The founding fathers of the classical school in criminology never saw themselves as contributing to a new discipline, or even to a distinct field of research. For them, their work on criminal jurisprudence and penal reform always took place in a much grander context: producing a body of work to support profound institutional reform, with the ultimate end of helping engineer a good modern state. Indeed, the classical school has had a lasting influence on criminal law and penal practices. Yet no one can deny its paramount contribution to criminological thought. It is one of the pillars of the discipline of criminology, and guaranteed to appear in any textbook or introductory course on the subject. Moreover, its ideas remain influential, particularly its philosophy of crime, which served as the foundation of the neoclassical school that emerged in the late 1960s, and which continues to inform contemporary criminological theories such as situational crime prevention.

A great deal has been written on the classical school, and I shall not attempt to cover this literature in its entirety. This chapter aims, rather, to locate the role of the classical school in the history of knowledge production within the multifaceted field of criminology. First, I wish to rethink its position vis-à-vis the positivist school. Was the transition from the classical school to the positivist school a paradigm shift? Or can we also recognize some shared conceptions and, as such, some continuity between them? Mainly, however, I wish to inquire into the classical school’s ideological core, whether manifest or hidden. I consider in what ways this school serves an ideology of social control. What type of social regime does it support? How do its cultural and philosophical notions inform this type of criminological understanding? What was the socio-political and socio-economic context in which such penal knowledge was produced? And if this knowledge indeed helped shape a regime of social control, who did this change benefit? In this respect, the chapter traces the ways in which the classical school builds a narrative of responsibilization, classical responsibilization if you will, which places responsibility for crime on individuals and not on social conditions, and on this basis justifies state violence in a penal guise.

Inter-organizational relations research revisited

Committed to the idea of re-pluralizing the discussion and exploration of inter-organizational relations (IOR) within international relations (IR), this volume began from the assumption that a broader understanding was required of what exactly is to be examined and of how this research could take place. To achieve such a broadening, three levels offer room for innovation. These relate to subject matter or research object (organization type and policy field/societal sphere), theory and methodology.

First, at the level of the research object, innovation seems to be easiest to achieve. The narrow focus of the study of IOR on intergovernmental organizations (IGOs) can be countered by broadening the research agenda to non-governmental organizations (NGOs) and multinational enterprises (MNEs). This is done in Chapters 5, 6, 7 and 8, while Chapter 2 addresses the relations of a hybrid form of governance. Besides IOR in the dominant policy fields of security (Chapters 3, 4 and 6) and economy (Chapter 7), topics linked to the rule of law (Chapters 2 and 3) and sports (Chapter 8) are also covered. The same holds for a topic from security studies that is not directly associated with it (Chapter 5). However, more could have been achieved here with regard to pressing issues such as health or climate/environmental policy (but see, for instance, Eckl and Hanrieder, 2023; Holzscheiter, 2015; or Smith et al, 2021).

Second, on theoretical innovation, this volume contains only one contribution based on a rationalist approach. Rationalist accounts have come to dominate the discussion of IOR in IR so far. This discursive power is not only reflected in numbers of publications; it is also wielded through the capacity to create and disseminate key terms, such as ‘interorganizationalism’ (Koops, 2008; also Biermann, 2009), or to define the field (Koops and Biermann, 2017). Regardless of the reasons for their dominance, this volume enlarges the space for alternatives to rationalist accounts. In addition to sociological neo-institutionalism (Chapters 3 and 5) and classical pragmatism (Chapter 8), which have already been proposed in the introduction, options include post-structuralist discourse theory (Chapter 3) and relational sociology (Chapter 7), along with combinations of rationalist regime complexity with constructivist considerations from (critical) norms research (Chapter 4) and public administration with organization studies (Chapter 6).

Introduction

Like many other health systems, the NHS has been regarded as more like a sickness than a health service, failing to place health before healthcare, and to focus ‘upstream’ on the ‘social determinants of health’ (SDH) (for example, Wanless 2002; Marmot and Wilkinson, 2005; Hunter 2016a). This has implications for both aggregate health and health inequalities. First, while life expectancy in the UK in the twentieth century increased 38 years for men and women, equivalent to an increase of 4½ months per year (ONS, 2015), much of this improvement in life expectancy and health status more generally, is associated with the SDH (Marmot, 2010). It has been estimated that only 10–25 per cent of the health of a developed population is attributable to the healthcare system (McGinnis, Williams-Russo and Knickman, 2002: 83; Harrison and McDonald, 2008: 165). However, only ‘around 5% of the total UK government healthcare expenditure’ is devoted to preventive healthcare, with about half of NHS staff not regarding prevention as a core part of the work of their organisation (Faculty of Public Health, 2019; see also Exworthy and Morcillo, 2019).

