By any account, the NHS is in crisis, and a crisis more acute this winter than we have seen before. Some have described the challenges facing the service as a ‘perfect storm’ of pressures, and whilst there is a debate about whether it is a question of quantity of funding or how that funding is used, there are some alarming statistics that it is hard to get away from.
Dr Alex Gates, an NHS doctor from Bath, highlights some of the key issues. The first relates to community care, which has been drastically cut by the Conservative Government as part of George Osborne’s ‘austerity’ measures.
An ageing population brings with it more complex health needs. Many of these are best addressed in the community and not in an acute hospital bed. But most of our community beds have been closed, so as a GP there will be nowhere for me to send my frail 85 year old patient who has had a fall at home and can no longer cope.
This is compounded by a dramatic shortage of beds, compared both with the past and with other health services.
In 1987 there were over 297,000 beds available in England. By 2015, this number was just 130,000. This is a drop of about 56%. Even more worrying is the drop in mental health beds, down from 67,000 beds in 1987 to 19000 in 2015.
In 2014 the UK had 273 hospital beds per 100,000 population. Compare this to Germany (823 beds per 100,000 population) and even Greece (424 per 100,000)…
Overall, our spending on healthcare is at the low end of developed countries as a proportion of GDP—and that it has been significantly cut under the Conservatives in contrast to the previous growth under the Labour Government. (It is worth noting here that all European countries have halted the growth on health spending since 2008, but that Britain has slowed its progress in catching up with others, and several have quickly overtaken us.) Many people would like to see the discussion depoliticised—but I was not encouraged when my MP, Anna Soubry, complained that local Labour politicians were making political capital out of the call for depoliticisation!
But underlying the politics and the finance, there are much deeper issues which are crippling the system, and they are issues where theology might have something very significant to contribute. They centre on how we view health, and how we see the people involved in the system and how they work.
What is our theology of the patient? The NHS was established after the war as a ‘free at the point of delivery’ service on the assumption that, as existing medical conditions were resolved, people would become healthier and in less need of medical help over time, so that the demand on the system would be self-regulating. This failed to take into account the possibility of growth in the technologies of health care, meaning that more and more could be offered, but it would become more expensive. But it was also built on the assumption that most people had an inherent reluctance to make use of the system, based on a sense of moral responsibility for their own welfare. This was completely undermined by the move (here and in other systems of national provision) of a customer/producer relationship, where the patient is now a ‘customer’ or ‘consumer’ of health services offered by a ‘provider’, most notably in John Major’s ‘Patients’ Charter’. Such an approach is incompatible with a health service ‘free at the point of delivery‘.
This relates to our theology of health. It seems in most debates about the system that health is seen as an absolute standard which people might fall below, and the healthcare system is there to rectify the deficit. There seems little sense of health as a gift for which we are responsible stewards, which needs to be nurtured and even invested in, not just by individuals, but communally and in relationship and partnership with others. All the evidence shows that may aspects of health are seriously affected by quality of relationships, and that an ageing population needs to be thinking about long-term, personal and relational investment in health and well-being over a lifetime.
On the other side of the system, we need to consider a theology of vocation for those involved in the medical professions. The long history of antagonistic relations between doctors and Government reached a new low when Theresa May appeared to blame lazy GPs for the current crisis; even if this had a shred of truth in it, it would have been a profoundly unwise move to make in the current context.
The head of the Health Select Committee has said Theresa May must apologise for trying to “scapegoat” GPs over overwhelming pressure faced by the NHS. Former GP Sarah Wollaston told The Independent the Government was “failing to take responsibility for a system-wide issue which is not just about primary care”.
The idea that you can have the same number of doctors working for the same money but offer more appointments and work longer hours for the same pay is a basic error of maths. The NHS has for a long time depended on foreign-trained doctors; 27% in the service were not trained in the UK. The application of market forces on education is making that worse, and ever-increasing workloads, combined with the new cap on pension funds, means that something like half of all doctors in their 50s are considering early retirement. In the past, many went into medicine (both doctors and nurses) from a sense of vocation; if the shortages are to be addressed, then it will be essential to recapture this sense of being ‘amateur’, of being involved from a love for the job and a sense of calling.
