IRISC

International Research Institute into Spirituality and Change

By a strange coincidence today, 31st May, is "Census Day" for the NHS in which Alan Milburn the Secretary of State for Health has invited patients staff and public to have their say in "creating a modern NHS fit for the 21st century". Leaflets, a website [1], public fora, Modernisation Action Teams, and high profile ministerial activity are part of a comprehensive strategy for change. The need for change is characterised as stemming from changes in technology and treatment, responding to the need for consistent high quality service across the country, and faster and more convenient services, and tackling the causes as well as the consequences of health problems [2].

The Prime Minister has set out five challenges that face the NHS [3]as it prepares to make best use of the four-year package of funding announced in this year's Budget:

Partnership - working together to ensure the best possible care - including the integration of health and social services, ensuring no unnecessary admission and that the stay in hospital is only as long as clinically necessary.

Performance - Further action to deliver the organisational and clinical performance and productivity desired: looking at measures of performance, quality standards, accountability.

Professions and the wider NHS workforce - the delivery of modern, flexible patient centred services: looking at education, training, incentives, management, working practices.

Patient care - looking particularly at response and waiting times, improvement of access, and patient’s rights.

Prevention - promoting healthy living, tackling variations in care, looking at particular issues such as cancer, heart disease and other major killers.

In order to address these challenges six Modernisation Action Teams have been established that draw together expertise from frontline health professionals, patients and user groups, academics, policy makers, and health care managers. The management of change and service provision is at the heart of this policy, and the stated focus is on transformation of how resources can be delivered to the patient. The Secretary of State has promised, "All our energy in the next few months will be to build commitment to change in all parts of the NHS, improving the quality of clinical care and the performance of the system as a whole" [4]

This continues Government policy under both recent administrations, which has focussed attention on changes in the management of the NHS. Soon there will be more changes to Primary Care Groups and the wider spread of Primary Care Trusts [5], which will probably lead to further changes in the organisation. There have been significant changes with the introduction of NICE (the National Institute for Clinical Excellence) [6] and the Commission for Health Improvement [7]. Perhaps less often seen apart from high-profile advances, there have been great changes in practice as well. Over the last few decades there have been substantial reductions in the number of acute and particularly psychiatric beds available [8].

In the case of acute patients, even with fewer beds (average change 1985 -1998 2.3% annual reduction) , many more patients have been treated (average change 1985 -1998 1.4% annual increase {130 thousand increase}) , with a massive rise in day case surgery (average change 1985 -1998 8.7% annual increase {232 thousand increase}) [8]. Some of this change has been achieved through changes in clinical technique. For example a hernia might have involved an operation followed by several weeks in hospital when the NHS came into being, by the eighties it would have reduced to about five days in hospital, now it may be a day case. Less invasive techniques, and an emphasis on mobility have made such changes possible. Further impetus to this type of change has been given by well-publicised financial constraints.

In the case of psychiatric patients, (beds reduced by an annual average of 4.8% 1985-1998) an emphasis on community care and shorter treatment periods (in the same period inpatients increased by 1.4% annually, outpatients by 2.8% and day case attendance by 3.1%) [8], coupled with a greater range of drug therapies has enabled conditions to be stabilised within a month, or even without hospital treatment. There is a much greater use of treatment and care within the community. Partnership and performance are seen to be at the heart of the achievement of better health. [9] The pattern of both psychiatric and acute care has been towards shorter and more intensive treatment - and as an aside at this point, this has implications for spiritual care as well.

The current trend is for control of treatment to move outside of hospital to Primary Care Groups or the new Primary Care Trusts.[10] The future impact of this pattern is not clear. However it is likely to put increased stress on staff to make more intensive and "cost-effective" use of resources. It could well further increase the role and responsibilities of managers at a more local level in the provision of medical care, possibly further diminishing the traditionally imperial role of the consultants within the hospital, already somewhat eroded by previous reforms. It seems clear that today’s consultation is intended to continue and possibly speed the present pattern of change.

It is difficult to predict how this will affect medical practice. Before the "scientific" approach to medicine, much of medical practice involved listening to what the patients had to say and using very simple and sometimes ineffective treatments to try to relieve the symptoms. Present medical practice is less dependent on what the patient says, and more dependent on technological investigation, to indicate an underlying pathological problem. The clinical staff then treat this pathological problem.

