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The Battle for the National Health Service

England, Wales, and the Socialist Vision

Opening Ceremony Celebration of NHS. London 2012 Summer Games

Actors in a sequence meant to represent Britain's National Health Service (NHS). Performed during the Opening Ceremony at the 2012 Summer Olympics, Friday, July 27, 2012, in London.

David Matthews is a lecturer in sociology and social policy at Coleg Llandrillo in North Wales, and the leader of its degree program in health and social care.

Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide.

Aneurin Bevan, In Place of Fear, 79

“Socialist social policies are, in my view, totally different in their purpose, philosophy and attitudes,” from those of capitalism, wrote the British social policy academic Richard Titmuss in 1967. “They are (or should be) pre-eminently about equality, freedom and social integration.”1 However, equality was not the only central ideal: “Socialism is about community as well as equality,” Titmuss argued. “It is about what we contribute without price to the community and how we act and live as socialists.”2

Integral to Titmuss’s ideal of socialism was his approach to policies for the provision of public services. He maintained that egalitarian social policies could not be achieved without “an infrastructure of universalist services.”3 This meant making the same means of existence—beyond a residual or minimal level—available to all members of society. By making services universal, users would not be subject to any humiliating loss of status, dignity, or self-respect.4 That is, universal services prevent humiliation because they do not discriminate, and this would in turn mean that they would provide better services to the poor. In addition, if services were not provided universally, they might not be made available at all, or, those who could purchase them privately would do so, leaving the rest of society to rely upon a lesser, residual service, deepening social divisions and inflicting a sense of inferiority and shame.5

Responsibility for the provision of welfare, Titmuss claimed, should primarily be assigned to the community, with all members contributing to each other’s welfare in a spirit of fellowship and solidarity.6 This community provision of welfare would be achieved largely through the state, with the government programs and directives reflecting the general desires of the community. “It is the responsibility of the state, acting sometimes through the processes we have called ‘social policy,'” Titmuss wrote, “to reduce or eliminate or control the forces of market coercion which place men in situations in which they have less freedom or little freedom to make moral choices or to behave altruistically if they so will.”7

Origins of the NHS

Titmuss frequently invoked Britain’s National Health Service (NHS) as the epitome of this kind of welfare universalism, arguing its scope and services were more comprehensive than any other aspect of the welfare state.8 Of the mature capitalist countries after the Second World War, the United Kingdom was among the first to implement a collectively provided universal health care system, establishing the NHS in 1948. And it was the pursuit of socialism, through class struggle, that led to the creation of the NHS: universalism, collectivism, and social solidarity were the pillars on which the system was built. To understand this history, we must examine the life of Aneurin Bevan, a central figure in the fight for democratic socialism in Britain. To this day a controversial figure on both right and left, as Minister for Health and Housing during the 1945–50 Labour government, Bevan institutionalized in the NHS his vision of a socialist Britain.

Bevan was born in 1897 in the mining town of Tredegar, South Wales. By the time of his birth, the region was one of the largest coal exporters in the world, and the Welsh coalfields expanded and contracted with the rhythm of British capitalism’s imperial impulses. This imperial expansion was often predicated on the existence of surplus capital that could not be absorbed within the domestic economy, much of which was in turn directed towards the United States, the largest market for British surplus capital from the mid-nineteenth century up to the eve of the First World War. U.S. domestic expansion in this period was frequently stimulated by this absorption of British surplus capital, further accelerating demand for UK exports, including coal. All of this, as historian Gwyn Alf Williams argues, placed the society and economy of South Wales “in the export sector of British imperial capitalism.”9

On this economic base, a working-class culture was built that shaped Bevan’s values. Material disadvantage and poverty, with class conflict always in the background, marked his youth. The early 1900s marked a period of increasing working-class self-assertion, with South Wales arguably the heart of a growing class consciousness in Britain. At a young age, Bevan absorbed the ideas of Eugene V. Debs and Danial De Leon, along with the anti-materialism of Jose Enrique Rodo. Marx was also an important source of inspiration. Later in life Bevan acknowledged that “in so far as I can be said to have had a political training at all, it has been in Marxism.”10

