Change and reorganisation are ever-present facts of life in many professions, and healthcare is no exception. This paper examines some of the challenges for Christians living and working in the changing context of healthcare in the UK. Many of the key principles will be equally applicable in other walks of life.
Recent years have seen major changes in the organisation of healthcare in the UK, particularly in England. The Health and Social Care Act (2012) led to fundamental changes in the structure of the National Health Service (NHS), with most budget decisions now resting with groups of local GPs (known as Clinical Commissioning Groups or CCGs).
Though much debated, these latest reforms were only the latest in a series of fundamental re-organisations. Since 1990 we have seen, in general practice alone, moves to (and away from) GP fundholding (a system whereby GPs directly managed funds that paid for patient's healthcare); the emergence and abolition of Primary Care Groups, then Primary Care Trusts and now the advent of CCGs.
Christian involvement in healthcare has a long pedigree in the UK and elsewhere, stretching back to the monastic hospitals of the medieval period. Many of the major hospitals which provided the foundations for the NHS were originally set up by Christians. St Bartholomew's, St Thomas', St Mary's and St George's are examples in London. Similarly many of the country's leading medical schools began with Christian initiatives. Even now, there are many Christians working in state healthcare institutions, but since the formation of the NHS, there have been fewer opportunities for explicitly Christian organisations providing healthcare to be part of the system (a small number of Christian general practices are the main exception).
Even in the context of a secular, government organisation, many Christians have been strongly supportive of the perceived principles of the NHS. This means that fundamental changes in the system can be unsettling, and lead to a feeling that the institution they work in no longer shares their fundamental values.
Can any essentially secular health system share fundamental Christian values? Although the aim of ensuring that healthcare is provided to all resonates strongly with Christian principles of love and justice, Christians will vary in their assessment of how fully the NHS should, can or does fulfil this. The low pay offered for jobs such as portering or cleaning with the NHS raises concerns about justice; attitudes to abortion funding and provision raise questions about whether the system really respects human life. So while Christians may feel very much 'at home' with some aspects of the NHS, there will be other areas that raise serious questions. Indeed, should any Christian feel at home in any secular system? Does there come a point that the tensions are so great that we need to 'come out' of the system and work in another way?
God's big plan
Christians believe that history is proceeding along a divinely directed trajectory as God works out his grand plan of salvation. God created the world and, in spite of mankind's rejection of him, has instituted a plan through history to gather his people for eternal fellowship with himself. God's dealings with the nation of Israel in the Old Testament, the coming of the promised messiah Jesus Christ and the establishment of the church drawing people from all nations are key parts of this plan. We live in the period between Jesus' first coming, in which he achieved our salvation through his death and resurrection, and his second coming leading to the final judgment and the establishment of a new heaven and new earth.
God is sovereign over all physical, spiritual, social and political processes (Daniel 2:21, 4:17, 5:21). All governing authorities, including those of the government and NHS, are ultimately responsible to him (Romans 13:1-17). As God's people, however, Christians live in a time of tension between the 'now' and the 'not yet'. God's kingdom has been inaugurated but will not fully come until Christ returns in judgment. Christians are therefore called both to be 'in the world' whilst not being 'of the world' (John 17:11, 15-16). We are called to do everything in the name of Christ (Colossians 3:17) and with all our heart (Colossians 3:23). We are to be fully involved – being called to be 'salt and light' (Matthew 5:13-16) and to 'shine like stars' (Philippians 2:15) – whilst not allowing ourselves to become morally compromised. We do not 'belong to the world' but have been 'chosen...out of the world' (John 15:18-19). We are citizens of another country and serve another king.
Strangers and aliens
The apostle Peter describes God's elect (Christians) as 'strangers in the world' (1 Peter 1:1), and 'aliens' (1 Peter 2:11). We are called to 'be holy' – to be set apart – because we are 'a chosen people, a royal priesthood' and 'a holy nation' (1 Peter 2:9). Our good deeds should cause others to 'glorify God' (1 Peter 2:12).
