumed to be inherent in citizens of a properly organized society and in News from Nowhere everyone appears to abound in health. Edward Bellamy, in Looking Backward, however, thought that even in Utopia they would still have the sick, the crippled, the disabled and the blind, and speaking of the year AD 2000 said that ‘those who cannot work are conceded the full right to live on the produce of those who can’. He saw with astonishing clarity the principle of universality of services. ‘A solution which leaves an unaccounted-for residuum is no solution at all. Our resolution of the problem of human society would have been none at all had it left the lame, the sick, and the blind outside with the beasts to fare as they might.’
Bellamy, writing in 1887, saw clearly that not only should health be a human right but that a medical service would have to be organized by the State. He rejected the idea of a bureaucratic and impersonal service which he thought would not create the proper and desirable doctor-patient relationship. ‘The good a physician can do a patient depends largely on his acquaintance with his constitutional tendencies and conditions. The patient must be able, therefore, to call in a particular doctor, and he does so, just as patients in your day.’ He is, of course, speaking to an 1887 traveller who has arrived in AD 2000 with a very inquiring mind. ‘The only difference is that, instead of collecting a fee for himself, the doctor collects it for the nation by ticking off the amount from the patient’s credit card.’ (Bellamy not only invented credit cards but prophesied radio.) His book became the bible of many reformers and as it coincided with the great public health developments that were just beginning, put health in the forefront of political discussions. It was, however, the early Fabians who first made health a truly political subject and it was the Minority Report on the Poor-Law (1909) signed by Mrs Webb, George Lansbury and two other members (but generally attributed in large measure to Sydney Webb) that first spelled out the need for the first principles of ‘a State medical service’. The principles of such a service would lead ‘in practice as well as in theory, to searching out disease, securing the earliest possible diagnosis, taking hold of the incipient case, removing injurious conditions, applying specialized treatment, enforcing healthy surroundings and personal hygiene, and aiming always at preventing either recurrence or spread of disease in contrast to the mere “relief” of the individual’. At that moment even the Webbs and George Lansbury did not see how they could insist on a free service for all but they demanded ‘a unified service on public health lines’. ‘It is clear,’ they went on, ‘that in the public interest neither the promptitude nor the efficiency of the medical treatment must be in any way limited by considerations of whether the patient can or should repay its cost.’
After the beginning of the twentieth century it was of course the rising tide of the political Labour movement and of the trade unions that forced Lloyd George to introduce the National Health Insurance system in 1911. Such a concept had no place in his basic political thinking at that date but the trade union demand for better conditions included the need for some form of medical care, at least for those in work which at that time meant mainly men, except in a few industries. this was finally accepted, but only for those of low Income.
That system of Health Insurance, providing general practitioner care and drugs for those paying their weekly stamps was to last until 1948. But it was seen by pioneers in the medical profession to be quite inadequate; and indeed the principles of today’s health service were already clearly stated before the NHI Act became law. Most people who write about health services are completely ignorant of the exact and continuous line from these pioneers through to the National Health Service. There were many false trails and side-tracking movements but the writings of a handful of men around 1910-14 were the real origin of all that is now important in health services. In 1910 Benjamin Moore, a Liverpool physician, could write, in The Dawn of the Health Age, ‘Now there is a great and general awakening of the public mind, voiced by the thoughts and actions of millions of the best of the inhabitants of the country, toward a real scientific and continued endeavour to deal with the problems of poverty and disease in a way that means eradication from the race and not merely amelioration of the lot of the individual.’ He was probably the first to use the words National Health Service, the construction of which ‘is a process which will require a generation for its completion and the collaboration of many active minds of skilful administrators’.
So he demanded a service which was national in structure, preventive and curative, in which all doctors would be salaried in a ‘unified system of hospitals and doctors no longer in deadly opposition to one another but working for a common cause, in short a modern machine and weapon of warfare against disease, instead of a fragmentary and motley museum of survivals from antiquity’. GPs would service between 460 and 500 families and surgeries would be run on an appointment system, ‘no crowds, no sweated work’; the GP would ‘have no rivals, no bills to bother about. . . free from a hundred embarrassments in his work from which he now suffers’. He saw no division but rather complete cooperation between the GP, the hospital doctor, the public health officer and sanitary inspector to get rid of all infectious disease.