Second, the temporal pattern for health inequalities is more complex. There has long been a recognition of health inequalities in terms of geographical and social class differences in life expectancy since at least the Chadwick Report 1842 (for example, Bambra, 2016). However, while overall health, in terms of life expectancy, broadly increased for much of the twentieth and early twenty first century before stalling or reversing in recent years (Marmot et al 2020a), health inequalities have increased at some times and reduced at others. For example, according to Robinson et al (2019), absolute inequalities in the infant mortality rate (IMR) increased between the most deprived local authorities and the rest of England between 1983–1998, decreased during the period of the English health inequalities strategy (1999–2010), but increased again in the period 2011–2017.

This chapter will thus examine the ways in which the NHS has addressed the issue of health and health inequalities. First, it focuses on four chronological periods of policies on health and health inequalities in the 75 years of the NHS. Then, it explores health and health inequalities through the four analytical lenses introduced in Chapter 1, before moving to evaluate policies concerned with health and health inequalities.

Introduction

The quality and safety of healthcare remains a global health policy priority with the likes of the World Health Organization and major international forums promoting standards and methods for improving care quality (WHO 2022). The English National Health Service (NHS) exemplifies such trends where the significance of quality as an NHS priority has been framed, in a large part, by the many high-profile failings and scandals in care quality dating back to the late 1960s. Scandals around long-term care at Ely, unsafe paediatric heart surgery at Bristol Royal Infirmary, the systematic neglect of patients at Mid-Staffordshire hospital and very recently, the prominent failings at multiple maternity units provide a disturbing backdrop to the NHS and the quality of care (Mannion et al, 2018; Knight and Stafford, 2022). Such events have often been followed by investigations and Public Inquiries and led to extensive recommendations, many of which look similar from one report to the next, arguing for increased transparency, support for speaking up and whistleblowing, culture change, better governance and reforms of professional regulation (Powell, 2019).

The response to quality failings has instigated a range of regulatory responses and the need for greater quality assurance (Waring et al, 2010). National improvement and performance management programmes from the early 2000s onwards have been implemented by a succession of regulatory bodies from the Centre for Healthcare Improvement (CHI) followed by the Healthcare Commission and then the CQC. In responding to such events, the NHS has also been the testbed for many innovations in quality improvement and management, often drawing from the experiences of other safety-critical or high-quality industries (Waring and Bishop, 2010; Millar, 2013). This is exemplified by the growth of specialist agencies and charities committed to promoting care quality such as the Modernisation Agency, the Institute for Innovation and Improvement, NHS Improvement and The Health Foundation (The Health Foundation, 2021).

And yet despite such an emphasis and policy innovation, the commitment to quality and quality improvement has not been constant. The focus on quality and quality improvement has competed for attention among other policy priorities, especially cost and responding to exogenous events such as the COVID-19 pandemic. Such variable traction and success have led to the quality agenda appearing more like fads and fashions rather than a sustained policy approach (Ham, Berwick and Dixon, 2016; Molloy, Martin and Gardner, 2016).

Introduction

Is capitalism the only way to organize the economy and production relations? Is profit the only value that can be created by organizations? Taking capitalism and capitalist forms of organizing as the only possibility for an economic and political system limits our vision; we do not see or try to experiment with alternative forms of organizing. In this book our aim is to show that organizations shaped by non-capitalist forms of production relations and value creation orientations and practices do exist. In so doing, we view alternative consumer cooperatives (ACCs) as an alternative, non-capitalist form of organizing. Activists involved in ACCs refuse to accept the prevailing power relations and experiment with a different surplus generation and governance model; their practice is based on the ‘ethics of solidarity’ (Gibson-Graham, 2003); rather than opting for profitability they aim to establish solidaristic, unmediated and trust-based ties between rural petty commodity producers and the urban middle class. Their daily practices are prefigurative; they experiment with what they aim for. They envision direct democracy and organizations devoid of hierarchies and inequalities. These are not fantasies, they are, at least to a certain extent, practised.