At times Christians in Britain may not feel like exiles. It is easy to point to apparently Christian elements in our society; numerous church buildings; national laws with at least some parallels with the Ten Commandments, an established church (at least in England). Yet we are still set apart. We are citizens of heaven, currently living on earth. Though our physical home may not have changed when we became Christians, our allegiance shifted from earthly rulers to the one true ruler of the universe.
Seeing ourselves as exiles can be particularly hard to reconcile with working in the NHS. Aren't we carrying out God's commands and expressing his compassion as we care for the sick? At least some Christians are strongly wedded to the principle of providing care free at the point of need. Even if we feel 'at home' in this system, we also need to reflect on things which are wrong. The constant change (one of the few certainties in the NHS) means that re-organisations of the system provide an opportunity to reflect on our real status at work; as workers dedicated to our jobs not for our own sake, but because it is the Lord whom we serve.
How are exiles to behave?
For much of biblical history God's people have lived as exiles and have worked in state systems. Joseph, Esther, Mordecai, Nehemiah and Daniel and his friends served in state systems in the great empires of Egypt, Babylon, Media and Persia. The early Christians lived at the time when the Roman Empire was dominant and throughout the last twenty centuries have served in state systems and empires all over the world. If we accept that we are living as exiles in our current world of work, how should this affect our behaviour? Are there things we cannot go along with? Are there other things that we must just accept and get on with?
Fortunately we're not short of biblical guidance. Large parts of the Old Testament deal with the exile of the Israelites from Jerusalem. This of course was a much more obvious exile than ours in some ways – the Israelites were physically taken to Babylon in stages, as recounted in 2 Kings 24-25.
Daniel is perhaps the most famous example of an exiled Jew. Although he is best known for his refusal to compromise by continuing to worship God against King Darius' orders (Daniel 6:10), and refusing Nebuchadnezzar's food (Daniel 1:8), he worked hard and effectively within the alien Babylonian system and was rewarded with great responsibility for his integrity and commitment (Daniel 6:4). His close friends Shadrach, Meshach and Abednego were similarly honoured and promoted (Daniel 3:30).
As well as these and many other examples in Scripture, we have the instructions given to the exiles by God through the prophet Jeremiah. Given the utter apostasy of Babylon, the instructions are quite surprising: 'Build houses and settle down... marry and have sons and daughters... increase in number there' (Jeremiah 29:5-6). For anyone still tempted to try to destroy Babylon from within, 'Seek the peace and prosperity of the city to which I have carried you into exile. Pray to the Lord for it, because if it prospers, you too will prosper.'
Daniel, it seems, followed just this advice. Earlier on, Joseph was effectively an exile when in Egypt. His pattern of behaviour is similar to Daniel's; there are certain 'red lines' he did not cross (in his case not lying with Pharaoh's wife in Genesis 39:12), but at the same time he rose to a high position within Pharaoh's administration. He worked for the good of Egypt – but this ultimately turned out to be for the good of the Israelites as well. His position and intervention in Egypt was used by God to save his father Jacob and his family, including Judah, who would become the ancestor not only of David and Solomon, but of Jesus himself.
Indeed, Jesus' time on earth can be seen as a kind of exile. Not only his time as a literal exile as a baby in Egypt or his temptation in the desert, but his whole time on earth, away from his Father in heaven. Like Joseph and Daniel before him, Jesus knew his mission and stayed focused on it but he did not ignore the wellbeing of the world he was in, spending time healing the sick, speaking about injustices, and ultimately dying to save its people.
1 Peter affirms that we are exiles today too. It may not be as obvious as it was for the Israelites in Babylon, but we are ultimately citizens of heaven (Philippians 3:20). Anything we do here on earth is in the context of being exiles. So, how might the principles above work out in a changing health system?
What has this to do with the modern NHS?