As the son of a coal miner, he was also profoundly influenced by that industry’s vibrant trade union politics. At age thirteen he began work at a local colliery, and by the time he left the pits at twenty-one he was an experienced trade unionist, having become chairman of his miners lodge at nineteen.11 From within this culture, Bevan saw that the afflictions of poverty and unemployment were not a consequence of individual fecklessness, but of the structural operations of capitalism. This realization came not just from intellectual understanding, but from the scars of experience.

Although he remained an active union representative after leaving the mining industry, Bevan came to conclude that parliamentary politics, rather than industrial action, was the most decisive weapon the working class had for the advancement of socialism. Control of the state would be instrumental, indeed indispensable, for collective action. This struggle for a Parliamentary road to socialism began in 1929, when Bevan was elected as the Labour MP for the constituency of Ebbw Vale, an area that included his hometown. Steeped in working-class culture, Bevan had an authority to speak on behalf of the laboring masses of South Wales, and he acted as their impassioned representative.

Early on, Bevan recognized that of the basic social needs that could only be fully met through collective provision, health care was the most urgent. In no small part as a result of his own experiences, he knew that financial constraints created significant barriers to health and medicine. It was paramount that the means to good health be available to all. No society could legitimately consider itself civilized, he argued, if those who required medical support were denied because they lacked the means to pay. The universal and collective provision of health care would guarantee that the best skills and facilities be provided to all members of society, free of charge.12 Bevan did not play down the radical ambitions of his plan: “A free health service is pure socialism,” he announced, “and as such is opposed to the hedonism of capitalist society.”13 Though it was Bevan’s skills as a politician and negotiator that would ultimately make the implementation of his vision possible, the NHS’s origins nevertheless came from his commitment to socialism—a conviction based on his own experience of the struggles and successes of the working class in South Wales.

A Working-Class Institution

In the struggle for a more egalitarian society, a public health care system, along with other universal welfare services, undoubtedly represents a vital institutional advancement. Nonetheless, some influential Marxist analyses tend to characterize state welfare as a concession that ultimately sustains capitalism by aiding the accumulation process and “legitimizing” the system—all of which serves to suppress resistance from below. What these arguments miss, however, is the role of class conflict in establishing these same services.14 It is a regrettable irony that so many Marxists, who view class struggle as central to historical change, have ignored its influence on the development of modern welfare provision.15 Historian John Saville argued the we must recognize both the influence of the political calculations of the ruling class, and, significantly “the pressures which have come from the mass of the population as the perceptions of economic and social needs have gradually widened and become more explicit.”16

Without disputing that state welfare programs have facilitated capital accumulation and encouraged support for capitalism among the working class, it must nevertheless be recognized that in many cases these policies owe their existence to direct collective action or to efforts by industrial and political representatives of the working class. Titmuss’s ideas accorded with this understanding. The motivating impulse behind the establishment and evolution of welfare in Britain, he argued, was the spirit of solidarity that helped define the working class of the nineteenth century, encapsulated in the creation of mutual aid societies, cooperatives, and trade unions, all established to counteract the corrosive social effects of industrialization.17

In the rapidly industrializing Great Britain of the nineteenth century, rates of disability, illness, and death were inevitably high. In South Wales, both miners and their employers accepted these afflictions as facts of life; few questioned that the coal-mining process was hazardous to the point of death.18 This, however, did not inhibit workers from seeking health and safety protections, and in South Wales, whose geology made it one of the most dangerous coalfields in Britain, adequate health care was imperative. In the absence of health care services from employers or philanthropists, and without any sizeable middle class in the region, it was left to the miners to provide their own health care.19 A variety of community-based self-help organizations emerged in the form of mutual aid and “friendly societies,” becoming vital sources of care for people throughout the coalfield.

