"The Battle for Health": A Political History of the Socialist Medical Association, 1930-51 (review)

John Stewart. "The Battle for Health": A Political History of the Socialist Medical Association, 1930-51. The History of Medicine in Context. Aldershot, U.K.: Ashgate, 1999. viii + 259 pp. $84.95.

This is a fascinating text for all who are interested in middle-class socialism in Britain during a period in which the Labour Party increasingly adopted a social democratic perspective. The Socialist Medical Association (SMA), an affiliated organization of the Labour Party, was founded in 1931 by a small group of radical physicians for the purpose of developing policies and propaganda promoting the creation of an integrated, universally accessible system of preventive and therapeutic medical services. John Stewart uses the SMA's contribution to the debate surrounding the planning of the National Health Service to tell a broader story about the complicated relationship between democratic socialism and the rise of professional society. As a result, he paints the politics of health care onto a much larger canvas that tries to depict the forces of social and political change in the twentieth century.

In the example of the Socialist Medical Association, middle-class socialism reconciled the dilemma of prioritizing welfare provision over economic reconstruction by identifying the struggle for social citizenship as the linchpin of an egalitarian and just society. Furthermore, middle-class medical socialism was largely metropolitan--three quarters of its membership were from London--and believed that the route to a society of socially equal citizens was through the creation of devolved democratic institutions. Thus the SMA president from 1930 to 1951, the radical London GP Somerville Hastings, argued for a universal health-care system, funded by local taxation, run by local authorities, and accountable to local elected representatives. The democratic ideal was extended into programs for reforming medical practice itself. Hastings and his colleagues believed that medicine had become too complicated to be practiced by individuals and needed to evolve into systematic teamwork organized through "health centers" that might mirror the experimental model set up at Peckham.

As Charles Webster has pointed out, the Labour Party was slow to make health care a central issue, but Stewart demonstrates the way in which the SMA was highly influential in forming Labour's early policies regarding reform--first through its role on the Party's Public Health Advisory Committee, and, more significantly, through its influence upon Labour's flagship local authority, the London County Council (LCC). In London, the SMA managed to more or less realize its ideal of a municipalized integrated service. Stewart shows that the SMA gathered increased influence in the planning of the NHS through its membership in the BMA's Medical Planning Commission (created in 1940), despite its often hostile relations with them. However, it was perceived as a radical fringe by the majority of the British medical profession and was ignored by research groups, such as Political and Economic Planning, who wanted to maintain a strictly politically neutral image.

As the Public Health Advisory Committee became increasingly controlled by the Labour Party leadership during the war, the SMA's influence upon it waned, and the ultimate shape of the NHS bore little resemblance to the devolved democratic ideal accomplished in the context of the LCC. The SMA lost faith in Aneurin Bevan, who they believed had capitulated unnecessarily to the demands of the BMA. They felt justified in having helped to create a free and integrated service but they bemoaned the loss of the local ideal in its organization and the almost insignificant support given to the creation of local health centers. Initially, the SMA had not rejected the idea of regionalization because they saw it as a counterforce to centralization, but only if it was structured around regionally elected representation rather than professionally controlled authorities. Their failure to imprint their ideals upon the structure of the service was no surprise...