This approach has shown remarkable success in the control and treatment of acute infectious diseases (although there is some evidence for improvements even before the drug therapies due to improvements in public health and general standards of living [11]). There is evidence of some success with chronic disabling disorders as well. The very success of these approaches has led to people living longer. (see also projections by government actuaries [12])

However, as people live longer, they tend to need further medical intervention and older people are now the largest single group of users in the hospital. This success has also prolonged the life of those with chronic disabling disorders (e.g. some cancers, stroke, renal disease, breathing problems, etc.) as well as those with genetic disabilities. These populations would have been amongst the most susceptible to acute infection. Long term this prolonging of life can have a profound effect upon the person and their family. In many cases, medical intervention is palliative - dealing with or controlling the rate of worsening of symptoms, rather than offering a long-term improvement. The social and emotional (and sometimes financial) cost to the individual and their family can be high.

In many areas, in particular poorer ones, a considerable proportion of the population may have conditions severe enough to interfere with daily life. [13] Areas with a high ethnic population can show both positive and negative variations in the incidence of particular conditions. Some of this can be explained by genetic factors, more by behavioural factors (smoking, diet, exercise, alcohol) others by social factors (housing, poverty, education, occupation) and some by emotional factors (love, self-esteem, hope).

The model that influences our understanding of this is a scientific problem-solving approach. Norms are established, needs and diseases are identified, procedures and therapies are used to optimise the outcome. Such a model is often unquestioningly implemented. A few people such as Foucault and Illich have questioned this as a medical construction [14], but in the main its remarkable pragmatic success in some areas, e.g. acute infectious disease and improved surgical technique, have left it unassailed.

However the model is left with a major difficulty. Its success has vastly increased the quantity of life for each individual. But such success is not easily transferred to the quality of an individual’s life, and the way it affects those in relation to the individual. In particular, the focus of professionals working with the patient can be on treatment of a particular condition or set of conditions and the wider needs can be left unmet.

Mark Cobb and Vanessa Robshaw [15] begin to grapple with this question (e.g. on pages 10-11 of The Spiritual Challenge of Health Care where they look at the requirements for different specialists. They talk of the need for ordinary sympathy and recognition of concerns above and beyond the specific symptoms - including "suffering, pain of more than a physical nature, relationships with family and friends in a state of illness ..." And ask for the training and practice of all health care professionals to reflect the need for spiritual care to be wider than just the premise of the chaplain. However I think there is a fundamental flaw in their discussion in that they fail to question the model which lies at the basis of this thinking.

The emphasis in this model is on problem and solution, need and achievement, patient and professional. The simplicity of this is appealing. The chaplain can get drawn to imitate the model by for example initiating a Spiritual Needs Assessment as discussed by Mark Cobb [16]. The chaplain as well as other professionals can too easily get drawn into this way of thinking. (S)he can press for spiritual needs to be assessed along with physical, social and psychological needs. Goals can be set and implemented. Effects can be evaluated. In all this the person can be lost. In trying to treat a particular (in this case, spiritual) aspect of the individual, the focus can be reduced to specific religious or cultural needs which can be processed and controlled by the appropriate professional like any other need.

As Mark Cobb rightly points out a drawback of this approach is that a focus within spiritual care on efficiency and effectiveness is in tension with the subjective and experiential needs that make the spiritual care significant. The routine and the impersonal may be rational and manageable, but caution is needed if we think that by their application we can approach the needs of unique individuals.

One reason for the inadequacy of this approach as Janet Bellamy [17] points out (The Spiritual Challenge of Health Care p188) is its reliance on linear thinking. The problem solving approach regards the self as a collection of needs, which can be allocated to a series of particular professions who are in business to meet them. The emphasis becomes the professional giving specific support to the patient to meet a specific need. Several professionals may be involved meeting different needs. Multidisciplinary approaches may well be a source of additional stress to the professionals involved, as they may require some co-ordination and unification of approach.