During our field study and analysis of the secondary data we have seen that the founders of the ACCs are inspired by the works of diverse economies, alternative organizations and are involved in prefigurative politics. Thus in this chapter, in order to provide a background for the underlying premises and practices of the ACCs, we elaborate on the tradition of diverse economies (Gibson-Graham, 2003, 2006, 2008, 2014; Gibson-Graham et al, 2013) and alternative economic spaces (Parker et al, 2014; Parker, 2017) in order to explain how ACCs experiment with a non-capitalist form of organizing and operate with a non-capitalistic form of work, shaped by the premises of alternative food networks and the values of the food sovereignty movement. Activists involved in the ACCs deliberately search for and experiment with practices that will dislocate hegemonic capitalist relations. Such attempts by the ACCs are prefigurative since activists create ‘new’ within the ‘old’ (Leach, 2013) with the ‘conflation of their ends with their means’ (Maeckelbergh, 2014, p 350).

Introduction

The first of these revealing statements, by the Welsh Labour Secretary for Health and Social Care, gives a partial account of the origins of the National Health Service (NHS). The second, by the then Scottish National Party (SNP) first minister, emphasises her government’s commitment to NHS ‘founding principles’. The third ignores NHS history, with the Sinn Féin minister citing a post-war World Health Organization aspiration. None mentions the UK or NHS England. We are thus alerted to healthcare’s highly politicised nature, the relevance of its history, the significance of devolution, and that its treatment in many social policy and historical texts notwithstanding, the ‘NHS’ is not monolithic.

Introduction

This chapter will aim to answer the question ‘What kind of health system is the NHS, on how does it compare to others?’. It aims to do this through an examination of a range of different health statistics from the OECD, G7 and Commonwealth Fund and by locating the NHS in relation to a recent typology of health systems. The strategy is to consider the NHS in 2019 (the last year pre-COVID-19), and compare statistics for total spend, funding sources, capacity (doctors, nurses, beds, scanners) and health outcomes at that date as a means of exploring changes during the pandemic and to try and see its effects. These three elements cannot capture all the dimensions of health systems (and measures of care will also be introduced), but they do cover many of the most distinctive dimensions of differences between such systems. Having explored changes during the pandemic in terms of the UK in relation to other countries in the OECD, it then performs further comparisons with the G7 group of nations and the 11 countries included in the Commonwealth Fund’s most recent reports, and which it argues reflect better comparisons as they are made up of advanced industrial nations which the UK would more often regard as its peers, and so are likely to be facing more similar challenges in relation to healthcare than countries that less obviously fit into that category.

The chapter then performs two further comparisons – with the situation in 2000 (broadly 20 years ago, and at the beginning of the period in which the NHS Plan was meant to expand resources for the health service) and 2009 (the end of the funding expansion under the NHS Plan, and after which there was a change in government) to consider whether the position of the NHS in comparative context has improved or worsened since. This date was chosen to get some sense of how the NHS has changed over the last 20 years under governments of different political parties, but also with a pragmatic eye in that good comparative data often becomes much harder to come by prior to that date.

Introduction

The activists involved in the ACCs are against authoritarianism; they value participation, solidarity and equality. As discussed in Chapter 3, the hegemonic neo-liberal project deliberately excluded some groups (women, the secular middle class and people with a specific political orientation) from economic and social life. As a consequence of the implementation of neo-liberal policies, after 2001 most of the activists became precariat; they deliberately refused the governing principles of investor-owned companies and the managerialism underlying them. Being against authoritarianism, neo-liberal policies and the politically exclusionist attitude of the ruling groups, the activists aimed to develop an alternative governance based on the principles of equality, inclusion and participation.

Experimenting with democratic and dialogic decision-making practices, they decided to get rid of the hierarchical relationship in the newly formed cooperatives. Using a diverse economy approach as a framework (Gibson-Graham 2006; Gibson-Graham et al, 2013) we analysed the work practices of the ACCs that are based on ‘zero-hierarchy’ and ‘consensus-based collective decision-making’. By experimenting with various practices negotiated among their members, activists involved in the ACCs aim to prefigure a post-capitalist society that is just, democratic and egalitarian.

