I can claim little more than an amateur's interest in the contemporary shifts in culture that surround us as we enter the twenty first century. Having spent twenty years in Inner-City General Practice and sixteen of those involved in education and training, however, I do feel able to comment on the profound upheavals that the NHS has undergone in that time, and to seek to relate them to the wider cultural changes that have engulfed our society in the last quarter of a century.
Post-modernism is the collective term used to describe the end of the modern era and the death of the Enlightenment project that began back in the seventeenth century. The Enlightenment ushered in a way of thinking that dominated the development of the industrial nations with its belief in the supremacy of reason, the inevitability of progress, and the rise of the nation-state.[1] All of these things have now been consigned to history. The dominating themes of the post-modern era include the loss of grand meta-narrative (a unifying world-view held by the majority of people in any society - in our case the Judao-Christian one). With it came the deconstruction of hitherto sacrosanct institutions and language, the cult of individualism, and the emphasis on process issues (such as management science) rather than content.[2, 3]
It can be argued that the Judaeo-Christian value system that under girded the major institutions of our society (Medicine, Law, Education, the Media and indeed Government itself) lost its grip. It began back in the sixties when a whole series of laws were changed that reflected the rise of liberal humanism as a dominant world-view. Not all of this was bad, of course, as the rigidity and intolerance of some of the laws that had supposedly controlled moral behaviour since Victorian times were replaced with more flexible, tolerant ones that mirrored changing times and opinions. The liberal humanists have had little time to rejoice, as their perspective has in a few brief years become just one of many possible interpretations of reality in a society that no longer believes in the possibility of unifying truth or total explanations of the way things are. Whereas in the seventies and eighties Christian doctors and other health professionals who were opposed to abortion, for example, were considered reactionary and narrow-minded, now such an opinion is simply one of many possible views, supported increasingly by empirical evidence from ever more detailed and early technological methods of examining the developing fetus. I shall consider each of the features of post-modernism listed above, and relate them to the NHS today.
Loss of grand meta-narrative
For the best part of two generations, Christians had a fairly comfortable time in the NHS. Its foundational principles of free at the point of access health care for all, based on sound scientific medical research, funded and regulated by government from general taxation, were in harmony with Christian concern for equity, justice and truth. More than this, the caring ethos of the health service was strongly Christian in tone, and thousands of individual Christians contributed enormously to the climate of compassion, high standards, and going the extra mile that made the service in its earlier days the much-vaunted 'envy of the world'. (The council of reference of the Christian Medical Fellowship lists many such individuals). In General Practice, the contract negotiated in the late sixties that resulted in the renaissance of the discipline, also placed the doctor-patient relationship (which might extend over thirty or more years) at the centre of the major access point to health care for the entire population. This gave enormous potential for Christian doctors to be there for their patients through many ups and downs of life, as well as their births and deaths, as trusted and known medical advisors, quietly demonstrating the love of Jesus in compassionate, skilled medical attention and care over many years.
Although thousands of Christians continue to work in the NHS, today's climate is very different. One of the major reasons for this is that the world-view and the values that surrounded its formation are simply not there any more. This has radically changed the way that the public view the professions. There is no longer the assumption that a professional person has high integrity and is motivated by a desire to do the best for their patient or client. (With good reason, perhaps a cynic would add, mindful of recent media revelations about incompetent doctors.) Indeed, many, if not most young doctors today see medicine as a job rather than a vocation and the NHS as a largely outdated and not very good, but at least secure, employer. The sense of commitment to high standard, compassionate care by the professionals, and the respect that this engendered in patients and public, can no longer be assumed in today's NHS. The memory and heritage of Christian values that gave rise to these things has gone, making it a less comfortable and more challenging environment for Christians to work in.
Deconstruction
For many years the NHS existed as a venerable institution that was used as a vote catcher at election time by successive governments, and was held in affectionate and respectful regard (tinged with impatience at its waiting lists) by the public. Those working for it could safely assume that like Mount Everest it was there, and would remain so for the duration of their professional lives. All that changed in 1990 when Margaret Thatcher's clever advisors prompted the introduction of the internal market. This was a brilliant political manoeuvre that had the key players (in terms of managers and lead clinicians) scrambling for cash for their hospital (trust) or practice. They were, however, failing totally to challenge adequately the chronic under-funding and laissez-faire public sector management that had caused the problems in the first place. Since then change has continued at a frightening pace, instituted by successive political administrations that have studiously ignored the morale-lowering effect that this has on the overburdened professionals struggling to keep the service going.
