Introduction
Nigel Lawson, a former Chancellor of the Exchequer stated in 1992 that: “The National Health Service is the closest thing the English have to a religion, with those who practice in it regarding themselves as a priesthood.” Thirty years on, little seems to have changed, and the National Health Service (NHS) remains an unquestioned dogma of the British media and political classes. It was noticeable how, during the December 2019 British general election, all political parties paid obeisance to this totemic issue, swearing that the NHS would only be safe in their hands, and all promising massive spending increases for this already huge bureaucratic institution.
The aim of this unit is to question this dogma, and to sketch out how we might rethink welfare. The focus will be on healthcare, which seems important in the wake of pandemic. It is also an area where international comparisons can be made. The unit will argue that the UK’s current highly centralised and bureaucratic welfare system is not, as is commonly asserted, an epitome of Catholic social teaching but indeed contrary to it. There is a brief illustration of how welfare worked in practice during the Middle Ages combined with a description of how we got to the current position in the UK. Lastly, the conclusion looks at a potential revival of the hierarchy of values as presumed by Newman, and recently revived by Alasdair MacIntyre.
Health and welfare in the UK
The first question that will be considered is whether, even in the purely instrumental terms in which these questions are normally discussed, the centralized UK model of healthcare is as good as is often claimed. UK government expenditure forecasts for the fiscal year to March 2024, are shown in table 12.1. The total spending includes categories that are not listed which make up the remaining 31 per cent of government spending. This includes categories such as debt interest and transport.
TABLE ONE – Planned UK government expenditure 2023-24
| Programme | Cost £bn | % of Total |
|---|---|---|
| Public Pensions | 204 | 18 |
| NHS | 221 | 19 |
| Social Security | 162 | 14 |
| Education | 109 | 9 |
| Defence | 80 | 5 |
| Internal security | 44 | 4 |
| Total | 1,145 | |
Most governments in the past would have been astonished that defence and the police, the core functions of government to provide internal and external security, amount to less than 10 per cent of total UK government spending. It can be further contended that the government monopoly of welfare and education, sustained by very high levels of spending, can lead to a kind of ‘systemic monoculture’ where the only thing that matters is meeting the government’s latest set of standards and underlying values are neglected. A good example of this might be the way hospitals have turned gardens into profit-making car parks, when all the evidence suggests that the presence of a garden has a significant positive impact and therapeutic value that tends to be neglected in the current system.
In the UK, healthcare provision is essentially the monopoly of the NHS. The NHS is a government agency which is one of the largest employers in the world with 1.4m staff. It is often declared to be the best healthcare system in the world. It is true that research carried out in 2017 by the Commonwealth Fund, a US think tank, ranked the NHS as the number one health system in a comparison with those of 11 leading economies. However, the Commonwealth Fund research was based upon five categories such as screening systems, speed of access, and equitable access ignoring income. The NHS fared badly on ‘outcomes’ such as cancer survival rates. Since one might feel that the successful treatment of major diseases is the primary purpose of healthcare, the relevance of a survey, such as that by the Commonwealth Fund, which only allocates 20 per cent of its methodology to outcomes, is surely open to question. By way of example, under the methodology of this study, a system that gave the same access to all people to a very low level of care would fare better than a system that provided a much higher level of care to everybody but where some people could access even higher standards.
The King’s Fund is an independent charity working to improve health and care in England. In May 2018 it produced a detailed report analysing health data from 21 OECD countries, and stated that the NHS was continuing to fall behind other comparable countries. In particular, it noted that the UK had around the lowest per capita numbers for doctors, nurses and hospital beds in the OECD. It concluded:
Although no one would argue that the UK should make decisions about health care based solely on these international comparisons, the consistency with which the UK falls short of other countries’ health care resources is striking. Dissatisfaction with the NHS is now at its highest level since 2007.[1]
Indeed, peer-reviewed studies of cancer survival rates show that England and Wales lag well behind the rest of Europe. It generally ranks 19th or 20th out of 29 countries, with lung cancer survival rates so poor that they are next to bottom, above only Bulgaria. In September 2019, the medical journal The Lancet published a study, based upon research on some four million patients in seven leading economies by the World Health Organization (WHO) carried out over 20 years. The study showed that patients in Britain had the lowest survival rates for five out of seven common cancers. It was ranked bottom for bowel, lung, stomach, pancreatic and rectal cancer; next to bottom for oesophageal disease; and third from bottom for ovarian cancer. Further, whilst all countries had seen absolute improvements in survival rates since the 1990s, the UK’s relative position was significantly worse than at the study’s inception, when it was bottom for three out of seven cancers.
