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Feature Christmas 2011: Food for Thought

The assault on universalism: how to destroy the welfare state

BMJ 2011; 343 doi: (Published 20 December 2011) Cite this as: BMJ 2011;343:d7973

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Re: The assault on universalism: how to destroy the welfare state


Martin McKee and David Stückle (1) published recently an important article about strategies on how to destroy the welfare state, which -as they pointed out- are seeking inspiration from a social model (the American) in which poverty is never a consequence of misfortune, but idleness.

Such strategies have also reached Spain (2) being justified by the serious economic situation facing the country. Under the pretext of trying means of saving money in health care, the Spanish conservative government has approved a Royal Decree Law (a legislative instrument only used exclusively in emergency situations) that radically undermines the foundations of our national health system, as much regarding citizens' rights as in relation to the structure of services portfolio (3).

The passing of the General Health Law of 1986 (14/86 April 25) represented an historical change in the Spanish health system. The country changed from a system funded through contributions from affiliated members to the Social Security (Bismarckian model) into a universal system, financed through taxes, and free at the time of delivery. In short, a health care system clearly inspired by other national health models, such as the NHS.

The General Health Law recognized the right to health protection and health care of all Spanish citizens, as well as foreigners with established residence in the country. In contrast, the new Royal Decree Law substantially modifies the right of subjects to receive health care in Spain, which changes now to be not “the citizen” any more, but "the insured”, clearly defining what is meant by this.

The word Assured and the concept of Assurance are not accidental. Neither is the establishment of four modes of services portfolio for the “new” national health system: basic, supplementary and ancillary. In addition, the combination of both dimensions facilitates future opportunities of health service provision in Spain by different types of providers, public and private. Ultimately, it means a mutation from a tax funded health service towards a insuree´s state of health.

The Spanish government justifies the reform as necessary to improve health outcomes and the costliness of the health service. This kind of misinformation is one of the tactics recommended by Oliver Letwin (4) –currently Minister of State of th British Government- for privatizing public assets against the wishes of the electorate, as Reynolds et al have cleverly described (5).

As in the United Kingdom, the beginning of the end of the national health service in Spain may be getting even closer. More than ever we must remember the famous Tolstoy´s quote: “There are no conditions of life to which a man cannot get accustomed, especially if he sees them accepted by everyone around him”.

(1) McKee M, Stuckler D. The assault on universalism: how to destroy the welfare state. BMJ 2011;343:d7973 doi.

(2) Rajmil L, Fernández MJ. Destruction of a less developed welfare state and impact on the weakest, the youths. Available at:

(3) Real Decreto-Ley 16/2012, de 20 de Abril, de medidas urgentes para garantizar la sostenibilidad del Sistema Nacional de Salud y mejorar la calidad y seguridad de sus prestaciones. Available at:

(4) Letwin O. Privatising the World: a study of international privatisation in theory and practice. London: Casell Educational Ltd, 1988; pp 63-73. ISBN 0304315273

(5) Reynolds L, Lister J, Scott-Samuel A, McKee M. Liberating the NHS: source and destination of the Lansley reform. 29 August 2011.
Available at:

Competing interests: No competing interests

27 April 2012
Sergio Minué-Lorenzo
Senior Lecturer
José Fco García Gutiérrez, Juan José Mercader-Casas
Andalusian School of Public Health
Campus Universitario de Cartuja. 18080 Granada - Spain