In South Wales, worker-organized medical aid societies gained a reputation for providing more comprehensive health services than those of similar institutions in other parts of Britain.20 Membership was based upon a regular payment, from which recipients would receive free health care at the point of use. In Tredegar, higher-earning workers contributed a greater sum. The Tredegar medical aid society was established in the early 1890s, and by the 1920s contributors could benefit from the services of five doctors, one surgeon, two pharmacists, one physiotherapist, and a community nurse. Though coverage was initially limited to male workers, by the second decade of the twentieth century, wives and children could qualify for support, along with retirees and those no longer working due to disability. Significantly, these societies were democratic institutions, governed by elected committees, giving members the opportunity to oversee their performance.21

Bevan had direct experience with the operation of Tredegar’s medical aid society; he chaired its hospital committee during the 1920s. During his tenure, membership was expanded beyond miners to include workers in other trades, making an estimated 95 percent of the town’s population eligible to receive support.22 The society became, in other words, a true community health service. In the otherwise grim conditions of life in a Welsh mining town, Bevan grew up with a collective model of universal health care, an expression of class struggle that illustrated the need for collective, autonomous action by the working class. When he entered politics, Bevan was determined to promote the lessons of Tredegar for the good of workers across the country. Reflecting years later on how this early experience of successful class struggle had informed his vision for the NHS, Bevan explained: “All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to ‘Tredegarise’ you.”23

On the tenth anniversary of the NHS’s founding, Bevan claimed that its purpose “was to provide a comprehensive, free, health service for all the people of the country at time of need” and to “organize the practice of medicine in such a fashion as to reach the people who needed it most.” Emphasizing the service’s ability to promote social solidarity, he argued “There is no more pleasant sight to be seen in the world than can be seen outside a maternity clinic in Great Britain today, where women of all classes in the community mingle together, taking their children to be weighed and to be examined.”24 It is thus possible to argue, without exaggeration, that the NHS was a working-class creation, emerging directly from the class struggle, becoming, as Bevan’s biographer and fellow left-wing Labour MP Michael Foot argued, one of the finest institutions established on the foundations of democratic socialism.25

Bevan’s vision of a system of socialist health care was enshrined in law by the 1946 National Health Service Act, which stated that “it shall be the duty of the Minister to provide throughout England and Wales…” services of hospital accommodation, medical and nursing services, and specialist medical treatment obtained either in hospital or the community.26 Though modest in tone, the importance of this statement cannot be disputed: by law, the government was now obliged to guarantee and distribute health resources on the basis of need to all citizens throughout Britain.

This legal requirement remained central to the NHS for much of its history. However, since 2012, it has come under threat from marketization and privatization. The extent of this threat, however, has been complicated by the advent of devolution: since the late 1990s, independent legislative institutions have been established in Scotland, Wales, and Northern Ireland. Although varying in statute-making authority, all retain control over the operation of the NHS within their territories. In less than two decades, the result has been a rapid regional divergence in the design, delivery, and distribution of health care among the four countries of the United Kingdom, with each exhibiting alternative approaches to the ideal of a collectively provided universal system. Arguably the starkest differences are those between England and Bevan’s homeland of Wales.

England’s Neoliberal Turn

The United Kingdom is part of a larger trend that has seen the restructuring of public health systems in many advanced capitalist countries, driven by factors including technological development, ageing populations, and shortages of health care professionals.27 Yet the decisive factor, as in other sectors of the welfare state, has been the neoliberal push to remake health care in the image of the “free market.” In England, the greatest single blow to universal health care in the NHS’s history came with the enactment of the Health and Social Care Act (HSCA) in 2012.

The law abolished the NHS’s foundational guarantee of universal care, instead requiring only that “the Secretary of State…continue the promotion in England of a comprehensive health service.”28 While the onus remains on government to fund health care for individuals who live in England, it has withdrawn its responsibility, and that of all future governments, to provide health care for all citizens. Rather than being the direct responsibility of government, the provision of health care has been transferred to an autonomous public body, NHS England, which controls the majority of all health expenditure and directs the overall operation of the English NHS.

