Health and society

By Nick Spencer 06 Jun 2003

The bloody face of an unknown 94 year-old woman dominated the news in late January 2002. Having  fallen in her Stoke Newington flat and gashed open her head, Rose Addis was taken to the Whittington Hospital in north London where she sat unwashed in casualty for three days.

Mrs Addis’s ordeal would have remained a minor incident had not her furious daughter contacted her MP, Iain Duncan Smith, and her grandson at the Evening Standard. Within days the patient’s photograph was on every front page in Britain. The story was lead item on the television news and the subject of a particularly venomous Prime Minister’s question time.

Within a week or so the scandal had died down but by that time it had plumbed impressive depths. Relatives, who had taken 2½ days to visit the old woman, were smeared as liars or, at least, absurd exaggerators. The old woman, it was suggested, was ‘confused’ and/or a racist. The Labour spin machine was charged with attempting to crush a justifiable complaint and the Conservative front bench with exploiting a political football. Patient confidentiality was ignored and the press managed to find other ‘horror stories’ about the Whittington. The whole story was sordid and sensationalist, with sinister manoeuvring, unpredictable twists and dramatic confrontations better suited to a soap opera than a public service. [1]

The national soap opera

The comparison is appropriate. Nigel Lawson once wrote that the National Health Service was the closest thing the English had to a religion. When the post-war Labour government declared war on the “five giants” of want, idleness, ignorance, disease, and squalor, the NHS became the most iconic of all the attacks. Its condition is less a comment on the nation’s physical well-being as on its moral health. So powerful is the commitment to its very existence, that even the Thatcher administration was deterred from dismantling it.

For such an important national icon, however, it appears to be in very poor health. The Rose Addis scandal was not an isolated incident but merely one more story which put hospitals on the front page. In the first few months of the year the public read about patients dying on trolleys in hospital corridors, foreign nurses being imported and British patients being exported. Stories of incompetence, malpractice, under funding, and low morale were legion. Terms such as ‘bedblocking’ and ‘postcode lottery’ passed into common parlance.

NHS-specials in virtually every national newspaper told us that the British spend $1,000 less on health per person per year than the Germans, and $2,500 less than the Americans and that that in Britain we have 1.7 practising physicians per 1,000 population, compared to 2.5 in Australia and 3.3 in France. [2] Although currently public satisfaction figures are some way off the low points of 1990 and 1996, it is clear that this particular, much valued, patch of our national flag is badly frayed. [3]

The diagnosis

With over fifty years history, 1.5 million employees and an annual budget of £60 billion (soon to rise to £100 billion), one would not expect the NHS’s condition to be easily explicable. A number of factors have conspired to cause the current problems and whilst the origin and extent of each is debatable, its reality is not.

The cost of patients

The seeds of the NHS’s financial crisis were sown years before the organisation was even conceived. Far from being created ex nihilo, the NHS inherited the assorted arrangements of various public authorities and voluntary agencies and harmonised them around the fundamental principle of healthcare which was available to all, free at point of delivery and provided on the basis of need rather than ability to pay. This had been the principle behind the medical philanthropy of William Marsden who opened a dispensary for advice and medicines in 1828 at which treatment was free of charge and “the only passport… poverty and disease.” The overwhelming demand for Marsden’s service led to brink of bankruptcy in 1920 at which point the organisation was forced to ask patients to pay whatever they could towards their treatment.

Aneurin Bevan, the driving force behind the NHS’s foundation, recognised that far from being particular to the 19th century, this would be a persistent problem for the new health service: “We shall never have all we need…expectations will always exceed capacity.”

The problem peculiar to today is that the unprecedented shift in the population’s age balance will affect the NHS in two very significant ways: supply and demand. A higher proportion of older people will leave a smaller proportion of tax payers to supply the funds, whilst a higher number of older people will create greater demand on the services provided. Although the long term prospects are slightly less daunting, a rebalancing of the population pyramid is a long way off and demographic pressures on the NHS will get worse before they get any better.

The demands of patients

This burden of the number and cost of patients is compounded by the particular demands of patients today. Here the problem is three-fold.

Firstly, in a society which has lost any agreed idea of life beyond death, it is natural to deify health. If the ‘here and now’ is all we have, it is absolutely imperative to get it right. Failure cannot be tolerated. As Roy Porter wrote, “Rendered a mark of failure, death [in the twentieth century] became a taboo, something to be deferred.” [4] Today British society idolises health, beauty and appearance more than ever before. The inability to achieve good looks and a good lifestyle is often perceived as a real failure.