Not only is the service itself being deconstructed (Labours' recent NHS Plan being the latest scattering of the jigsaw pieces), but the language used in documents detailing the next round of management changes has itself lost any objective meaning, in true post-modern fashion. On many occasions in the last few years I have read a circular several times, showed it to colleagues and managers, and we have all eventually agreed that we don't have a clue what it actually says. It is particularly difficult for Christians to cope with this, as not only do we assume that words have meaning and importance, (we believe for instance that the Scriptures communicate God's Word to us) but also we find that our values that helped sustain the NHS as it was prior to 1990 seem increasingly to be irrelevant to the fragmenting, government-driven protocol systems that today's NHS is becoming.
Individualism
Demographic changes over the last fifteen years show an increasing number of people living on their own through choice, as well as increasing numbers of single parents and isolated elderly people. The great god consumerism has become a rampant force, affecting all areas of life and leading to a virtually twenty-four hour society where the shops never close, and lifting a telephone can get you almost anything you want at any hour of the day or night. The loss of family and social networks of support has resulted in the loss of coping skills for illness, which coupled with consumerist expectations has led to an inexorable rise in patient demand for health care on a twenty-four hour basis. The advent of co-operatives and deputising services have been how General Practice has sought to deal with this, and NHS Direct and Walk in Centres are the present government's attempt to meet the individual consumerist agenda.
The one big problem with all this is that health is not a consumer product. It is inextricably linked to lifestyle and choices for which individuals may be personally responsible, as well as being determined significantly by wider issues such as poverty, housing and employment or lack of it. As Christians we need to be critical of government when it fails to address these issues and tries to make the Health Service respond to the individualist, consumer-driven demand in the false assumption that this will improve people's health.
It is always easier for governments to do cosmetic, vote-catching things than to tackle the wider issues that are the real problem. All the spending on efforts to persuade people to stop smoking, for example, (which is now an explicit responsibility of health care professionals under the National Service Framework for Coronary Artery Disease) panders to the individualist perspective. Putting the price of cigarettes up significantly would be far more effective, but might reduce the tobacco revenue that raises lots of money for the Treasury. The truth is that poverty, housing, education, employment and personal responsibility are and always will be much more significant factors in determining health or lack of it than any individual services provided by professionals. This has been known for years, yet still the gap between rich and poor continues to grow and NHS staff are made to do things of no proven benefit simply because they reflect the drift of post-modern society.
Process issues
It is no coincidence that things like Clinical Governance, NICE, CHIMP, PCG's, PCT's and Revalidation are all coming into being now. These are all management systems that reflect the final feature of post-modernism that we're considering. The emphasis has shifted from what we are doing to how we are doing it, and how we can show that we've met the various pre-determined targets along the way. In a system that has no values to guide and drive the professionals who run it (such as the NHS today), it is inevitable that the increasingly powerful managers will impose control protocols and log frames that demonstrate whether or not their agenda is being met. Not all of this is necessarily a bad thing, and medical conditions (such as diabetes) where clear evidence exists about what constitutes effective practice in terms of reduced morbidity and mortality clearly benefit from well-organised and structured care. Patients stand to benefit from a well-organised diabetic clinic with evidence-based protocols more than from a disorganised one without such protocols and Christians have no problems complying with that.
However, there are problems in imagining that something as complex and variable as medical practice can be controlled and regulated so tightly that every last decision and action of the professionals within the service can be determined. It's the patient as a person made in the image of God, with their unique problems and situation, to whom the doctor is responsible. If they don't happen to fit the latest protocol or guideline, the doctor as an independent, compassionate and skilled physician will take such action as he or she believes to be in the best interest of the patient, whatever the protocol says. This I believe is an important freedom for doctors working in any health care system, and there is some risk that present trends in the post-modern NHS will threaten it. As Christians we must remain responsive to the true needs of individual patients and act like the highly educated professionals we are, not as servants of the state management systems that government seems to want us to be.
There are however positive aspects to all this change that I shall consider in closing. The loss of a unifying world-view and the values derived from it has led to a resurgence of individual spiritual searching, exemplified by (for example) the New Age movement, meditation, Eastern religions, numerous alternative therapies and various forms of counselling and psychotherapy. Rather than seeing these as a threat and ranting against them from the pulpit (as has sometimes happened), I believe Christians need to recognise the opportunities they may give. It is much more acceptable now to talk about personal spirituality than it was just ten years ago. The dominance of materialistic humanism has declined and the aching void that it gave rise to is driving many to search more deeply for personal meaning and truth. Thus it is possible to talk about God and prayer without automatically getting a cynical response.
Perhaps more than ever, the need for truly-patient centred doctors who listen empathetically to their patients' concerns and respond with compassion and skill, is paramount in the post-modern NHS. This will never diminish, whatever changes in the means of delivery of health care occur. It is here that a Christian doctor can continue to demonstrate the love of Jesus and remain the patient's advocate and friend, speaking up for those who are confused and marginalised by the sweeping cultural changes that society and the NHS is undergoing.
