The NHS as a theological institutionBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7225.1588 (Published 18 December 1999) Cite this as: BMJ 1999;319:1588
The ideal remains strong, but the practice too has to measure up
“I believe with perfect faith in the NHS, in its ability to provide all health care for all people free at the point of use, in its ability to be equitable, fair, and compassionate, in its capacity to be efficient and effective, and, above all, in its capacity to give patients and users choices about the sorts of services they should receive.”
The NHS is like a theological institution. Its adherents, most of the population of the United Kingdom, believe in it passionately. Politicians who itch to reform it find themselves hopelessly out of sympathy with public opinion. Like the BBC, the NHS is an institution that binds the people of the UK together. It is seen to be fair, there when you need it, and the best in the world if you are seriously ill. No matter that the evidence is not necessarily there Like theological belief, belief in the NHS rests on assertions, apparently revealed truths—and woe betide those who try to say otherwise.
In part, that is because the NHS was set up with a moral purpose. It was new, exciting, encapsulating social progress, a guarantee of safety after the war, and a form of social contract. Fifty one years on, it is apparently much the same in the public mind: “[The NHS] symbolises the right of every human being to the dignity of health care based on need not wealth. It is the tangible experience of what I mean by community, working together—and paying taxes together—to create and sustain it in the interests of each individual in the community. It is driven and maintained by public service, by people dedicating themselves to the service of others.” (Tony Blair, prime minister, speaking at the 50th anniversary of the NHS, July 1998).
Since its creation politicians have invested the NHS with a value way beyond that of providing health care to a population in a rational, efficient manner. They paint the picture of an organisation whose value transcends that of preventing, treating, and curing illness. It is also a service that brings people closer together, which we trust to look after our minds and bodies, helping us to be born safely, live healthily, and die as painlessly as possible. Klein has described the NHS as a “church for rationalists,” created out of a missionary zeal born of the conviction that planning health care rationally and fairly was the best way to improve the nation's health.1 It was created with a vision of people of all classes sharing risk and receiving care side by side. Yet in describing it thus Klein also asked whether the NHS was still a church or now a garage. I would still argue for church, or at least theological institution, because it rests so much on belief about collective values and far less on scientific evidence and on true measures of effectiveness. Yet belief alone may not sustain it.
Ever since its creation the NHS has been a subject of constant public concern. Every political party has claimed to be the defender of the faith and accused others of putting it in peril. There is an endless stream of media stories of falling standards, underfunding, and delay. Such high public expectations are burden. With “postcode rationing” now a well established fact of life in the NHS, its position as a universal care provider seems under threat. With more people seeking financial redress from the NHS when they do not receive the care they expect, there is a growing feeling that the public wants more than the NHS can ever provide. Few ever seek financial redress from their churches, which suggests a growing view that the NHS is more a standard public service and less a belief system.
That poses an immediate risk to the relationship between the NHS and society For it presupposes a loss of faith in doctors, the priests of the theological institution. Recent scandals have publicised the failings of the medical profession. The media, which once unquestioningly regaled the public with the miracles of modern medicine, is now more sceptical. Society has become more secular in its outlook, more consumer oriented, and less willing to trust professionals. The NHS seems to be becoming less of a church and more of a garage, giving consumers (not citizens) whatever care they can get within the limits of medical science.
Certainly there is greater scepticism, and the priests are not so trusted Yet one might argue that this is no different from liberal approaches to religious faith: testing assertions, accepting variant authorship and interpretation of holy writ, and understanding that those apparently eternal truths have to be set in their context. And the liberal faith has prevailed. Public devotion to the concept of a tax funded, universal NHS has actually increased since the early 1980s, as concern about its wellbeing has grown.2 Even Margaret Thatcher dared not privatise the NHS, merely introducing attenuated market forces into the service.
But the NHS of the future will have to adjust to a new relationship with society. Creature beloved of the faithful it may be, but the liberal and intellectual among the faithful will be impatient with being asked to believe three impossible things before breakfast. The ideal will remain strong, but the practice of the priests has to measure up. To receive public trust they must show that they give good value for our votes and money. The quality of care provided must fit those concepts of compassion and fairness written into the original holy writ of 1948. Priests who misbehave must be disciplined Individual temples that are unwelcoming must be reformed. New ways of praying—at easy access, walk-in services that complement the continuing relationship with a priest—must be welcomed. The belief is in universal availability. No one wants to wait two weeks to pray.
The challenge for the NHS is to continue to meet the expectations of a service that is felt to embody what is good about our society, with a moral purpose. But support is not unconditional, and if the NHS cannot show that it is still good for our health, public faith, and political support, will be eroded. As in modern Britain, the faith may appear in new ways—from the evangelical (NHS Direct) to the fundamentalist (integrated care, holistic approaches, and complementary medicine), and the orthodox must take note.
A recent study from America showed that people who go to church regularly live longer than those who do not.3 Faith remains a key to good health. That faith does not have to be in religion. It can be in a family, a community, and public services But well founded faith in the NHS is a vital component of its role in making society feel better about itself and helping individuals to feel secure that they will be looked after at times of need. So recognising the NHS as a creature of faith, an institution in which people have faith, is essential if it is to recognise itself as the product of a value base. And that value base in turn requires it to be more coherent about what it is, who it is for, and how its priests and priestesses will be good to its congregants. Then no prophet will need to come along and condemn them for failing to do what is right. To paraphrase the prophet Micah: “For what does the Lord require of you, but you deal fairly, love compassion, and walk truthfully in the path of ethical practice.”