There is scarcely an item of disease prevention or form of medical care which we argue about today which Dr Benjamin Moore did not discuss. He wanted a preventive health service for, he said, ‘more care is bestowed by the law upon the succulency of oysters than upon the safety of the human beings who eat them’. He wanted a proper occupational health service for ‘disease is secondary to the calls of industry and commerce; the overcrowding and insanitary conditions in many workshops are a dishonour in face of our knowledge as well as a constant menace to life and to health’. He demanded, in 1913, that ‘disease should be made a primary consideration in the country and the Health Service should be under the care of a Cabinet Minister directly responsible to Parliament and people for the maintenance of health and proper control of disease. But it is small wonder he got little support for he actually thought a Minister of Health should ‘possess professional and technical knowledge of his subject’.
The medical profession as a whole did not listen to Benjamin Moore, especially when he spoke of the wonderful effects of a salaried service – ‘Book-keeping, debt collections and bad debts would have vanished like an evil dream, and the doctor would at last feel that he was an honoured member of a scientific profession, with time and interest to study the problems which he had chosen for his life work, instead of being, as he is now, a small tradesman with a declining business.’ But he influenced many including Dr H. H. MacWilliam, then beginning his career at Walton Hospital, from which twenty years later was to come The Walton Plan for a hospital service. However, so many people did support Dr Moore that he was able to establish the State Medical Service Association which held its first meeting on July 26, 1912, and continued to exist, with varying fortunes and activities until it was replaced by the Socialist Medical Association in 1930. But the line of thought was continuous, for among those who were active in both associations was Somerville Hastings to whom the Labour Party owed more than it has ever acknowledged for the working out of a practical health service. However, it is worth recalling what the State Medical Service Association said at its inaugural meeting. Among other things, the basis of the programme was to include:
- The whole profession to be organized on the lines of other State Services now in existence.
- Entry to the profession to be by one State examination.
- Each member of the Service to be paid an adequate salary, increasing gradually according to length of service and position in the service and to be entitled to a pension.
- Members of the public to have as far as possible free choice of doctor: but no doctor to be called upon to have charge of more than a specified number of patients.
- The service to be preventive and curative; all hospitals to be nationalized and used for the purposes of consultative, operative and therapeutic work at the request and in conjunction with the patient’s own doctor.
- The service to be open to every man, woman and child – rich or poor.
By October of the same year 135 doctors had joined the State Medical Service Association and meetings were held all over the country, deputations were sent to see the Prime Minister and others: and invitations, of which few were accepted, to be Vice-Presidents were sent to prominent people including such political opposites as Arthur Balfour, Ramsay MacDonald, Neville Chamberlain, Mrs M. G. Fawcett, George Barnes, Donald MacAlister, Oliver Lodge, W. A. Appleton and Arthur Henderson.
The State Medical Service Association was fortunate in having among its members many who were ready with the pen. Dr Charles A. Parker acted as Secretary for a time and contributed articles to many journals and two of these were reprinted from The Medical World as a pamphlet in the autumn of 1912. He was one of the first to draw attention to the bad distribution of doctors and to relate that to death rates. Hampstead had one doctor to 476 people, a birth rate of 14 per 1,000, an infantile death rate of 60 and a death rate from infectious diseases of 0.56; Walsall had one doctor to 2,096 people, a birth rate of 29, an infantile death rate of 133 and a death rate from infectious diseases of 1.52. Bermondsey was another example with corresponding figures of one doctor to 4,065, birth rate 31, infantile deaths 157 and infectious disease death rate 3.93. No wonder he demanded that the salaries paid to doctors in Bermondsey ‘must certainly be as good as those paid in Hampstead and possibly better’.
