From triple helix - summer 2018 - NHS 70 years old
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5 July commemorated 70 years of the UK's National Health Service. I briefly wrote for Triple Helix for the 50th anniversary (1) and the 60th, (2) so now want to reflect at greater length on Christianity's influence on medicine and the first 70 years of the NHS.
The first 1900 years since Christ
There had been strong medical traditions in the Buddhist, Jewish, Arab, Greek and Roman worlds but from the earliest days of the Christian church their radically different ethical approach was influential. The church began to change society's attitudes to the sick, disabled and dying. At the end of the first century Clement recorded in Rome how the Christians provided relief for widows; and during a second century plague in Carthage when pagans threw sufferers into the streets for their own protection, the bishop led Christians out into those streets to welcome sufferers into their own homes.
Constantine's Edict of Toleration in 311 gave Christians official sanction to express their convictions in public service. The Roman Emperor Julian who came to power in 355 was the last to try to reinstate paganism, but noted that to succeed the old religion would need to care for people better than the Christians did.
The 'Dark Ages' cover the period between the fall of Rome in 476 and circa 1000, but even so Charlemagne (742-814) decreed that every cathedral should have an attached hospital, monastery and school. Famous hospitals such as Barts and Thomas's were founded in the mediaeval period with a spirit of Christian service. The 18th century evangelical revival pioneered by the Wesleys and Whitefield led to a new age of hospitals, where the body was cared for as much as the soul. These institutions were mainly meant for the sick, the poor, and were supported by voluntary contributions. (3)
The 20th century
Medicine was beginning to become more respectable as a profession. Scientific advances started to resemble something we might recognise. The 1911 National Insurance Act underwrote general practice, the Great War (1914-18) reduced the numbers of men available. This began the very slow liberation of women. But the 1920s and 1930s were decades of great inequality with economic depression only beginning to lift in 1935. Even so, there were still over one million unemployed by the start of World War Two.
Professor Roy Porter (1946-2002) wrote: 'War is often good for medicine. It gives the medical profession ample opportunities to develop its skills and hone its practices. It can also create a post-war mood eager to beat swords into scalpels. The astonishing success of antibiotics used upon troops during the Second World War heightened expectations of wider public benefits. Only in Great Britain, however, was it followed by a dramatic reorganization of civilian medical services.' (4)
The concept of the National Health Service was blueprinted in the 1942 Beveridge Report on Social Insurance and Allied Service by civil servant Sir William Beveridge (1879-1963). It sought to take on the five giants perceived to threaten society: Want, Ignorance, Disease, Squalor and Idleness. Beveridge's 1942 slogan about comprehensive welfare provision 'from the cradle to the grave' summed up these ambitious aims.
Disease would be overcome by a new health service 'available to everyone according to need, free at the point of service, without payment or insurance contributions and irrespective of economic status. All means tests would be abolished.'
The landslide Labour Party victory in 1945's General Election allowed implementation. A bill introduced in April 1946 received royal assent in November and 5 July 1948 was the appointed day for its inauguration. Both municipal and charity hospitals were simply nationalised overnight and the Secretary of State for Health, Aneurin Bevan, became responsible for 1,143 voluntary hospitals with more than 90,000 beds and 1,545 municipal hospitals with 390,000 beds. (5)
There was much resistance from the medical profession about loss of private practice. Bevan boasted that he had 'won over the consultants by choking their mouths with gold'. GP fears of a full time salaried practitioner service were overcome by letting them remain separate from hospitals as independent contractors.
Christian doctors' concerns were about losing the freedom to work as Christians, but this never materialised, at least at that stage. There was great rejoicing about abandoning the need to extract payment from the poor.
Porter summed up the reorganisation as 'efficient and fairly equitable…powerful, popular and, by international standards, exceptionally cheap'. (6)
Where are we now?
We remain incredibly blessed by healthcare free at the point of need. It is indeed so popular that ten years ago former Chancellor Nigel Lawson described the NHS as 'the nearest thing the English have to a religion'. (7) However, we now realise the fundamental flaw of the thinking behind Beveridge: that if we are able to reduce inequalities and improve the general health of the population, we will spend less on treating patients.
Beveridge failed to predict the astonishing (and expensive) advances in scientific medicine, the increasing expectations of the public, and the advances in longevity that have caused many more to live many more years, though often with multi-morbidity. Social changes leading frequently to disintegration of the family, and diseases and disorders of unhealthy lifestyles have added to the mix. There is no need to dwell at length here on underfunding, too few beds, disconnect between health and social care, growing inequalities, issues of staff morale, and the possible effects of Brexit.
Is there hope for the NHS, or does the 3,000 year-old pronouncement of the Psalm of Moses apply? 'The length of our days is seventy years - or eighty, if we have the strength; yet their span is but trouble and sorrow, for they quickly pass, and we fly away.' (8) If 1948 was the cradle of the NHS, are we in 2018 digging its grave? There is an encouraging amount of optimism around. CEO of the King's Fund, Chris Ham wrote on 5 May of a cross party consensus that, 'Spending on the NHS and social care needs to increase by substantially more than inflation over the next 20 years and should be paid for by a dedicated tax... Survey evidence shows that the public is increasingly anxious about the state of the NHS and that there is support for tax rises to increase funding. Tax rises are now backed by a majority of supporters of all the main parties.
Ham also considers top priorities: mental health services, general practice, and improvements in cancer care, and emergency care. (9) A constant refrain across the political spectrum is 'the need for social care to receive additional funding as well as the NHS'. The Prime Minister's recent addition of social care to the then Health Secretary, Jeremy Hunt's job title may be significant. At the time of writing, the PM was expected to make an announcement on the scale of promised funding to mark the 70th anniversary. The thought of significantly more money and recognition of a cross party common sense consensus have led to hopes that 'the country has arrived at a second Beveridge moment'.
A personal view
Although later called out of clinical work, I loved my 14 years' clinical medicine. I had the privilege of being a GP throughout the 1980s, when the motto was, 'if it ain't bust, don't fix it'. Older patients told me of their fears about payment before the NHS came in. I'm glad I never had to ask for money.
A year in the USA where there is no universal health coverage confirmed why I have always been a fan of the NHS. I remain ardently committed to healthcare free at the point of need, and am ready to put more tax money where my mouth is. I would welcome a second Beveridge moment.
But there is 'too much medicine' now. Nobody seems to be allowed to die. We have forgotten that life has a natural end. Fears about dying are almost never discussed among health professionals and the public. Nobody appears to spend time any more preparing to meet their Maker. We desperately need to bring Christianity and medicine back together.
Andrew Fergusson is a former GP and communicator at the interface of Christianity and medicine. In retirement he is active in local churches and in Christian publishing
1. Fergusson A. Editorial: From the cradle to the grave. Triple Helix 1998; Summer: 3
2. Fergusson A. 'Diamond geezer' or ripe for retirement? The NHS at 60. Triple Helix 2008; Summer: 4
3. Beal-Preston R. The Christian Contribution to Medicine. Triple Helix 2000; Spring: 9-14
4. Porter R. The Greatest Benefit to Mankind. A medical history of humanity from antiquity to the present. London: Fontana, 1999:652
7. The English reformation - National Health Service. The Economist, 20 November 2014. econ.st/2L1MV8R
8. Psalm 90:10
9. Ham C. Cross party approach to NHS and social care, BMJ 2018; 361 (2 May)