Prior to 2012, the administrative work of the NHS system was managed mainly by Primary Care Trusts (PCT), which executed the government’s health priorities, according to the regional needs of service users and providers. With the abrogation of the universal care requirement, however, this administrative system has become obsolete.29 PCTs have been superseded by Clinical Commissioning Groups (CCG) as the main providers of regional health care under NHS England. Composed of health professionals, including general practitioners and financial administrators, their purpose is to secure the provision of services relating to secondary care, community health, and mental health and learning disabilities services. It is to these independent, quasi-private consortia that much of the delivery of the English NHS has now devolved. The language of the HSCA allows CCGs a broad margin of discretion regarding what services they provide: a group “may arrange for the provision of services or facilities as it considers appropriate” to “such extent as it considers necessary.”30 Freed from any legal mandate for consistent standards of care, the services and resources provided through NHS England can now vary widely by clinic, city, and region. Further, in an act that strikes at the heart of the principle of universalism, the HSCA permits CCG service providers to set their own eligibility and selection criteria for patients. For the first time in the history of the NHS, patients in England can now be turned away.31

Repealing government responsibility and delegating care provision to independent regional authorities has exposed the NHS to an unprecedented threat of privatization. CCGs can administer services directly or subcontract them to private providers. Although the circumstances for public provision remain, CCGs have in effect been legally compelled to outsource services. While couched in the language of “consumer choice” and patients’ rights, CCGs must ensure that during the commissioning process they protect the rights of patients to choose providers, promote competition, and adhere to best practices relating to procurement. In other words, CCGs must allow the private sector an opportunity to provide services; any state monopoly over health care would be illegal.

Evidence suggests that since the establishment of CCGs, private sector provision has increased significantly. In the year after the HSCA came into force, an estimated £13 billion in NHS contracts was advertised, almost three times greater than the previous year, with a 30 percent increase in advertising encouraging bids from private groups and charities. These contracts pertained to over seventy different services, compared to forty in 2012. Sixteen were worth over £100 million, with the largest totalling £1.2 billion. Private health care firms were not the law’s only immediate beneficiaries. An estimated £200 million in contracts went to the business services and consulting industry, including leading firms such as Ernst and Young, Deloitte, and McKinsey.32 By 2015, 40 percent of contracts awarded, worth a total of £2.5 billion, went to the private sector—just 1 percent less than the amount awarded to NHS providers.33

For this rapid privatization to occur, it was necessary for the legal duty to provide universal care to be repealed. For, as Bevan recognized, marketization fundamentally contradicts the values of universalism and collectivism. Universal services allocate resources based upon need, while the private sector is always concerned above all with the pursuit of profit.34 The costs involved in delivery mean that some health services, communities, and patients, are more profitable than others. Far from guaranteeing patients a fair “choice” of services and providers, private contractors are freed from any obligation to deliver services that might threaten their bottom line.

Defending Universalism in Wales

In Wales, where the HSCA does not apply, a very different approach has been adopted. The historical link between the country’s working-class culture—as represented by Bevan—and the NHS’s universal protections is widely celebrated in Wales. As the 2005 Welsh Labour Party election manifesto proclaimed: “Wales is the birthplace of the NHS, one of our country’s proudest achievements. Equal access for all according to need not ability to pay—those key principles command overwhelming support in Wales.”35

Responsibility for most core health care functions have been devolved to the Welsh National Assembly. As with NHS England, the Welsh NHS receives the great majority of its funding from the British Treasury. However, the overall organization and planning of health care remains the direct duty of the Welsh Assembly Government. The government in turn delegates municipal services to Local Health Boards (LHBs), established in their current form in 2009, after the market-driven distinction between purchaser and provider was abolished, eradicating a system of fragmented competition. LHBs plan, design, and commission primary and secondary health care regionally, engaging with local government during the process.