To get better distribution of doctors he wanted the population divided into units of 100,000 with its hospital as the centre of all medical care but all GPs ‘as essential a part of the staff of the hospital as are consultants’-and all Medical Officers of Health to have their headquarters in the same building as all other doctors. But all doctors would also work at ‘receiving stations’ well equipped with instruments and all modern appliances. Each 100,000 unit would, he estimated, need 86 doctors, six resident in a 200-bed hospital and 50 GPs of various grades. The 80 non residents would then cost £36,000 a year! The cost to the nation would have been £24 1/2 million. Those who find it difficult to calculate how many doctors we need today would be interested in Dr Charles Parker’s figures:
| Consultants and specialists | 12,150 |
| Resident Medical Officers | 2,430 |
| General Practitioners | 20,250 |
| 34,850 |
What a service that number, organized in such a way, could have given to the population of that date, 40 1/2 millions.
These early reformers were quickly labelled ‘socialists‘ and one Dr R. T. Irving of Southport went to great lengths to explain and discuss the term. He considered the British Medical Association’s views to be ‘unbusinesslike, impolitic contentions – they are never unselfish, they demand much from the public and guarantee no better service in return’. He thought ‘a National Medical Service is socialistic; it is an attempt to better health and life that the individual may more readily assert himself’. He wanted less money for his ervice than Dr Parker but did not set out his ideas so clearly.
Clearest of all was Dr Milson Rupert Rhodes of Didsbury, Manchester. A pamphlet based on an address he gave in 1912 to the BMA in Manchester is dedicated ‘to my fellow workers in our beloved profession, who, in the BMA, in the National Medical Union and in all other societies, are united in the cause of Medical efficiency and the public good’. He took the headings of the State Medical Service Association quoted above and extended them in the greatest detail.
He did not use the words Health Centre and he thought of every doctor having access to hospital beds, and so he asked for a ‘central depot to be instituted in every locality’; doctors in the neighbourhood were to act as the management committee although the facilities were to be provided by Government. The central depot, he declared, ‘will thus be in the nature of:
- A cottage hospital.
- A centre of scientific work in the locality.
- A nursing home.
- A board room for doctors.
- A medical library and
- A central supply depot both for sterile instruments, sera, laboratory equipment and therapeutic apparatus.’
He visualized that while most patients would get surgical treatment free there would be some ‘of the poor middle class, never yet provided for’ -who could get operations done at a moderate fixed tariff since surgeons would ‘not require the great fees of the present day as they will receive proper remuneration for their hospital work’. He did not advocate, as some of his colleagues did, a complete salaried service, but was obviously trying to find a compromise which would provide a national service with some place for modified private practice. He thought Manchester should give a lead to the rest of the country and quoted with approval from a Manchester pamphlet of 1889 in which a Dr Rentoul had proposed the formation of a Public Medical Service which the doctors refused ‘because they thought it would affect their money interests’. Dr Rhodes believed the medical profession were wrong then and should, in 1912, see that a national service would release doctors ‘from all base and degrading advertising expediencies, from flunkyism and all that is mean and unmanly’.
The Minute Book of the State Medical Service Association is fascinating reading. Sydney Webb gave an address on the need for and possible structure of a Board of Health. He was quite emphatic on a point that was to crop up again in 1946, that doctors should not be members of governing committees but should work through advisory committees. He and others had, of course, no doubt the medical administrators would have a very important place and that management committees should be small. The SMSA met regularly and all through World War I continued its work, discussed its relations with the rising Labour Party and continuously advocated the setting up of a Ministry of Health as a preliminary step to a national medical service.
It must indeed have been a great effort to keep such a highly specialized organization going during war time and yet the executive met seventeen times during that period. Many members resigned because of war service or because they could not afford the fee but the EC retained their names on the membership list. Mr Somerville Hastings appears to have assumed as early as February 1915 the job he continued to do for the next forty years ‘drafting a circular to go out to all members’ and at the same time giving unparalleled leadership.
The annual subscription was fixed at 2/6d and every member was to get ‘such literature as the Association might publish’. Because of travel difficulties a small committee of London members was given executive powers.