A hundred years ago, the sociologist Max Weber argued that bureaucracies have a tendency to follow their own agendas of self-preservation and expansion, whilst increasingly ignoring the purpose for which they were originally established of helping others. Does the NHS fit Weber’s criticism? In December 2019 the OECD produced an international study showing that British GP partners now earn more than three times as much as the average UK employee, so that the UK ratio of doctors’ pay to average earnings is amongst the highest in the world. Yet there was growing dissatisfaction among patients in the UK with the amount of time they were given for appointments, with Britain lagging in the bottom half of the league table. The study also showed that the UK had the second lowest number of doctors in Europe compared with its population – overall 2.8 doctors per 1,000 people, compared with an OECD average of 3.5 doctors per 1,000.[2]
There is also evidence of weak accountability in the system. For example, for several years there had been public complaints alleging poor care at the maternity unit of the Shrewsbury and Telford Trust, with the Health Secretary ordering an inquiry in 2017 following concerns about infant deaths. Nevertheless, the Trust was awarded £1 million by NHS Resolution for good maternity care in September 2018. Within a few weeks of this award, however, the independent regulator, the Care Quality Commission (CQC), rated the trust’s maternity care as ‘inadequate’ and, by December 2019 CQC reported that services at the midwife led unit at the Royal Shrewsbury Hospital were suspended.[3]
The NHS and the COVID pandemic
In this section, there is a brief discussion of how the UK has done compared with other countries in coping with the Covid-19 pandemic – obviously a thorough analysis would require a paper of its own and a final verdict will not be possible for a number of years. The initial public response certainly confirmed Lawson’s point about the NHS as a state religion. The British public were exhorted to come out into the street every Thursday evening at 8pm and Clap for Heroes, i.e., NHS staff.
The government promoted the slogan “Protect the NHS!”. This was little questioned by the British media. It was only the foreign press that objected that the slogan was the wrong way round: i.e., that it was the job of the health service to protect the public, not vice-versa. Likewise, stringent criticism tended to only be made overseas. The lead headline of the Australian Sydney Morning Herald (3rd May 2020) was “Biggest failure in a generation: Where did Britain go wrong?” The article quoted Dr Richard Horton, editor in chief of The Lancet: “The handling of the Covid-19 crisis in the UK is the most serious science policy failure in a generation.”
The following facts are especially pertinent:
- When the pandemic broke out, hospitals were advised to discharge elderly patients back into care homes even though it quickly became that clear that Covid mortality rates were much higher in the elderly. There were 28,186 excess deaths recorded in English care homes from 2nd March to 12th June 2020, 18,562 of which were attributed to Covid.
- At the same time, the NHS found its stocks of personal protective equipment (PPE), such as breathing equipment and face masks for front-line healthcare workers, were not fit for purpose. This led to an extremely expensive global scramble to find PPE whilst NHS staff were left poorly protected.
- When the government decided to make ‘track and trace’ a key policy objective, NHS England adopted a plan based upon centralising testing in its own facilities, rejecting the use of private sector laboratories as had been used in Germany. This proved impossible to do at scale, and the whole track-and-trace system had to be redesigned again from the beginning, with valuable time having been lost.
- One of the key metrics in judging the healthcare system’s effectiveness in controlling the pandemic was that of excess mortality. There were nearly 697,000 deaths in the UK in 2020, 85,000 more than would normally be expected based on statistical patterns. In May 2020 the European Centre for Disease Prevention and Control (ECDC) produced a “z-score” to compare excess mortality rates across countries, taking into account factors such as population size and pre-existing mortality issues. The higher the z-score, the higher the number of excess deaths, with a score higher than z15 classified as ‘extremely high excess’. Peak excess z-scores in spring 2020 were: 44.1 in England, 34.7 in Spain and 22.7 in Italy.
The UK’s poor performance in tackling the Covid pandemic was all the more surprising given that the British state imposed greater restrictions on individual freedom than any other major economy. Table two rates countries 1-100 (100 being the most stringent), taking into account workplace and school closures, restrictions on public gatherings, international travel controls and stay-at-home requirements, among others.
Table Two –Lockdown stringency index
| Country | % |
|---|---|
| US | 45 |
| France | 64 |
| Australia | 65 |
| Italy | 82 |
| Germany | 83 |
| UK | 86 |
Source: University of Oxford, Blavatnik School of Government Response Stringency Index
Table three summarises the economic and medical consequences of the pandemic in 2020. It is limited to the world’s leading seven economies, the so-called ‘G7’. It uses data produced by the OECD in December 2020, as well as data produced by the United Nations for the Covid death-rate per 1 million people in each of the G-7 countries as at 20th January 2021.