This relates to a theology of decision-making. Almost all decisions in healthcare are now ‘protocol-led’, that is, a decision can only be agreed once a series of checks have been made and routines have been followed. It is rarely reported, but this takes time and so adds to costs and introduces delays. The aim is to ensure consistency and avoid litigation—now a substantial part of NHS costs—but it eliminates the need for professional judgements, and dehumanises the process of decision. It is an approach which both responds to and reinforces a lack of mutual trust, between healthcare professionals and between carers and patients.
Finally, we need theology of resources. The Private Finance Initiative was hailed as a way of pain-free investment in health infrastructure, but it has turned out to be a way of mortgaging the future for the sake of the present, and repayment of costs is another significant drain on finances. Healthcare infrastructure should be commodified as a source of profit.
It's not an aging population or patient demand that's created a crisis in our NHS.
Posted by EvolvePolitics on Saturday, 14 January 2017
If we do not tackle these fundamental assumptions, the crisis will only get worse—and these can only be tackled by some sort of national conversation. John Pike, a Bristol GP, posted this extract from a doctors-only website:
NHS will need 50% extra – government advisers
The NHS budget will have to increase by half in the next 50 years to keep track with growing numbers of elderly people, according to government forecasters. The prediction – equivalent to £88 billion worth of spending – emerged in documents published by the Office for Budget Responsibility. They are equivalent to a 2% increase in spending annually.
The OBR, which advises the government on its financial plans, warns that the rising costs of health care could make public finances “unsustainable.” It says governments will either have to raise taxes or cut other areas of spending. The estimates show the NHS budget would increase from £140 billion in 2020 to some £228 billion by 2066, a figure adjusted for inflation.
Richard Murray, of the King’s Fund, told The Guardian: “The OBR’s acceptance of the need for a larger long-term increase in the proportion of GDP we spend on health is a welcome dose of realism, but also highlights the current pressures on the NHS. Given that plans for the rest of this parliament will see health spending fall as a proportion of GDP, it is another reminder that it is unrealistic to expect the NHS to continue to operate within spending plans at the same time as continuing to offer the same level of service.”
The conversation needs to start now, and theology has something vital to contribute.
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12 thoughts on “Can theology save the NHS?”
a very minor point that doesn’t affect the substance of your piece; the shortage of native-born doctors is entirely artificial and is driven by a deliberate decision to keep supply of native-born doctors low, so that those who are permitted to qualify have uniformly excellent career prospects. In 2008, the BMA (Britain’s most successful cartel, by a mile) voted to ban any new medical schools opening and to restrict the quantity of places at existing schools (http://www.bmj.com/content/337/bmj.a748). Only very recently has the government raised this cap on places https://www.theguardian.com/politics/2016/oct/03/jeremy-hunt-promises-to-end-nhs-reliance-on-overseas-doctors-after-brexit).
Medical school places are and always have been massively over-subscribed (in 2014, something like 12.5 people applied for every pre-clinical medicine place through UCAS)
Andrew, I agree that it would be hard to agree that everything the BMA does is in the best interests of the health service overall. But it takes two to tango antagonistically. Are the BMA in charge of University tuition, or is the Government?
Hunt’s agreement to increase numbers has come very late, and suggests that the responsibility does in fact sit with Government—who therefore are accountable for the long-term problem.
And of course the main issue has never been EU doctors. The largest contributor is India, who alone supplies 11% of NHS doctors.
Excellent, balanced and informative. The public needs to be informed of the above description or “prescription”!
Ian Paul is in a position of moral theology & care. He researches his subject and is in an excellent position of close proximity to the NHS and therefore knows what’s really happening and the ideas which need to be addressed.
It would be interesting in Ian’s proposed national conversation to look at the various broad reasons for expecting the NHS to offer their free services:
1) Sickness for which the patient is not responsible
2) Sickness which has some relation to the patient’s own choices (mostly lifestyle)
3) Treatment for addiction related conditions
5) Related to childbirth
6) Related to old age
7) Related to mental health
8) All other elective procedures which are not needed for survival or pain relief (eg
plastic surgery, fertility treatment etc.)