While health care in England now operates at arm’s length from the government, through independent CCGs that have turned increasingly to the private sector, in Wales the government retains direct control. The Welsh NHS operates under the legislative authority of the National Health Service (Wales) Act of 2006. In comparison to recent reforms in England, the act makes the government’s legal responsibilities clear: “The Welsh Ministers must…provide or secure the provision of services.”36

The Welsh NHS has rejected the ideology of competition and the fragmented, unequal services it produces; instead, health care remains a planned system, directly achieved through mechanisms of the state.37 Originating from the Welsh Government, an initial strategic health plan for the whole of Wales is devised and implemented based largely on policy goals and targets. From this, LHBs implement the strategy in accordance with the health needs of their regions.

Privatization, which has become rampant in England, is minimal in Wales. If anything, it has been rolled back: the years since the inception of the National Assembly in 1998 (with law-making powers first granted in 2006, with this authority being enhanced further in 2011) have seen a continued reduction in the use of private facilities by the NHS, and little use of the controversial public finance initiative (PFI), whereby private consortia raise capital to finance the construction of health care facilities, which are then leased to the NHS at inflated prices until eventually becoming public property, often decades later. Data on the Welsh NHS’s use of PFI are limited, but the relatively small quantity of PFI financing in Wales suggests the extent of popular opposition. In the spring of 2015, the total capital value of all PFI projects in Britain came to £57,687 million, of which the value of projects in Wales constituted only 0.9 percent. This can be compared to those of Scotland, which amounted to 9.8 percent, and of Northern Ireland—whose economy and population are quantitatively smaller than Wales’s—which represented 3.4 percent.38 In its manifesto for the 2016 National Assembly elections, Welsh Labour could credibly declare that “we have stood firm against privatization and will keep the profit motive out of our Welsh NHS.”39

The continuing strength of public provision in Wales reflects not only a preference for planning over competition, but also a deeper ideological resistance to the neoliberal agenda that has now dominated English politics for more than three decades. Since the creation of the National Assembly, Welsh Labour has governed continuously, either alone or in coalition with other left parties. In that time, it has often moved to distance itself from its counterpart in England, especially during the New Labour era of Tony Blair’s premiership, which extended the marketization of social programs begun under Thatcher and Major. The welfare state of the postwar boom was characterized as inefficient and outdated, a relic of “old” Labour Party values.40 The Labour Party in Wales has rejected this path, often invoking the proletarian national culture that shaped Bevan’s worldview. Even as much of its industrial base has disappeared, the Welsh Labour Party has framed its social policy agenda in Bevanite terms of solidarity, community, and universalism.41

In 2002, Welsh First Minister and Labour leader Rhodri Morgan announced his agenda for government. Central to this program would be the pursuit of equality of opportunity, access, and outcome.42 The maintenance and enhancement of universal welfare services, Morgan argued, would be crucial to this project. Echoing Titmuss, he claimed that it was overwhelmingly the case that services reserved for the poor were poor services.43 Moreover, like Titmuss, Morgan said that it would be the community, supported by the state, that would provide welfare, “on the belief that government can and must be a catalyst for change and a force for good in our society.”44 “The actions of the Welsh Assembly Government,” he declared, “owe more to the traditions of Titmuss, Tawney, Beveridge and Bevan than those of Hayek and Friedman.”45

These principles have informed the organization of the Welsh NHS ever since. Starting in 1998, a year prior to the first National Assembly elections, the then-secretary of state for Wales in the British government reassured wary voters that “none of the values enshrined in the NHS when Aneurin Bevan created it will be lost. The NHS in Wales will continue to be a truly national service available to all on the basis of need. Need alone; not ability to pay; not who your GP is and not where you live.”46 A symbol of this universalist commitment was the eradication of prescription drug charges. Introduced throughout Britain in 1952 by a Conservative government and then abolished by Labour in 1965, only to be reintroduced in 1968 by the same administration, in 2007 Wales became the first country in the United Kingdom to eradicate them again. In England they remain in place, and though prices are heavily subsidized, patients are subject to rigorous means testing to determine their eligibility for free provision. In Wales, all residents, regardless of wealth or class, receive free medicine.