As was to happen again in World War II, the impact of war made many members of the medical profession ask what was to happen when peace returned. It is said that two factors inclined many toward a salaried service, their war time experience of such a service and the fact that incomes were very low. Much discussion took place ‘more pronounced in Lancashire and the North than in the South’. At its meeting on April 19, 1917, twelve members considered two draft plans for a State medical service and it was decided to seek an interview with the President of the Local Government Board and to press on him the urgency of setting up a Ministry of Health. That the subject was becoming one of importance is shown by the publication by the, of three lengthy articles on the post war reconstruction of the medical services. All foresaw changes, particularly the article of Sir Bernard (later Lord) Dawson which was to be further elaborated in a Ministry of Health ‘Consultative Council’ report two years later. The indefatigable Drs Moore and Parker gave the arguments for a salaried unified health service, and this time pressed the need for group practice at ‘clinical centres’. They visualized all health workers working together and said ‘the work of the clinical service would centre around the hospitals or treatment centres in close touch with the hospitals and general practitioners would share the clinical work and form an integral part of the staff of the hospitals. They would work in groups.’
The Lancet wrote a leader on the articles it had published and summarized its own views in a very forward looking way. ‘There appears to be no doubt in the public as well as the professional mind that now is the appointed time for placing the medical profession on a more stable basis, both as a calling for its members and as a service whereby the health of the people is to be maintained by the best preventive and curative measures.’ If not all was done that could have been done at least a Ministry of Health was established and had a physician, Dr Christopher Addison, as its first Minister. He at once set up a Consultative Council on Medical and Allied Services with Lord Dawson of Penn as its Chairman and its first task was to consider the kind of scheme necessary to provide ‘such forms of medical and allied services as should be available for the inhabitants of a given area’.
When this body quickly presented an interim report because it felt the matter was urgent, and when it accepted that ‘the general availability of services can only be effected by new and extended organization, distributed according to the needs of the community’, and when it recommended Health Centres as the SMSA had been pressing for ten years, that body suffered a typical setback, some of its members thinking the job was finished and failing to realize just how long a battle still had to be fought before the Health Centres would be built. The Dawson Report is often spoken of as if it invented Health Centres but as we have shown this is far from true. It did accept the basic principle that ‘the best means of maintaining health and curing disease should be made available to all citizens’. It spoke as if the work of the SMSA had already established the concept of the Health Centre for it said ‘A Health Centre is an institution wherein are brought together various medical services, preventive and curative, so as to form one organization.’ But the Dawson Report shows no inkling of group practice and its Primary Health Centres were a combination of a cottage hospital with plenty of private pay-beds and a clinic, and the GP was to be left to decide which of his patients would be seen in his own surgery or at the health centre. The Secondary Health Centres were an ill conceived attempt to bring some kind of organization into the hospital service but never found favour. As to the main plank of the SMSA, whole time salaried service, the Dawson Report adhered to the profession’s reactionary view that ‘by its adoption the public would be serious losers. . . whole time salaried service would tend by its machinery to discourage initiative, to diminish the sense of responsibility and to encourage mediocrity’. A strange reaction so soon after a war in which surgery in the hands of whole time officers had made great advances. As it turned out, political changes and post war problems drove the health service question into the background.
It was not surprising, therefore, that the membership of the SMSA fell, although Dr Charles Parker continued as Secretary. It was the work of a few new members, Mr Somerville Hastings, Dr Lyster (a medical officer of health), Alfred Salter, later MP for Bermondsey, and Dr Hector Munro who was still doing propaganda thirty years later, which kept the movement alive. Meetings tended to be small and infrequent although the same names continued to appear in the historic minute book. Dr Jane Walker, a real pioneer among women physicians, acted as Chairman and then as Treasurer, but Mr Somerville Hastings with his friend Dr Lawson Dodd were most active inside the Labour Party. Indeed the members of the executive committee were busy also in the Fabian Society and as an advisory committee on health matters to the Labour Party.