Table Three: Impact of Covid-19 on G-7 countries 2020
| Country | 2020 GDP change | Covid 19 death rate per 1m population |
|---|---|---|
| Canada | -5.4% | 491 |
| France | -9.1% | 1,102 |
| Germany | -5.5% | 609 |
| Italy | -9.1% | 1,394 |
| Japan | -5.3% | 38 |
| UK | -11.2% | 1,389 |
| US | – 3.7% | 1,266 |
Sources: GDP OECD World Economic Outlook Dec 2020
Death Rate: United Nations Data January 2021
The table shows that the UK had by far the worst economic contraction, with the economy forecast to decline by 11.2 per cent combined with the joint worst deathrate (that is, similar to Italy).
The NHS did have one undoubted positive achievement – fast and effective mass vaccination. However, it is telling that this was accomplished by the government establishing an independent Vaccination Taskforce, outside the normal NHS operational structures. It was led by Kate Bingham, a venture capitalist with particular expertise in medical companies, with other leaders recruited from the private sector, the voluntary sector and the army. It also used many staff from general practice which is the one part of the NHS which operates semi-autonomously with GPs generally being self-employed and being partners in their practices. The Vaccination Taskforce had the following achievements:
- It took entrepreneurial risks by identifying a number of the most promising vaccines in the summer of 2020, when it was not known whether any of them would work, and making legally binding purchase orders on a massive scale.
- It ensured that large-scale pharmaceutical manufacturing facilities were available to make these vaccines in the UK, so that other countries such as those in the EU could not divert them to their own populations.
- With the help of the army logistics team, it set up a large-scale and effective mass inoculation system.
Nobody denies the skill and dedication of front-line NHS staff who worked tirelessly to try and save lives in difficult conditions and at the risk of their own lives. But it can certainly be argued that the system in which they are working in has let them, and us, down. The success of the Vaccination Taskforce shows that effective leadership, and a system permitting it to function, is what is required.[4] We do have limited data and the analysis here is insufficient to draw strong conclusions. However, it can certainly be said that there is no evidence that the NHS has performed better than other forms of health provision and there would seem to be a prima facie case that it has performed relatively poorly.
Welfare and Catholic social teaching
Let us move on and examine the guidance given to us by Catholic social teaching on welfare issues. The Second Vatican Council of the early 1960s, which renewed the working of the Catholic Church, calls upon people to work together for the ‘common good’. This was defined, for example in Gaudium et spes: “The common good, that is, the sum of the conditions of social life which allow social groups and their individual members relatively thorough and ready access to their own fulfilment.” (26)
That the Church should take care of the poor and sick is highlighted in paragraph 42 of the same document: “When circumstances of time and place create the need, (the Church) can and indeed should initiate activities on behalf of all men. This is particularly true of activities designed for the needy, such as the works of mercy and similar undertakings.”
It is striking how the first great Catholic social encyclical, Rerum novarum (published in 1891) contains much material on how a Catholic alternative to state welfare provision might be constituted, although this is often ignored by commentators. In paragraph 36, it strongly endorses the establishment of mutual self-help groups: that is, workplace institutions which offer help to those in need, such as relief to these who cannot work through illness or injury or those left widowed. The document reminds us of the medieval guilds which offered such support: “History attests what excellent results were affected by the Artificer’s Guilds of a former day…such associations should be adapted to the requirements of the age in which we live.”
However, it also notes (39) that the Church has created charities and facilitated alms-giving throughout its history but warns that these bodies have been appropriated or ‘nationalised’ by governments, a theme to which we shall return: “In our own times, the State has laid violent hands upon them, taken away their rights as corporate bodies, and robbed them of their property.”[5]
Two principles seem particularly relevant when examining welfare issues. The first is Christian anthropology, the point that the Church’s understanding of humanity is based upon the person defined in relation to others and fulfilled through small associations. The second is subsidiarity, the principle that decisions should be taken by the lowest and most local level, rather than by a central authority.
