British Public Health History: the politics of universal healthcare

The Socialist Healthcare Association (SHA), originally named the Socialist Medical Association (SMA), played a seminal role in pre-war and post-war health politics, guided by its founding president, Somerville Hastings (1930-51).  The group’s promotion of socialised healthcare effectively helped redesign the UK healthcare-system, contributing to the principles and design of the NHS, through its collaboration with the Labour Party. 

This coalition of socialist doctors and scientists, supported by medically astute left-wing politicians, “significantly contributed” to advancements in progressive healthcare through their actions and writings in the 1930s and 40s.  Their historical efforts can be reflected upon as a lesson in what progressive policy makers can achieve when given the chance. Let they also act as a lesson in how public health rights were fought for and won.

The SHA continues to contribute to Labour health policy today, and support progressive health campaigns, while still maintaining distinct moral principles in relation to the provision of healthcare.  Within the context of Coronavirus, the need to understand the politics, and thus history, of our healthcare system has never been more imperative.  Through a brief history of the SHA and the origins of the NHS, within the context of ideas such as social and socialised medicine, this article will try to illustrate how the organisation shaped our public healthcare today, what this public healthcare could look like, and where it has gone astray. 

A Brief History of the Socialist Medical Association

In its early years, the SMA’s socialised medical paradigm had influence over the Labour Party, both directly and indirectly. While the SMA did not achieve all its objectives through the 1945 Labour Government, it contributed valuable examples of good scientific-governance of public healthcare, through the London City Council (LCC) municipal system.  Prime Minister Neville Chamberlain’s Local Government Act had transferred significant power to county councils in 1929, making the LCC the most powerful local authority in the country.

Thus, when Labour ascended to power in London in 1934, with Hastings as chair of its Public Health Advisory Committee, the LCC used this power to improve the city’s municipal-system, aiming to equal or excel the voluntary health-sector.  The relative success of socialised healthcare in action, juxtaposed to the market and voluntary sector, made an impression on the Labour establishment.  Although the locally organised LCC was not the final blueprint for the NHS, the progressive principle of healthcare as a right of any citizen of London resonates in the NHS’s philosophy.

What Health Politics?

The health politics relevant to the NHS’s creation can be categorised between the concepts of social and socialised medicine, both championed by the left. The latter is a more extreme structural transformation of healthcare, nationalising healthcare entirely, and removing private practice. The former embodies the ethos of the latter, in terms of socialist values about the egalitarian healthcare, but stops short of denying private healthcare practice. 

John Ryle was Regius Professor of Physics at the University of Cambridge during the 1930s and 40s, and former physician to King George V. He was described as part of the “clinical elite” and “effectively the founder… of social medicine”.  He represented a health politics paradigm that opposed the total socialisation of healthcare, which would include the removal of private healthcare markets, but supported a state-salaried healthcare workforce and the universal, comprehensive holistic-care for all individuals due to his belief in social medicine.

Both socialised and social medicine hold the principle that “health is one of the rights of man”, and there is a moral justification for interventions to improve social environments and public health factors, such as nutrition and working environments.   Such interventions increase the chances of an individual achieving their potential and further ambitions, a historically New Liberal justification for state intervention in the early 1900s, which informed this left-wing medical-political paradigm. 

Professor Ryle, a promoter of social medicine at the time, argued for a holistic approach to health, medicine and society, where doctors would be students of human nature and develop rational, but innovative, healthcare-plans. This would mean taking “into proper account the needs of the body and mind, of whole and part”, addressing poverty also as a ‘social pathology’ – well within the New Liberal scientific method of rationalising society, and how this author believes social problems can be viewed and treated.

The progression of health politics and history from 1945 to the present day has seen the predominance and misuse of McKeown’s theory; that economic gains and living standard improvements had ultimately been the greatest factor in improving public health over the nineteenth and early twentieth century. This erroneously overlooks the role of public health intervention in contributing to this public health improvement. The invention of vaccines, antibiotics, and proper health standards all contributed to longer life expectancy and healthier lives. While this theory was debunked in the 1980s, the New Right (Margerat Thatcher and Ronald Reagan essentially) co-opted the idea that public health was a subsidiary to the economy, and was not in fact, a product of political intervention (or non-intervention). 

The history of public health, and thus present health politics, is actually one of “grand social intervention” according to Szreter. The SHA defends the practice of political intervention in medicine and opposes the state’s relinquishing of responsibility to the market or aggregate economic growth. The organisation continues to advise Labour health policy, through the party’s democratic mechanism, while acting as a platform for open medical-political discourse critical of government. For example, Roy Trevelion has highlighted the potential danger in lucrative 10-year NHS contracts, for running the new Integrated Care Service (ICS) system, as they are open up to unaccountable international healthcare giants in a UK-US post-Brexit trade deal.

