Liz Peretz: Speech from Socialist Health Association conference, 1 July 2023
Photograph: Edith Tudor Hart/Suschitsky from ‘Working-class wives. Their Health and Conditions
Lessons from the 1930s – blueprints and red lines
How those advocating ‘reform’ are taking us back to pre-NHS days
Why is it worth opening the conference with some words about the 1930s – about what health services looked like then, before the NHS, and what the state of people’s health was at the time?
First: we are back, thanks to austerity, to breath-taking inequalities not so different from those in the 1930s. Children’s height is reducing year on year, they go without meals, without heating. Chronic ill-health – physical and mental – is increasing to levels not unfamiliar[MOU1] 90 years ago.
Second: while we still have our NHS free at the point of need, underfunding, private sector plundering, 40 years of being forced to act on business principles – to tighten the belt, balance the books – have brought us to the brink of the chaotic, fragmented world of British health services described by contemporaries in the 1930s. It’s as well we peer into the past to see what might be ahead.
And third, to my mind most important: those contemporary commentators developed plans for the future, with blueprints and red lines, principles, and prescriptions. These give some interesting lines of thought for us, as all parties are beginning to limber up for their manifestos, and as Unions, professional groups, campaigners, and patients pull together thoughts for the future.
The clearest and most straightforward prescription for a future Ideal Health service I’ve drawn on is that of the SMA – the Socialist Medical Association, the original name of the Socialist Health Association. It was first delivered to an appreciative Labour Party Conference in 1932 by our first secretary and president, Dr Somerville Hastings, MP for Reading (who would have been incandescent about Thames Water!).
Following hot on its heels was the 1937 report ‘The British Health Services’ (begun in 1934) by an independent think-tank, Political and Economic Planning (PEP for short), whose key members had been trained by Maynard Keynes, unashamedly capitalist while believing in state intervention.
A healthy population is essential
Both start with a clear message that our government doesn’t seem to have understood: it is in our national interest to have a well and content population. The costs of ill-health far outweigh by 8:1 the costs of a decent all round health service – prevention is in the long run much cheaper than simply concentrating on illness. Here is a quote ‘The more careless about health the community is, and the more often its members need serious doctoring, the worse doctoring they are likely to get because the cases coming up for attention will be too many and at too late a stage.’ And the costs to the nation of working days lost, benefits, compensations – in 1936 the Government paid out £12 million to workers in compensation for accidents. Health here includes – clean water, good working conditions, healthy eating, physical exercise, decent housing, an end to overcrowding. To quote the PEP report ‘we need to create boldly and consciously the conditions in which a healthy population could grow and flourish.’
No place for profit
A second message – profit making firms should be removed from our health services. Another quote ‘Cunning Swindlers… deliberately… exploit for their own profit… the credulity of the public.’ This might be over the counter ‘cures’ or nursing home places, or private doctors overprescribing or telling their patients what they want to hear. There was no profit to be made in promoting health, or dealing with mould in housing, so ‘health’ services remained ‘sickness’ services; and you were often ‘treated’ for something with expensive ‘quack’ cures over the counter which never meant to live up to their advertising campaign, only to make a quick profit. And profit makers thrive on competition, not co-operation – whereas health needs the highest level of co-ordination and cooperation to be effective.
Post-code lottery 1937 style
Which brings me to message number three. Detailed surveys like the 1937 report reveal an extraordinary, fragmented patchwork of health services – more like a set of unassembled ill-matched patches, overlapping in some places, entirely absent in others. Public, old poor law, voluntary, private, paid for by donation, contribution, insurance, government grant – every part of the country totally different, even down to the level of means testing. This was the chaos of the 1930s despite the Ministry of Health – established in 1919 to improve the nation’s health.
In Merthyr if you fell pregnant you had to rely on the charitable ladies bringing you free milk and marmite from London to their grace and favour clinic. In Tottenham you had the full array of free (very generous means testing terms) clinics before and after the baby arrived. The reason for the national chaos? Too much ‘regulation’ at arm’s length allowed poor practice – lots of Tory authorities turning a blind eye, not inspecting regularly enough, not employing enough inspectors. Despite around five pieces of legislation and much handwringing, it was still the case in 1935 that one mother in 260 died in childbirth; and life expectancy had only improved by five months since 1871. In fact in some areas, it was sliding backwards from the 1920s figures. The lesson here is that permissive legislation isn’t enough, and ‘monitoring’ doesn’t ensure a decent service, let alone improve it. A nation needs a better grip than that.