Some gaps in the Welsh system nevertheless remain. As in England, free dental care is not universally available, but in both countries, care is free for those under eighteen, full-time students, and pregnant women and new mothers, hospital patients, and social security recipients. Further, LHBs sometimes vary in the services they provide, based upon their analysis of regional needs. Consequently, the Welsh NHS cannot be considered wholly universal at all levels, but it has nevertheless stayed far closer to the service’s founding principles, based upon the political ambition to pursue a society built upon equality and solidarity.

England and Wales thus represent two very different, indeed incompatible, approaches to health care. Though neoliberalism in England has recently suffered a popular backlash—in the form of Brexit and a leftward revolt in Labour’s rank-and-file membership—at the level of government and political economy, it remains influential as ever. The government has effectively absolved itself of the duty to provide health care, which has fallen to regional bodies of professionals increasingly compelled to purchase provision from private firms. In the process, the principles on which the NHS were founded are being steadily eroded. In Wales, however, an explicit effort has been made to defend these socialist values and formulate them for the twenty-first century. Like all health systems, the Welsh NHS has its challenges. Managing a universal health care system requires intense administrative and bureaucratic coordination, a task made all the more difficult by austerity measures imposed by the British Treasury in recent years. Nevertheless, Wales has defied the trajectory of many health care systems of the mature capitalist countries. Around the world, health care has come under increasing threat from predatory forces of privatization. The experience of Wales, from the workers’ aid societies of Bevan’s youth to the present day, is proof of an alternative: a health system that puts the health and well-being of its citizens over profit.