However, as medicine infiltrates every sphere of life, a medical solution to these failures becomes increasingly expected. My problems become my body’s problems or my brain’s problems. ‘I’ am removed one step from them, as is my responsibility, and it becomes all the more reasonable for me to expect someone else to fix them for me. The result is greater stress on the health service.

Secondly, as the likelihood of an early death or a painful life has fallen our anxiety about both has risen. Because we know more, we worry more. We are now aware that whilst the battle against bacteria may have been won, the war is ongoing. Abuse of antibiotics and the relentless course of bacterial evolution threaten a return to pre-penicillin days.

The decoding of the human genome has opened up new horizons in preventative healthcare but has also popularised fears that each of us may be carrying personalised genetic time bombs. A decade of food scares has made us acutely conscious of what we eat and drink. Asthma is on the rise and even though pollution levels in Britain are improving (and are infinitely better than before the 1956 Clean Air Act), we are alert to the very air we breathe. Although far from a nation of hypochondriacs, our preoccupation with health inevitably translates into greater use of healthcare services.

A third, and more subtle problem, is the consumer mentality which is so dominant today. 21st century Britain is a consumer culture, with choice, rights and service dominating the public’s vocabulary and mindset. Health may have very little in common with consumer goods but the consumerist worldview is pervasive. As patients become customers and choice a birthright, the health service is under increasing pressure to deliver to the standard demanded by marketplace ideology. Failure to do so has resulted in the rapid growth of legal claims against the NHS, an immensely costly trend in terms of confidence and morale as well as finances.

The role of medicine

The third major cause of the NHS’s problems is itself medical. Put simply, over the last 50 years medicine has lost its ideological way.

When the NHS was founded its mandate was clear and the expected improvement in the nation’s health was assumed would alleviate costs. Not only has this not come about but where acute infectious diseases such as TB or rheumatic fever have been (temporarily) defeated, ‘lifestyle disorders’ such as lung cancer or coronary heart disease have taken their place. This, combined with medicine’s ever growing capabilities, has opened up some daunting prospects.

If today there really is ‘a pill for every ill’ – and patients who demand them – the whole of life becomes medicalised and expectations from the health service are potentially infinite.  “In the nineteenth century it had been the physician’s role to minister over or administer a peaceful death; his modern successor seemed to promise to overcome death.” [5]

Hard questions follow from this change in medical mandate. How far should the medical profession seek to prevent ‘lifestyle disorders’? How far should it treat non-physical disorders? Where, indeed, is the dividing line between a medical disorder and sense of personal disaffection?

The media spotlight

The final element is less a cause of the NHS’s problem and more an explanation of why we these problems seem so momentous today.

Given the ubiquity of public involvement with the NHS, the urgency of the issues under consideration and the innate human interest of many stories, it is hardly surprising that newspaper editors choose to focus on salacious, scandalous or heart-breaking tales of medical woe. Bad news sells.

Public satisfaction figures offer a perspective on the media spotlight. People speak far more highly of the parts of the NHS than they do of the whole. Public satisfaction with GPs is generally high, with 76% satisfied vs. 15% dissatisfied, as is the level for dentists (62% satisfied vs. 19% dissatisfied). Similarly, although far from perfect, hospital inpatient and outpatient services are also more positively than negatively received. [6]

When one compares this to the far less positive evaluation of the NHS as a whole (roughly equal numbers of people satisfied and dissatisfied), it becomes clear that we are far more willing to criticise the NHS than its constituent parts. On an individual basis, we recognise the professionalism and effort of the medics we meet but because our every one visit to the GP is matched by a dozen ‘Rose Addis’ stories in the press, our overall impression of the service is more negative than our actual experience. We see the organisation through a glass darkly.

A Christian perspective

Any Christian perspective on the NHS needs to establish certain basic principles. Biblical societies had no concept either of the biomedical roots of disease or of institutionalised healthcare systems. Primitive health practices do appear to be at the root of some of the Levitical laws [7]but these, it has been argued, were “primarily ceremonial and only at times of practical use in the prevention of disease.” [8] Similarly, talk of modern national healthcare models is essentially anachronistic for a pre-modern society like ancient Israel.

