A theologian thinks about the NHS

I think perhaps more theologians should be thinking and talking about the NHS – not about ‘healthcare’ in general but about the specific possibilities, insights and challenges within this institution – an institution that is often described as (something like) a national religion, and in any case is a significant site for thinking about and living out some of our harder questions about human life. 

I’m presenting some initial reflections as a series of theses, in three groups, some with explanations. I do not think that the claims I am making here are all empirically testable; they are ways we might see the world. They are deliberately not framed in theological terms, but there is at least some theology going on in the background. I do not think that it is necessary to accept any particular theological position in order to accept or work with the theses.

The immediate trigger for the reflections is the NHS-based #LearnNotBlame campaign; nothing here has been endorsed by, or reflects the views of, anyone but me.

  1. People. 

People have limits, and they reach their limits

The NHS exists in the first place because of human limits – illness and injury and frailty, birth and death. It deals with the needs that our embodied limits create. The limits are not just something we know about theoretically, like the boundaries around a space that we might never choose to explore, or the limits to my abilities that I might never choose to test; in the case of illness, injury frailty, birth and death, we reach our limits, or are brought up against them. We rely on the NHS when we reach (some of) our limits. Much of the power of the NHS vision – of universal healthcare – is in the fact that we all have these limits and we will all at some point reach them.

We can’t predict and foresee all cases of people ‘reaching the limit’, but we can predict and foresee a great deal, both for individuals and for populations; that is how the NHS is able to work.

The people who work for the NHS are also people who have limits and will, at various points, reach them. A system that treats people as if they never get ill, or never suffer injury or exhaustion, or are never affected by birth and death – and that ignores the obviously predictable and foreseeable routes by which these limits can be reached – is based on a lie and will fail.

People live by depending on each other. Relationships of trust are not optional extras in human life. Nor are relationships of care.

Not only when we reach our limits – but definitely when we reach our limits – we depend on other people. We always begin, and often end, our lives by depending on other people to do more or less everything for us. Being dependent on other people – to the point of being forced to trust other people with our lives – is not an unusual, strange or problematic condition; it is a normal feature of being human.

Even when there is no one person whom I am forced to trust with my life, I trust innumerable people, most of whom I’ve never met and most of whom I won’t even know about, with things that are extremely important to my life. Giving and receiving trust is like the in-out breath of human life with others; we generally don’t think about how it works, we just do it automatically, and we don’t even notice it until it becomes particularly difficult.

People brought up against their limits are in need, not only of the practical support that keeps them going (which sometimes won’t be possible, because there are limits we can’t negotiate with), but of care; of being recognised, noticed, held and accompanied. That, again, is where we start our lives. Again, it’s part of the vision of the NHS; to care about and for each person in each particular limit-situation.

The people who work for the NHS are also people who live by depending on each other and are forced to trust each other, ordinarily and routinely, with extremely important matters. And, being brought to their limits in the course of their work, they need care; they need to be recognised, noticed, held and accompanied as the people they are.

People are bound to mess things up, sometimes catastrophically. People are bound to mess things up for each other, sometimes catastrophically.

What I’ve said so far is fairly uncontroversial and a matter of everyday observation. The claim that all people are bound to mess things up is more of a belief-statement, though I do find it a very persuasive one on the basis of everyday experience. It has most impact if we take it most seriously; people are not just limited (unable to work an indefinite number of hours without a break because they are human, not robots), people are also going to mess up even within their limits.

The world is such, and people are such, that I am going to do stupid, self-centred, lazy, power-hungry, prejudiced, ill-thought-out or mean things sometimes (as is everybody else). Moreover, because we all live by depending on each other, at least some of these actions will have consequences for others, and at least some of those consequences will be disastrously bad, and at least some of those bad consequences won’t be predictable. I’ll let people down, betray trust, fail to care, push people to the limit. Any truthful story about my life will include the very specific ways in which I mess up.

Each person’s life and story is important; and it always interacts with other people’s stories.

We’re a complicated web of dependence, and of mutual trust (and mistrust), and of reciprocal care (and failure to care); and although many of our needs and dependencies and limits and failures are predictable, each of us has a particular life and story that matters. The NHS originates with the desire to take each person’s life and story seriously, no matter what their roles or position in society – or within the NHS itself.

The most important story of anyone’s life is the story that begins and ends with care.

The NHS says: at the beginning and in the end, and at the limit-points along the way, we decide to extend care to each person: we decide, to the best of our limited and messed-up ability, to recognise, notice, hold and accompany them whoever they are. We say this is how human life is supposed to work.

We don’t know in advance what caring for each person will demand of us, although we can make some guesses. Care takes time.

 

  1. Systems. I’m just presenting this bit as a set of ‘theses’ about what we can and can’t expect (a system like) the NHS to do.

Systems help people to depend on each other with more predictability.

Systems are not going to make relationships between people fully predictable.

Systems are not going to overcome the limits that people have.

Systems are not going to stop people messing things up catastrophically (again), although they might be able to reduce and contain some of the consequences of people messing up.

In fact, systems have their own limits, and provide a whole new set of ways for people to mess things up catastrophically for each other.

Fortunately, systems aren’t the whole of life or the whole of anyone’s story.

Systems cannot care, but they can make space for care (by clearing the unimportant or predictable things out of the way as quickly as possible).

 

 

  1. Accountability.

Accountability is about telling the truth about how we mess things up (including, for each other).

We need accountability in order to tell, hear and learn from truthful life stories – to make each person’s life and story matter, as it interacts with other stories. And we need accountability in order to care and in order to make relationships of trust work.

The first reason to exercise accountability is to recognise, notice and hold the specific people involved – to care for and care about these people. It matters to be able to talk about what I did and what happened to you – even if there’s nothing more to be done about it – because our stories are important. The second, connected, reason to exercise accountability is to learn something about who we are and how we relate to each other; and to find ways to make these relationships work better.

Systems can help with accountability, within their own limits. Systems can’t do the relational work, the work of learning and of re-forming relationships, that makes accountability useful; the best they can do, and what they need to do, is hold open the spaces within which that work can happen.

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3 responses to this post.

  1. Thanks for this, Rachel; I found it thought-provoking. I’m a Quaker who does academic research in prisons, and what you have to say about systems and their limits rings very true for the way that systems operate in those institutions. Indeed, I think a lot of what you say has fairly general applicability, though prompted by the specific institution of the NHS. Can I ask if there is any particular reading which has influenced your reflections on systems and their limits? I’d be interested to explore some of these ideas some more.

    Reply

    • Hi Ben, thanks for commenting – and I’m glad you found this resonated with some of your experience. To be honest I’m finding it hard to identify specific recommended reading on this. Among other things, I was drawing on various debates in theology about the roles of states & other institutions that [at least some people would want to argue] are “good within limits”… Sorry not to be more help immediately, I will try to come back with more.

      Reply

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