When next the SMSA becomes reactivated it is December 1929 and new names have joined the few older ones still left. Mr Hastings has taken the place of Professor Moore as leader and is supported by Drs Ethel Stacey, Victor Patterson, Robert Forgan, Oscar Tobin, Arnold Sorsby; Dr John MacKeith, and Dr H. Billing among the twenty-six members who attended the meeting. Much discussion took place on whether the association was to be connected with the Labour Party and it was decided it should be ‘non-party’ and its name changed to National Medical Service Association.
Its views on policy were however an advance on those we have quoted from earlier pamphlets and very close to those which very shortly were to become clearly political aims achievable only through the Labour Party. The Association was to advocate:
- A free National Medical Service available to all members of the community and providing every form of medical, surgical, obstetrical, dental and preventive treatment.
- The provision of necessary institutional treatment, consultant and specialist services including bacteriological, pathological and X-ray, together with all known means for the treatment and prevention of disease.
- All to be coordinated in one service by the Ministry of Health.
There seems to have been no difference on these points as basic principles but there developed quite sharp divisions of opinion as to how they were to be attained. Dr Alfred Salter was particularly keen to make a step toward a national service through the extension of the existing health insurance scheme. He told a meeting that the quickest advance would be by extending health insurance to all dependents of workers for British democracy always advances ‘by stages and by grafting on to existing schemes’. But it would be essential to get the scheme under the control of the Ministry of Health and the local authorities instead of existing insurance committees. That was, in fact, the view of the Public Health Advisory Committee of the Labour Party. The general political atmosphere was so much in favour of such an advance that Dr Salter told the meeting that it would be presented to Parliament as soon as time could be found. Dr Salter could not guess it would be seventeen years before a Minister of Health could persuade Parliament to consider a National Health Service Bill.
A year later in 1930, the National Medical Service Association met for the last time. One subject discussed was whether it should amalgamate with the newly formed Socialist Medical Association but it was decided there was a place for both organizations. Events were to prove that there was no place for both and it was the more definitely political and much younger body, the Socialist Medical Association that was to survive. That this was so was probably largely due to the decision of Mr Somerville Hastings to accept nomination as President of the SMA, a position he occupied for twenty years. During the whole of that time, as we shall see, he kept up the continuous propaganda for a fully developed national health service which he had already been advocating since the end of World War I.
Public opinion was rapidly accepting the idea of a national medical service and in a way Somerville Hastings in lectures and articles to journals reflected this very accurately, since he maintained the closest contact with the people in his constituency, at that time, Reading. In 1928, the Lancet printed an article by him on ‘The Future of Medical Practice in England‘ which was very tentative but based on a firm belief in the inevitability of ‘the provision by the State of some form of public medical service within the next few years’. Lay audiences, he wrote, always applauded the idea and he called on the medical profession to begin planning such a service instead of leaving it to others whose scheme might ‘be ill digested and imperfect’. As a specialist, it is interesting to note Hastings fully appreciated the need for a scheme in which ‘the general practitioner may have an honoured place as the natural centre around which the whole scheme revolves’ .
Three years later, on May 10, 1931, Somerville Hastings gave the first Presidential address to the Annual Meeting of the Socialist Medical Association, setting out in his first sentence the role of that body. ‘It is the privilege of a new organization to see visions and dream dreams but in looking into the future we must be strictly practical.’ His basic principles for a new type of medical service were that it should be preventive, that ‘there must be no economic barrier between doctor and patient’, that all citizens should have a right to hospital care, that the team and not the individual should be the keynote but in that team ‘the general practitioner is essential’. The President told the SMA that such a service, guaranteeing choice of doctor and professional freedom, should operate from medical centres which ideally would also house the dental service, would have visits from hospital consultants and provide a basic industrial health service. It was in this speech that one brand new and important concept, that ‘specialists attached to the hospitals would also consult with the members of the general practitioner service in the patients’ homes’, first appeared. It was from this moment, indeed, that a great variety of thoughts on how a health service can best be provided began to come together and to make a cohesive whole but one of that ‘practical nature’ which was to appeal to the Labour Party and ultimately to the whole nation.