Moreover, the issues facing the NHS are so broad, complex and deep rooted that no one source, be it Biblical teaching or the recent cash injection, will provide an easy panacea. Nevertheless, a Christian analysis can provide a lens through which to evaluate the problems facing the health service and offer guiding principles for thinking through potential solutions.

One such principle is the scriptural understanding of health. This is best seen in the concept of ‘shalom’, which incorporates but exceeds the purely physical sense of the modern English word ‘health’. Healthy human nature is, in the Biblical view, undoubtedly physical but it is also mental, relational and spiritual. Full health demands a secure and well-balanced condition in each of these areas.

This idea is of particular use when one is faced with the temptation to reduce patients to conditions or wounds, a danger recognised as early as the 19th century “Medicine”, insisted one lecturer in 1882, “is about treating sick people and not diseases.” “The good physician treats the disease,” said another, “but the great physician treats the patient.” [9]

It also has implications for the role of the caring professions. These have historically been somewhat subordinated to biomedical areas of expertise and yet in terms of hours contact, most patients will spend a far greater time being cared for than being physically ‘mended’. If health transcends physical well-being, healthcare will transcend ‘pills and potions’.

A second consideration offered by Biblical teaching is that of the covenant principle. Although Biblical models of covenant vary widely, the general emphasis on mutual openness, loyalty, obligation, and trust can act as a valuable antidote to the more harmful effects of consumerism.

Consumerist principles are, at best, of limited use as a model for healthcare provision. True health is difficult to recognise, difficult to realise and impossible to buy. Rather than requiring simply a one-off transaction, it demands the ‘consumer’s’ long-term, full-time, high-intensity commitment just as much as it does the ‘provider’s’ efficient and professional use of resources. It is not too much of an exaggeration to say that as individuals we owe as much of a duty to the health service as it does to us.

A third relevant principle offered is the Biblical emphasis on caring for those who cannot care for themselves. The oft-mentioned ‘widow, fatherless and alien’ of the Old Testament were essentially those who fell outside society’s natural support networks; those, in modern parlance, in need of social security.

In an age where the basic principle of social security has become enshrined in the national conscience, the call to care for such people may seem rather anodyne. Yet the ageing of the nation, combined with key marketplace concepts such as efficiency and value for money which have been steadily imported into the public sector, can easily draw one into seeing the elderly as a burden or an inefficient use of resources. Whenever we are tempted to slip into this vocabulary and worldview, the Torah’s emphasis on those who are, by nature of their circumstances, more time, energy and money consuming, is necessary and important.

A final aspect of Biblical teaching which can help us think about health today is the perspective on life offered by the New Testament in particular. Whilst the importance of health is never doubted – Jesus’ fame, the gospel writers remind us, was heavily based on his ability to heal physical ailments – it is not everything. Suffering can be redemptive. Neither ill-health nor death is the end. Whilst this should never become a disincentive to action, it should offer us a peace which passes our ordinary understanding.

Nick Spencer’s booklet ‘Health and the Nation: A Biblical Perspective on Health and Healthcare in Britain today’ is available from the Health reports section of our website.

[1] cf. ‘Granny in the Middle’, The Telegraph, 27 January 2002

[2] Beth Egan, Comparing Health Systems, Prospect, April 2002

[3] Trends in Attitudes to Health Care 1983 to 2000 (Table 3.4), Sonia Exley and Lindsey Jarvis, (National Centre for Social Research, 2002). The most recent data show that 3% more people were satisfied than were dissatisfied with the NHS in 2000. This compares to 10% more dissatisfied in 1990 and 14% in 1996.

[4] The Greatest Benefit to Mankind, Roy Porter, (London, Fontana Press, 1997), p. 693

[5] ibid. p 693.

[6] ibid. Table 2.2. Hospital inpatient services: 37% more satisfied than dissatisfied.   Hospital outpatient services: 34% more satisfied than dissatisfied.

[7] cf. Leviticus 4:11-12, 7:15-19, 11:7, 11:13-19, 11:39-40, 13:1-46, 17:15-16, 19:6-7

[8] ‘The Levitical Code: Hygiene or Holiness’, A. Darling, in Medicine and the Bible, ed. B. Palmer (Paternoster Press, 1986), pp. 85-101

[9] Porter, op. cit, p. 682

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