I realise this is only my immediate listing of different reasons for treatment, and that there is obviously considerable overlap.
It seems to me that the theology regarding these areas does vary somewhat and it might cause us to query what and how much we should expect the NHS to do. However, I suspect that any attempt to refuse patients or to charge them when we suspect their condition is self inflicted would save little money and often cause them to present for other reasons at a later date. Ultimately we all gain by living in a society where people are healthy and sickness is treated, even if the self inflicted condition of some people is annoying to those who live exemplary lives. In any case we all must realise that there is a huge element of good and bad luck in our genetic inheritance and the circumstances when we are overcome by viral or bacterial infections.
I’m no expert but I’ve always understood that our taxpayer funded NHS is pretty financially efficient compared to other ways of funding, and it is hugely unifying for a nation which is pretty divided in other areas of life. In fact to spend less than 10% of GDP on it, yet to achieve the results it does, is pretty remarkable given that health is such a fundamental part of human existence. To raise it from our current 8% to 10% would clearly have a massive effect; few voters would argue with this if they could be sure that their extra taxes would indeed be earmarked specifically for the NHS (hypothecation). As usual HM Treasury would fight this eminently sensible idea tooth and nail because it takes power away from them! Of course you cannot spend money twice; our extra taxes would force us to consider our own financial priorities and to accept the need not to raise money from those who are already struggling.
So while, as Ian points out, there is theology which should inform us Christians about healthcare, I think a large part of what we do and how we pay for it amounts to common sense (and common sense is not unrelated to good theology!). But once we begin to use the NHS as a political football we kiss goodbye to common sense.
Raising from 8% to 10% would have a massive effect, yes. But, as Ian’s linked article points out, the problem is that you’re not dealing with a predictable or bounded cost structure. Demand is always going to expand to exceed supply. Today, 10%. Tomorrow, 15%. Then 25%. And so on.
Fundamentally, improvements in health care mean that people live longer which means that they need more health care. Yes, there are economies of scale – some drugs and treatments that used to be expensive and exotic are now common-place. Yes, a portion of health care goes to support people whose health issues are self-inflicted, and a “better” society would reduce the prevalence (and thus cost) of these issues. But the vast bulk of health-care costs serve to keep people who once would have died from old age alive a bit longer, and as these techniques become more successful it increases the number of people requiring these techniques and the demand for even more sophisticated treatments.
As an aside, this fuels a second economic issue: retirement benefits. When first introduced, only a minority of the adult working population lived to retirement age. Medical improvements leading to longer lifespans not only increase health care costs, but also non-medical costs associated with retirees.
Relying on people to naturally die off to reduce the load on a scheme designed to preserve life is economically naive. Mathematically, the scheme is (unintentionally) designed to keep costs growing. And, unlike any sustainable business, there’s no particular mechanism to grow income faster than costs. You’d basically need population to grow – and be gainfully employed – at a faster rate than whatever life-preservation technology you can invent, and do this in perpetuity.
At some point, you simply must start saying “no”. No, the budget is spent. No, *your* budget is spent. And there has to be some concept of an individual budget, or you’re left with a system where those who first present with extreme conditions consume all the resources and leave none for those presenting later with much milder conditions.
One “solution” is euthanasia. You get 70 years, and then society (gently and kindly) executes you. Let’s that off the table as immoral. But there does need to be some concept of a “share”. Once your share is used up, then we stop trying to preserve your life. Whether the “share” is based on age, condition, or resource consumption is a conversation and decision that *must* be had, because “to everyone as much as they need” *cannot* work if need is unbounded.
And yes, there will be a small number of individuals whose private means allow them to invest above and beyond their share. This is not unfair or unjust, any more than you can afford to holiday overseas and I can only holiday down the coast, or that you’re a good athlete and I’m an also-ran. Different people have different resources, and while it’s fair and reasonable to expect them to take to heart the principle of “to those whom much is given, much is expected”, demanding that others must have first claim on what they have is pure and simple envy. In practice, letting the rich spend on advanced medical technologies benefits everyone – they take the financial and medical risk, and the discoveries eventually become cheaper and everyday affordable. (Trickle-down economics works for all except the very poorest. It only appears to fail because we insist on evaluating everything as percentages, rather than note that even a moderately poor Westerner enjoys a “standard of living” that would – in part – amaze the richest of the rich from a century ago. I say this not to justify corruption or greed, but to note that so often we only see what is lacking, not what has been given already.)