It is often much easier for the professionals to pay lip service to a truly multidisciplinary approach. Technical skills are passed from one generation of professionals to the next within fairly strict professional groupings and limits. People feel most at ease with those needs they have been trained to deal with. This is in tension with the wide recognition that they are treating not just a condition or a disease, but a unique individual in their care. In my own area, a chaplain cannot offer spiritual care divorced from the patient’s natural concern about improvement in their physical condition.

Certain government initiatives (such as the Calman-Hine Report [18] and accreditation of cancer care services) have put a greater emphasis on multiprofessional working and co-operation between hospitals, hospices and community care. This can serve to promote a holistic vision of the patient, because its goal is a comprehensive understanding of human health. One difficulty of this task is highlighted by problems already experienced in accreditation, where the system has already had to be streamlined in order to deal with its very comprehensiveness. There may, however, be a more profound difficulty at the root of this. While I do not wish to devalue the great advantages of improved co-operation, it may be that a comprehensive understanding of health care cannot be built up from understanding the individual aspect of health that we treat at the moment.

Medical care may be promising more than it can deliver. Society may be looking the wrong way to find a solution to the needs it identifies within health care. People expect that clinical skill will deliver health and longevity, but even if that were acheivable, it does not mean that medicine can or should be able to address the fundamental questions of meaning, purpose and hope that are involved in the holistic vision.

Hauerwas [19] suggests that insight may be gained by remembering that the doctor’s "basic pledge is not to cure, but to care through being present to the pain". Yet the pain and the vulnerability that being present causes to the professionals involved can be intense. Some collude with the prevalent belief invested in their skills and progress, and find relief from the stress by concentrating those skills on patients more amenable to treatment.

But where do these somewhat random selections and observations lead us? We have looked at changes in management and technology that lead to substantial reductions in the time spent in hospital for many procedures. There is a much more rapid turnover of patients, a more efficient use of beds. The effects on both staff and patients can lead to an increase in stress. The impact on spiritual care is that it is often response to a crisis, and the possibilities of care over a longer period are much reduced. The higher demands of staff mean that they are often unable to offer the individual relationship they would like to foster, and both staff and patients can feel isolated from a truly caring environment. The present challenges given to the NHS suggest that this trend is set to continue.

Reflection and self-awareness about the prevalence of the problem-solving approach is the basis for this account of the values that shape medical care. But I step into this debate from where I stand. A trained scientist, yes, but one who enters this debate with commitments and convictions in line with the Christian tradition in which I now minister. I hope that I enter the debate as a rational agent, open to views other than my own. But as van Huyssteen [20] says it does not follow that rationality will lead to consensus as to what should be done. It is possible to be rational and hold quite different convictions from another rational being. As Kuhn [21] has pointed out we can function quite successfully on the basis of beliefs that we later reject as false, indeed this is normative in the development of science. Rationality can facilitate our cross-disciplinary conversation, but change in commitments and convictions is much more like a leap of faith. The census day today and the thrust towards modernisation are looking for that "leap of faith" or paradigm change within the NHS.

The necessarily finite experimental and interpretative nature of medical knowledge does not, I believe, allow us to uncritically extend its application to the pursuit of the Holy Grail of perfect health. However energetic the Action Teams, there will still remain intractable areas. A consequence of the mortality with which we were created is that health can only be maintained until a certain point. At the same time a plausible religious or philosophical solution to the ontological question may not be of much help to someone at a time of crisis, let alone help someone else contribute to their holistic well being. Nuanced views of the limits of enquiry for particular approaches may help us to move away from false certainties, but a singular broader and more complex way of understanding may not prove a firm foundation either. There is a legitimate diversity to our beliefs and commitments, and a legitimate diversity to our understanding of and response to changes in health care practice. If the Action Teams take this seriously, then they could find that their task is much wider than those who established them intended. My hope is that an open, rational, genuine, interdisciplinary conversation may be creative in allowing society as a whole to discover and agree appropriate directions in which to channel these changes, and I would encourage us all to engage with this endeavour.