The inadequacy of National Insurance
An examination of the much trumpeted National Insurance (NI) scheme – out of which came the panel doctor but for those in employment only, not their families and dependents – reveals another nightmare. There were something like 20,000 small insurance schemes and approved or friendly societies all connected to NI, all of which gave different levels of help if you were ill. With employers like Mr Morris in Oxford, who operated by regular layoffs of weeks at a time, this wasn’t even working for the workers – and it was not concerned with promoting health, or covering chronic debilitating conditions. Insurance is not the way. Nor were the myriad of contributory schemes – two pence for a family every week for a district nurse, a shilling for the GP for the whole family, and another two pence for the hospital. And every area had different rates and services – another nightmare that didn’t help the poorest, and didn’t guarantee the services which were in dire need of state support in the late 30s.
Blueprint for health not sickness
And so to the blue print: ‘health not sickness’. Both reports came up with very similar plans. For each, the key person was the family practitioner, working with colleagues in a beautifully equipped, publicly owned health centre with well-paid nurses, health visitors, midwives, district and practice nurses, secretaries. All the staff would be fully salaried through state funds, all the staff given free training, open to students from all social classes. All doctors would have a case load that allowed them to really get to know their patients, their housing conditions, their family relationships – a small enough workload so that they could do regular check-ups, spend time on research, on discussing cases with colleagues.
Paying attention to the social determinants of health – primary care and public health
The two blueprints also included public health directors (then called a Medical Officer of Health, or MOH), salaried through the local authorities and with local responsibility for sanitation, infectious disease control, good housing, workplace health, clean water, good drainage, nutritious subsidised food, and school health. The MOH and the local GPs would meet regularly to discuss outbreaks of scarlet fever or how to tackle poor workplace conditions or water quality. These very local twin services – tackling ill health and the social determinants of health together – would come under a local democratic Medical Committee, under a Ministry of Health, with expanded statutory powers and the funds to match.
The hospital service
At the time such an impossible overlapping and still inadequate muddle of private, public, municipal and voluntary institutions – would be firmly co-ordinated into a set of general hospitals, many with teaching facilities, to which the family practitioners could refer their patients. They also were to be staffed with publicly trained and salaried specialists and nurses.
How were the public to have access?
Here there was a divergence in approach. The PEP recommended some kind of means tested small fee to the public – possibly through insurance – but not fees that would deter those on low incomes. The Socialist Medical Association were unequivocal. The authors of The People’s Health demanded free-to-all access; and not just at the point of need, or sickness, to the whole range of doctors, nurses, hospital specialists and clinics, but also in health, for regular check-ups and advice.
What are the lessons for us now?
While we still have a free-at-the-point-of-need NHS, the whole range of services needed to tackle the social determinants of health and indeed prepare for future pandemics is in tatters. The 1930s MOH was in many ways more prepared than we are, with isolation hospitals, fever nurses, special ambulances and public health education always on the alert. Striving for health and happiness not just the absence of sickness – recognising that the costs of ill-health greatly outweigh the costs of providing services to promote good health – should be core to any social democratic, not just socialist, manifesto.
All existing public municipal and voluntary hospitals were co-opted into a coherent service in 1948, whatever their origin. They were all needed – and more – to ensure enough beds for the nation. A rational approach to the bed issue today might also propose co-option of the private stock, as well as the re-funding of hospitals so they can reopen beds, wards and operating theatres. This would be much better for long-term planning than handing money to private hospitals to clear NHS waiting lists only by poaching yet more NHS staff, and exacerbating the current NHS hospital crisis.
For the SHA – we should take pride in the 1932 report, but also acknowledge that we still haven’t reached the ideal health service – fully salaried staff in publicly provided fulsomely equipped local health centres and general hospitals – that Somerville Hastings and others envisaged. The SHA continued our criticism, throughout the building of the NHS and long beyond, and indeed some of our members, notably the Tudor Harts, father and son, pioneered in their general practice a lot of the ideas in The People’s Health, including undertaking ground-breaking research.
But one of the key messages – even stronger in the more social democrat PEP report of 1937 than the SMAs report – was: ‘keep the profit motive out’.
And for us all, keeping the profit motive out of our future health services is a lesson that must be learnt. Our NHS is currently riddled with the contract culture, the burden of PFI, and staff who have known nothing else but the purchaser-provider split. Any Party Manifesto worth its salt will take on that message and plan to act on it. If the 1930s capitalists themselves knew that profit was not the way to the healthy nation, surely we can know that too.
Liz Peretz 1st July 2023 – Associate Fellow, Department of Social Policy and Intervention, University of Oxford; We Own It; Keep Our NHS Public; SHA
[MOU1]Not unfamiliar – suggest just ‘familiar’