Thanks to Ian for pushing this conversation. We desperately need serious consideration of the philosophical and theological issues related to medicine and the preservation and extension of life. For good reasons, we all want the best possible without regards to cost, but few have the moral wisdom to see that this is as foolish with regards to medicine as in any other part of life.
Might I add two further points?
First, that medical technology will continue to bring an extensive range of (usually expensive) new treatments. I am currently against euthanasia, but it needs to be said that we are under no compulsion to use all technologies available to us. There is rooms for responsible individual choice here.
Second (and related) is the folly of so-called ‘ageism’*. It is entirely reasonable that treatments limited by cost, regional availability, availability of professional skill and facility etc, should be focused upon those who are likely to derive the most benefit from them. There is, therefore, not only an individual choice to be made, but a communal/national one also. This will involve, for some, a major move away from a ‘rights’-based morality towards a communal generosity.
*I write as one who has been drawing his pension for some years.
I am currently working on a dissertation around Stewardship of the physical body” as worship to God. I am interested in the beginning of your comments –
Sickness for which the patient is not responsible
2) Sickness which has some relation to the patient’s own choices (mostly lifestyle)
3) Treatment for addiction related conditions
my main area of work is about diet and exercise. do you have any writings / comments on this, please?
The sole difference between active euthanasia and the passive kind that simply withdraws the means to survive is in the comfortable conscience and safe reputation of those imposing it.
And that goes as much for poverty and homelessness as direct medical aid.
In my opinion the ideal of a ‘free’ NHS is an impossible ideal unless substantially lower standards are accepted. A ‘free’car, or a ‘free’ house, etc. for all is equivalently unachievable.
Living in Holland I pay approximately 10% of my net monthly income in health contributions. Also, in Holland, Accident and Emergency services have been intelligently split into an áfter-hours’consultancy on the hospital sites, at a premium rate using the pool of all local GP’s; and a true A&E ward which is specialized for the treatment of trauma and life-threatening conditions. People who insist on going to the A&E with a minor complaint are made to pay a punishingly heavy bill.
GP’s do not make home calls except in extremis.
The service we get is good, and we pay for it willingly.
In my opinion the NHS has become, theologically speaking, a great basket of idolatries. But it matters. Like ‘War and Peace’.
About the NHS I’ll sing a song
Sing rickety tickety tin
About a doctor I’ll sing a song
Who didn’t have her patients long
Not only did she do them wrong
She did ever one of them in, them in
She did every one of them in.
– We had to make do with gin
Surely the truth is in there is nothing wrong with the NHS and there is Nothing wrong with the social services as an ideology, rather the problem is the practicality of the coordination of the two. The monitoring of the two and the fact that it has taken the whole of my lifetime so far for government bodies to acknowledge the fact that corruption in both systems has set up some of the problems they now have to deal with . Who fought for drugs to be legal? who fought to lower the age of consent? Who fights for freedoms that destroy and why? Who decided that centralisation was the way forward? When actually what is needed is area based care with a central monitoring point accessible to all. Why do I say that? Well when care is area based there is the potential for abuse, IE if everyone knows each other they can give or deny care and support one another in that, leaving those out of favour to effectively at minimum suffer at worst die because people make judgements via social circumstance so if you are a single childless person with no dependants you may be deemed less important than a single mother in NHS and Social Criteria even if you have worked all your life. So the theology of that is care for the vulnerable ? The NHS criteria is “life threatening” so it does not take into account social circumstances the problem with this way of working is that one undermines the other and so you just swap funds around to stay in the same place. Mental health is best treated by a combination of medical and social care yet theses two pull against one another for funding. It is indeed complex. There are many many issues childlessness creates many many problems yet ethically many fought to prevent IVF alongside Baroness Warnock I wonder what the cost of ethics are? Yet without ethics we would be a monstrous society.