The Socialist Healthcare Association and Our Public Health

Both concepts of healthcare are premised on the idea of preventative, as well as curative medicine, which involves promoting and providing the facilitation of healthy and fulfilling lifestyles to combat long-term illnesses.  This both increases life expectancy and maintains a higher quality of life for longer.  Contemporarily, this concept has materialised, for example, as Public Health England, established 1 April 2013, an institution focused on dealing with issues of long term health, such as obesity, mental health, and pandemics.

It is important to note the transformation of the SMA over the course of the twentieth-century.  The SHA continues to act as an organ for social and socialised medicine, while evolving beyond its demand for a completely socialised health-care system. It abides by the principles of socialised medicine, without the need for rigid structural dogma.  The SHA is self-defined as “not a doctrinaire organisation”, while maintaining belief in free “universal publicly provided healthcare”, grounded in the principles of “true equality of opportunity and progressive taxation”.  Concurrently, the SHA has carried forward the demands for democratically organised health-care, “based on freedom of information, election not selection and local decision making”. 

Concurrently, the organisation supports different healthcare campaigns, such as the Reclaim Social Care Group (RSCG), in bringing their resolutions to Conference for debate and adoption. The RSCG’s demands “universal social care… based on a right to independent living”, underpinned by the principles of healthcare as a right, thus “free at the points of use”, “fully funded through progressive taxation”, “democratically run”, and “delivered locally”. This proposal emphasises the role of co-operation between local authorities, the NHS, service users and medical practitioners through democratic channels, premised on the belief that informal carers, as well as their older residents, are entitled to comprehensive “rights and support” as citizens of a country that still believes in universal healthcare.

Health Politics in Action

The SHA and the NHS embody principles that should be defended, as they articulate our right to healthcare as citizens, and a diluting or devaluing of these principles will allow a change in our rights.  Such changes are not malicious by default, although recent mistakes in social care have appeared outright neglectful, and suggests a lack of empathy or foresight.  It is important that all citizens are responsible in understanding the politics of public life, so one can engage effectively in holding politicians to account when passing legislation that threatens your healthcare rights.  Sadly it may be too late to protect those rights when your healthcare problem arises. 

The SHA, as a literary actor in civil society, could reiterate the NHS’s founding narrative, highlighting an individual’s right to public health, grounded in our history.  This would politicise the denial of our public health rights, and legitimise criticism of what appears to be beyond political control.  The availability of NHS contracts to American healthcare providers should have you worried.  Therefore, it is encouraging the SHA is calling for a “new Beveridge report for the 21st Century” and a “new social contract” to tackle poverty and inequality as public health issues.  The NHS was originally envisaged as an interconnected organisation; patients, communities and health practitioners would be contributors, as well as users or consumers of medical science. This is what Hart refers to as a culture of generative-learning, whereby collective action and accountability, through democratically organised local healthcare services, can create a truly responsive health service that listens to its public.

The SHA, as a platform for debate can continue to highlight the disconnected nature of local health-systems as a missed opportunity, with so many organisations in civil society that could provide affordable services if the Government would only engage with community better. Public health is deeply political and a lack of public awareness of this fact is making citizens passive to the denial of their healthcare-rights. Charities should not have to provide services in the place of government, the welfare state should protect you. The loss of services that individuals have experience over the years of healthcare spending cuts are part of the political redefining of our healthcare rights as citizens. Acknowledging the politics within medicine requires a historical view since “an awareness of the history of NHS reorganisation since 1948… might well have caused later administrations to pause” before more ineffective reforms and the inadvertent transformation and denial of our rights as citizens.

Our Future Public Health

There is an atmosphere of disbelief and sadness following the way social care has been disregarded and forgotten about during this crisis.  But there is resolve to never allow such negligence again.  We need a public health system that lives up to the principles of the NHS, and sees no older person feel ignored, unwanted or uncared for again.  One cannot demand equality of care, but one can demand that care is egalitarian, in the sense those who need it most shall receive more and in a more timely manner.  The SHA has a key role to play in civil society, alongside organs such as the British Medical Association, in pressuring and informing ‘high politics’ (MPs, Government Departments) into pragmatic and intelligent policy that prevents fatal mistakes from happening.  

It is always useful to be informed and able to hold politicians, and even medical professionals, to account on issues of public health.  Within the context of grassroots action, this publication would encourage you to explore the SHA’s different campaigns, or subscribe to the organisation if you become more invested.  Taking interest in a new issue would itself be a great example of ‘writing to action’; a small but integral contribution to the wider collective movement, initiated by reading this article.  As citizen-readers, you can engage as a promoter or follower of various progressive campaigns.  In both ways you are active within the progressive movement and part of a growing and increasingly conscious civil society with untapped political power.

By Oliver Storey

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