This chapter explains the ‘alternative’ governance model which the ACCs experimented with. In so doing, we examine how various practices of this governance model are developed and how conflicts that arise from this new governance model are handled. The chapter is composed of three parts: performance measures, form of organization and volunteer work.

In search of an alternative governance model

The roots of the ACCs and the prefigurative strand taken by activists can be traced back to the Gezi protests and the underlying values and practices that were developed in the subsequent ‘park forums’ and Occupy houses. Gezi was an occasion where the discontents of the hegemonic neo-liberal project – the white-collar workers, professionals and students, had a chance to experiment with an alternative model shaped by solidarity, direct democracy, participation, mutuality, consensus and cooperation. As stated by a food activist, “Gezi was a ‘call’, where people who were seen as a political, insensitive to societal and ecological issues came together to build a future society that is inclusive, democratic and egalitarian.”

In 1968 Samuel Huntington wrote that the ‘most important political distinction among countries concerns not their form of government but their degree of government’ (Huntington, 1968: 1). How governance is organised and what governments try to do is not the same thing as the extent to which governments have the tools and information to govern.

The story of NHS governance is most commonly told in terms of its form. Outside the UK, the NHS is often taken as the ideal type of a monolithic, centralised, state-run health system. Endless classes in health policy and systems teach it as the original and purest Beveridgean system, with strong political and administrative control over health services. Students or readers are lucky if there is much recognition of the fact that administrative devolution to Northern Ireland, Wales and Scotland existed for decades before political devolution in 1999, let alone the variable degree of central control that existed within the systems at any given time (Klein, 2003). Sometimes it doubles as an ideal-type for neoliberalism or marketisation, a useful story of a country that had a strikingly unified social democratic system and turned away from it to a series of very visible experiments with markets and ‘neoliberalism’, ‘privatization’ or ‘Americanization’ (Powell, Béland and Waddan, 2018).

Inside the UK, the history of the NHS is often written in much more subtle terms, influenced by a long tradition of research into NHS reforms, their politics and their effects. They are often superficially focused on form, as seen in the organigrammes of the NHS that decorate their pages. But there is a thread of something else, namely an interest in degree of governance. We can see this interest in discussions, reviewed in this volume’s introductory chapter, of the tension between central control and local activity (Klein, 2010), the balance of public and private ownership and finance, centralising and decentralising policies, the relationships between professionals and the state, efforts to understand the different kinds of relations at work in it (Exworthy, Powell and Mohan, 1999) and debates about the conditions under which various central policy tools are effective.

Introduction

We opened this book (Chapter 1) by observing that the NHS was in a parlous and unprecedented position. Now that the contributors have surveyed the period across a range of domains, there seems to be very little evidence to revise that verdict. Over its 75 years, the NHS has seen a number of ‘big bang’ reforms and many more, smaller incremental reforms (Tuohy, 2018). While there has been a great deal of analysis on the former (Robinson and Le Grand, 1994; Le Grand, Mays and Mulligan, 1998; Thorlby and Maybin, 2010; Exworthy Mannion, 2016), there is a danger that the smaller but cumulative changes of the latter may be missed (Powell, 2016).

Cumulative incremental changes are harder to detect and assess and receive less publicity than large-scale (big bang) reforms which are often heralded with much fanfare and public debate. Large-scale reforms of health systems such as the NHS may be somewhat constrained by its own logics (Tuohy, 1999) but they might also have a negative impact on the resilience of the NHS. Individual reforms (or a programme of them) may not necessarily lead to a loss of resilience at that time but repeated reforms may undermine the cohesion of its structures and processes. The rapidity of such change might only serve to weaken such cohesion further (Thorlby and Maybin, 2010; Exworthy and Mannion, 2016: 8; Timmins, 2012; Exworthy and Mannion, 2016: 8). Without a comprehensive and longitudinal evaluation programme, the cumulative impact of healthcare reforms will remain uncertain or unknown.

In this book, we have sought to offer a comprehensive analysis of the state of the NHS in its 75th year. The four analytical axes (governance; public/private, central/local, and profession/state; introduced in Chapter 1 and reprised next) provided an overarching framework which applied, more or less, to the individual chapters. The subjects of these chapters enabled, we argue, a comprehensive coverage of the main dimensions of the NHS in its first 75 years. We note, however, the absence of topics, such as workforce wellbeing and diversity, and environmental sustainability (among others), from our analysis but we urge others to engage with these topics in future research.