Being in exile is part of God's plan
It may not have seemed like it at the time as the Israelites were led off to Babylon, but their exile there was clearly intended by God. 'This is what the LORD Almighty, the God of Israel, says to all those I carried into exile from Jerusalem to Babylon' (Jeremiah 29:4 – emphasis mine). Joseph's brothers' 'intended to harm' Joseph by selling him into slavery, but God 'intended it for good to accomplish...the saving of many lives' (Genesis 50:20).
It may well be God's plan for us that we work in a largely secular environment, with mostly non-Christian colleagues and patients, who don't share our faith. Such an environment offers lots of opportunities to witness to the truth of the gospel through our words and actions, and to make visible God's mercies to the unbelieving world. But our witness isn't the only way in which we work in God's way.
Seek the prosperity of the city
We should work to the best of our abilities within the system in which we're placed, and value the good of the organisation in which we work. In doing this we not only obey the principles in Jeremiah 29, but also uphold the high view of work given to us in Genesis 1. As God's 'stewards' we are entrusted with gifts, training, resources and held responsible to care for his world as he himself cares for it (Genesis 1:28). We should make an effort to help with particular priorities in our organisation, striving to improve the quality of its work. This might include achieving financial balance, management processes, or promotion of what our organisation does.
Part of seeking that prosperity is praying. Do we have a prayer group in our workplace if there are other Christians? If so, we may well pray for our patients and ourselves, but how often do we pray for the health of the organisation, or the managers? Christians are urged not only to pray for 'all those in authority' (1 Timothy 2:1-2) but also to be subject to them: 'to be obedient, to be ready to do whatever is good, to slander non-one, to be peaceable and considerate, and to show humility to all men' (Titus 3:1-2). We are also to serve them 'with sincerity of heart and reverence for the Lord...as working for the Lord and not for men' (Colossian 3:22-25).
A number of dilemmas arise for doctors and medical students working in a non-Christian system. Here we consider one current problem, and list some others which you may wish to consider.
A major concern over the latest health commissioning arrangements is that conflicts of interest are generated. For example, a CCG might well have to decide who is granted the contract for a particular service and local GPs in that area might well tender for the service. Such GPs will be represented on the commissioning group making the decision. Or we might be expected to make decisions over services at a local hospital in which our spouse works, or we might have investments that profit when private health companies do well.
Even at the level of day to day work there are significant conflicts for a GP. Undoubtedly there are large savings for the NHS in using the cheapest drug in a particular class for example. But how do we deal with this when a patient, unhappy about being switched after reading a newspaper article, asks whether we make any money ourselves out of the change? Prescribing incentive schemes mean that there is often some (very limited) financial reward attached to targets, and this further muddies the water. The recent reforms mean that GPs are much more directly accountable for costs, both of medication and outpatient referrals. Are we to follow our own financial interest, the interest of the NHS, or the interest of the patient? Or a mixture of the three? It is all very well to claim to ignore financial factors, but even then the same measurement used to reward us for reducing prescribing costs will also often be used as a measure of practice quality by bodies such as the Care Quality Commission (CQC). The answers are not simple.
Undoubtedly integrity is key to dealing with conflicts of interest. The reality is that there are always such conflicts of interest, and our role is to handle them openly and with integrity, rather than shy away from them. Being able to explain why we have made particular choices is important. We need to put the patient's need first where possible, but pay regard to budgetary factors as well.
Other areas of tension might include rationing of resources, triage systems (where one patient is prioritised over another), and more obvious problems around beginning and end of life ethics. Confidentiality is another tension; not only day to day on the ward, but in sharing information with social services in child protection cases or balancing confidentiality with security if working in a prison or other secure environment.
'Shining like stars' involves doing our duties 'without complaining or arguing' (Philippians 2:14). Bitterness and cynicism are not part of a Christian character. Such commands can be challenging to follow, and we need to pray constantly for each other as we seek to obey.