(1) The National Plan for the New NHS http://www.nhs.uk/nationalplan/

(2) The National Plan for the New NHS : The Need for Change http://www.nhs.uk/nationalplan/needforchange.htm

(3) The National Plan for the New NHS : Challenges facing the NHS http://www.nhs.uk/nationalplan/challenges.htm

(4) The National Plan for the New NHS : Executive Statement

(5) The New NHS Modern and Dependable The Stationary Office 1997 eg "3.18 Primary Care Groups comprising all GPs in an area together with community nurses will take responsibility for commissioning services for the local community. This will not affect the independent contractor status of GPs. The new Primary Care Groups will replace existing commissioning and fundholding arrangements. All Primary Care Groups will be accountable to Health Authorities, but will have freedom to make decisions about how they deploy their resources within the framework of the Health Improvement Programme. Over time, Primary Care Groups will have the opportunity to become freestanding Primary Care Trusts". Web:- http://www.official-documents.co.uk/document/doh/newnhs/newnhs.htm

(6) NICE homepage http://www.nice.org.uk/index.htm

(7) Established by The New NHS Modern and Dependable The Stationary Office 1997, Web:- http://www.official-documents.co.uk/document/doh/newnhs/contents.htm

(8) The Government Expenditure Plans 1999-0 to 2000-1 The Stationary Office 1999. Web:- http://www.official-documents.co.uk/document/cm42/4215/4215.htm Details in Table 5.15: Hospital and community workload statistics :- 

(9) Saving Lives: Our Healthier Nation The Stationary Office 1999. Web:-http://www.official-documents.co.uk/document/cm43/4386/4386.htm

(10) The New NHS Modern and Dependable The Stationary Office 1997, chapter 5 Primary Care Groups Web:- http://www.official-documents.co.uk/document/doh/newnhs/wpaper5.htm

(11) Saving Lives: Our Healthier Nation The Stationary Office 1999. Chapter 2 The causes of ill health Web:- http://www.official-documents.co.uk/document/doh/ohnation/ohnch2.htm

(12) Population Predictions Government Actuaries Department 1998 figures Web:- http://www.gad.gov.uk/population/1998/england/pop5yeareng98-08.html#all

(13) Saving Lives: Our Healthier Nation The Stationary Office 1999 Chapter 4 Communities, tackling the wider causes of ill health. Web:- http://www.official-documents.co.uk/document/cm43/4386/4386-04.htm

(14) eg The Birth of the Clinic Michel Foucault Routledge 1997 (ISBN 0-415-035957-6) [Foucault ollks at language and documents how medicine is constained by the needs and models of clinics and doctors], and Limits to Medicine - Medical Nemesis: The Expropriation of Health Ivan Illich Marion Boyars 1995 (ISBN 0-7145-2993-1) [He talks of pathogenic medicine eg p 32-4 of clinical, social and cultural iatrogenesis causing illness]

(15) The Spiritual Challenge of Health Care ed Mark Cobb Vanessa Robshaw Churchill Livingstone 1998 (ISBN 0-443-05920-9) Introduction Body and Soul Mark Cobb and Vanessa Robshaw

(16) The Spiritual Challenge of Health Care ed Mark Cobb Vanessa Robshaw Churchill Livingstone 1998 Chapter 8 Assessing Spiritual Needs: an examination of practice p105-118 Mark Cobb

(17) The Spiritual Challenge of Health Care ed Mark Cobb Vanessa Robshaw Churchill Livingstone 1998 Chapter 13 Spiritual Values in a Secular Age p183-197 Janet Bellamy

(18) A Policy Framework for Commissioning Cancer Services A Report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales Guidance for Purchasers and Providers of Cancer Services April 1995 Department of Health November 1996 Web:- http://www.doh.gov.uk/pub/docs/doh/cancerfr.pdf

(19) Suffering Presence Theological Reflections on Medicine, the mentally handicapped and the Church Stanley Hauerwas T&T Clark 1988 p 78-79 (ISBN 0-567-29142-1)

(20) Rethinking Theology and Science Six Models for the Current Dialogue ed Niels Henrik Gregersen and J Wentzel van Huyssteen William Eerdmans 1998 (ISBN 0-8028-4464-2) chapter 1 Postfoundationalism in Theology and Science: beyond Conflict and Consonance J Wentzel van Huyssteen p31

(21) The Structure of Scientific Revolutions Thomas S Kuhn Chicago 1996 (ISBN 0-226-45808-3) chapter 9 The Nature and Necessity of Scientific Revolutions p92-110

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