Notes

  1. Richard Titmuss,Commitment to Welfare (London: Allen and Unwin, 1979), 116
  2. Titmuss,Commitment to Welfare, 151
  3. Titmuss,Commitment to Welfare, 123
  4. Titmuss,Commitment to Welfare, 129
  5. Titmuss,Commitment to Welfare, 128
  6. Titmuss,Commitment to Welfare, 127–28.
  7. Richard Titmuss,The Gift Relationship: From Human Blood to Social Policy(London: Allen and Unwin, 1970), 273.
  8. Titmuss,Commitment to Welfare, 195–96.
  9. Gwyn A. Williams,The Welsh in their History (London: Croom Helm, 1982), 189–201.
  10. Aneurin Bevan,In Place of Fear (New York: Simon and Schuster, 1952), 18-19
  11. Nicklaus Thomas-Symonds,Nye: The Political Life of Aneurin Bevan (London: I.B. Tauris, 2016), 23–27.
  12. Bevan,In Place of Fear, 79.
  13. Bevan,In Place of Fear, 86.
  14. Ian Gough,The Political Economy of the Welfare State (London: Macmillan, 1976). James O’Connor,The Fiscal Crisis of the State (London: St James, 1973).
  15. Michael Lavalette and Gerry Mooney, “Introduction: Class Struggle and Social Policy,” in Michael Lavalette and Gerry Mooney, eds.,Class Struggle and Social Welfare, (London: Routledge, 2000), 4–5.
  16. John Saville, “The Origins of the Welfare State,” in Martin Loney, David Boswell, and John Clarke, eds.,Social Policy and Social Welfare(Milton Keynes: Open University Press, 1983), 11.
  17. Richard Titmuss, “Social Welfare and the Art of Giving,” in Pete Alcock, Howard Glennerster, Ann Oakley and Adrian Sinfield, eds.,Welfare and Wellbeing (Bristol: Policy, 2001), 130–31.
  18. Kim Howells, “Victimisation, Accidents and Disease,” in David Smith, ed.,A People and a Proletariat: Essays in the History of Wales 1780–1980, (London: Pluto, 1980), 192.
  19. Ben Curtis and Steven Thompson, “‘A Plentiful Crop of Cripples Made by all this Progress’: Disability, Artificial Limbs and Working-Class Mutualism in the South Wales Coalfield, 1890–1948,”Social History of Medicine 27, no. 4. (2014): 708–27.
  20. Curtis and Thompson, “‘A Plentiful Crop,'” 713.
  21. Curtis and Thompson, “‘A Plentiful Crop,'” 714.
  22. Curtis and Thompson, “‘A Plentiful Crop,'” 713.
  23. NHS Scotland, A Labour Delivery, http://www.ournhsscotland.com/history/birth-nhs-scotland/labour-delivery
  24. Aneurin Bevan, “Speech in the House of Commons, 30 July,”Parliamentary Debates, vol. 592 (London: Her Majesty’s Stationery Office, 1958), cols. 1382–98, available at http://sochealth.co.uk.
  25. Michael Foot, “Bevan’s Message to the World,” in Geoffrey Goodman, ed.,The State of the Nation: The Political Legacy of Aneurin Bevan, (London: Victor Gollancz, 1997), 182. After Bevan’s death in 1960, Foot, would become Labour MP for Bevan’s parliamentary constituency of Ebbw Vale, and would go on to lead the party in the early 1980s, in opposition to Margaret Thatcher’s Conservative government.
  26. National Health Service Act 1946, section 8, http://legislation.gov.uk.
  27. Christopher Herman, “The Marketization of Health Care in Europe,” in Leo Panitch and Colin Leys, eds.,Socialist Register 2010 (New York: Monthly Review Press, 2009), 127. David Matthews, “Assistant Practitioners: Essential Support in a Climate of Austerity,”British Journal of Nursing 24, no. 4. (2015): 214–17.
  28. Health and Social Care Act 2012, section 1, http://legislation.gov.uk.
  29. Allyson Pollock and David Price, Duty to Care: In Defence of Universal Health Care (London: Centre for Labour and Social Studies, 2013), 12.
  30. Health and Social Care Act 2012, section 1.
  31. Allyson Pollock, “Morality and Values in Support of Universal Health care Must be Enshrined in Law,”International Journal of Health Policy Management 4, no. 6 (2015): 399–402.
  32. NHS Support Federation, “Contract Alert: Outsourcing in the NHS,” February 2016, http://nhsforsale.info.
  33. Dennis Campbell, “Far More NHS Contracts Going to Private Firms than Ministers Admit, Figures Show,”Guardian, April 25, 2015.
  34. Pollock and Price,Duty to Care, 9.
  35. The Welsh Labour Manifesto 2005 (Cardiff: Welsh Labour, 2005), 59.
  36. National Health Service (Wales) Act 2006, http://legislation.gov.uk.
  37. OECD Reviews of Health Care Quality: United Kingdom 2016: Raising Standards(Paris: OECD, 2016), 186.
  38. Figures calculated from Private Finance Initiative and Private Finance 2 Projects: 2015 Summary Data (London: Her Majesty’s Treasury, 2015), http://gov.uk.
  39. Together for Health: A Five Year Vision for the NHS in Wales (Cardiff: Welsh Labour, 2016), 10, http://gov.wales.
  40. Iain Ferguson, Michael Lavalette, and Gerry Mooney,Rethinking Welfare: A Critical Perspective (London: Sage, 2002), 151–76.
  41. Gerry Mooney and Charlotte Williams, “Forging New ‘Ways of Life’? Social Policy and Nation Building in Devolved Scotland and Wales,”Critical Social Policy26, no. 3 (2006): 608–29.
  42. Rhodhri Morgan, “Clear Red Water,” speech at the National Centre for Public Policy, Swansea, December 11, 2002, available at http://sochealth.co.uk.
  43. Morgan, “Clear Red Water.”
  44. Morgan, “Clear Red Water.”
  45. Morgan, “Clear Red Water.”
  46. NHS Wales, Putting Patients First, report to Parliament, January 1998, http://wales.nhs.uk.
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