It is difficult to seek the good of an organisation if we are not fully engaged with it. As Christians we rightly give a high priority to church and family but if we are constantly 'semi-detached' at work we will struggle to really seek the wellbeing of our workplaces. We need to put in sufficient time at work to do this; we should spend time socialising with colleagues where that is part of the work culture, and perhaps participate in workplace activities like sports teams or choirs if these exist and if our abilities allow us. As well as helping us to seek the good of our organisation, such engagement gives us more chance to share our lives and faith with those around us. It might well be that our workplace, rather than our immediate neighbourhood, is the primary mission field for many of us – after all we probably spend more of our waking hours there.
In for the long haul?
The Babylonian exiles were told clearly by Jeremiah that their exile would last beyond the lifetimes of those who originally went. Indeed Jeremiah 29:8 implies that false prophets may have been promising an early escape; God clearly disowns this.
We might earnestly desire to work in a system of healthcare run by Christians along biblical lines. The reality is that this is very unlikely. The advent of 'any qualified provider' may in the medium to long term lead to Christian run and led services becoming more widespread again, but even then, such services will still be under the authority of the part of the NHS in charge of them. Though we should by all means pray for a system more responsive to Christian concerns and values, we must also accept that we might spend our entire working lives in a largely secular NHS.
Conflicts of loyalty
The apostle Paul is quite unambiguous in telling the Romans to 'submit...to the governing authorities' (Romans 13:1). The context of a Roman empire at that time hostile to Christians makes his argument that governments have been established by God even more compelling. But this is not a call for unquestioning obedience. The Bible is very clear about two particular 'red lines': that we should not submit to obeying governing authorities when (first) they force us to do things which are wrong, or (second) try to prevent us from living and speaking in obedience to Jesus Christ. The Israelite midwives refused to kill Israelite babies when the king of Egypt ordered them to do so (Exodus 1:15-21). Daniel disobeyed King Darius when he was ordered to desist from public prayer and his friends did not bow down to Nebuchadnezzar's golden image. Peter said 'We must obey God rather than men!' to the high priest and Sanhedrin when he was ordered not to preach the gospel (Acts 5:29).
Daniel drew quite a particular 'red line' in Daniel 1; he makes some notable compromises (such as submitting to educational training, working in the court of a hostile king, and agreeing to a change of name), but he also chooses to draw a line on some issues, such as eating the king's food.
Some of today's 'red lines' are obvious. We must not participate in the intentional killing of innocent human life, even if the person in question is unborn or very ill. We must be truthful in our dealings with patients, colleagues, and managers, even when under pressure to lie, particularly where money is in question. We must defend our freedom to live and speak for Jesus at work. We must act with integrity if employing other staff.
How can we engage?
We need to engage with care, and avoid extremes. On one hand, we can risk seeing our work as a means to an end; as a place purely to share our faith, or to earn money to give to gospel work. Of course evangelism and giving are good things, but we can easily neglect our work and organisation if we treat our job as only a vehicle for other things. At the other extreme, we can be so keen to seek the good of our organisation that we become too at home there; completely assimilated into it, failing to see challenges and tensions, and keeping our faith firmly away from work.
One middle way to engage is to become involved in management structures and work on improving the system. The latest reforms have given more opportunities to GPs particularly. Indeed every doctor is a manager to a greater or lesser extent; principles around integrity and seeking the good of our workplace are no different when applied to management tasks than when applied to patient care.
Some of the ideas in this File may be uncomfortable for some. The idea that the NHS is not explicitly Christian may be hard for some doctors; others will find the idea of praying for the good of an institution that is clearly not Christian very difficult. Some of the applications are difficult also. Working with integrity and avoiding cynicism in the face of change sound absolutely reasonable, but very difficult to achieve on our own. We are of course dependent on God's grace to work in the system in which he has placed us; our main role is to live and speak for him where we are.
Laurence Crutchlow is a London GP and CMF Associate Head of Student Ministries.