The most basic principle of Christian anthropology, following Genesis, is that man is made in the image of God – imago dei. Hence the teaching repeatedly reminds us that “individual human beings are the foundation, the cause, and the end of all social institutions” (Mater et magistra, 219). Indeed, Gaudium et spes bases the idea of the ‘common good’ on the nature of the person:
For the beginning, the subject and the goal of all social institutions is and must be the human person, which for its part and by its very nature stands completely in need of social life. This social life is not something added on to man. Hence, through his dealings with others, through reciprocal duties, and through fraternal dialogue he develops all his gifts and is able to rise to his destiny. (25)
It is important to stress this point. The human person is the starting point for the Church’s social teaching. We have freedom so that we may be capable of love. To be a person, to be called to love, implies that we are also part of a society. There is a further point: persons do not exist in isolation. To be a human person is similarly to be part of a society, beginning with the family into which one is born. To love others is to serve them, to do them good. And in working to fulfil ourselves and each other, we work together: hence the repeated advocacy of ‘small associations’. The importance of small associations reflects the limits of a human person – we cannot possibly have deep relationships necessary for active service and love with large numbers of people.
Hence it is important to keep in mind the distinction between the person, defined in relation to others, and the individual, defined in isolation from others. Individuality is what marks somebody from everybody else: in its essence it is a principle of division or even isolation. Personality on the other hand is social, and it is only in social relationships that someone can be a person. The richer the personal relationships, the more fully ‘personal’ someone will be.
Probably no Pope has done more to develop the Church’s social thinking than Pope John Paul II who wrote three great encyclicals on the subject. Gregg (1999) shows how, through his intellectual life, John Paul II consistently expanded and deepened Catholic social teaching’s understanding of human anthropology as a major foundational theme. Humanity is the conscious subject of moral acts, but, at the same time, it is also a person, the imago dei, a creature who possesses the spiritual properties of reason and free-will. “It is these attributes of personhood which endow the human subject’s work-acts with their creative character and moral-spiritual significance”, Gregg argues (p. 218). Gregg further comments, that a fundamental error in much modern thought lies in its propensity to conceptualise humanity in materialistic terms – a faulty anthropology of man:
John Paul’s development of social teaching underlines a central point for anyone who wishes to study and/or develop Catholic social thought in a way faithful to authoritative teaching…(that) is profoundly anthropological in its orientation, in as much as it stresses that everything must be considered in terms of what man really is: a fallible spiritual creature called to an other-worldly destiny; a chooser; a knower; and the subject of moral acts, alone and in association with others. In this sense, John Paul’s teaching may be understood as constituting a call for Catholic social thinkers to ‘return to the person’, and ground their thoughts in a correct anthropology of man. (p. 231)
Gregg’s book was published six years before John Paul II’s death in 2005. But his insights are confirmed by what the Pope said himself on this topic in his last book, Memory and Identity, about the need for authentic freedom and a true anthropology: in particular, see Chapter 7, ‘Towards a Just Use of Freedom’, and Chapter 18, ‘The Positive Fruits of the Enlightenment’.
The concept of subsidiarity was first explicitly developed by Pope Pius XI in Quadragesimo anno, the encyclical commemorating the fortieth anniversary of Rerum novarum in 1931. However, the basic idea of restricting state power as much as possible is already found in Rerum novarum, particularly 9-10 on the primacy of the family as compared with the state, and 28-29 on the role of government. Quadragesimo anno defines subsidiarity thus:
Just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community, so also it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher association what lesser and subordinate organizations can do. For every social activity ought of its very nature to furnish help to the members of the body social, and never destroy and absorb them. The supreme authority of the State ought, therefore, to let subordinate groups handle matters and concerns of lesser importance, which would otherwise dissipate its efforts greatly. (79-80)
Gregg (2014) also discusses why Catholic social teaching implies limited government. In particular the principle of subsidiarity confers upon people the moral autonomy necessary if people are to freely make moral choices. Further, given that persons reach fulfilment through relationships with other people, then it affirms the priority of the family and other local associations above the state. Booth (2014, 40, 41) makes the following, related, observation:
The market economy appears much shallower than it really is, or should be, because of the expansion of the remit of the state…For over 90 per cent of the population decisions in relation to healthcare and education are taken by the state…We should ask whether taking away responsibility from families for essential services such as education, healthcare, savings, insurances and housing actually undermines the development and flourishing of the human person.
Responsibility and virtue
In his influential book After Virtue (1981), the moral philosopher Alasdair MacIntyre argued that in the modern world: ‘The language of morality is in a state of grave disorder…We have – very largely, if not entirely – lost our comprehension, both theoretical and practical, of morality’. (p. 2) His point was that, whilst modern society continues to use moral language, it does so in ignorance of the traditional understanding of the meaning of moral concepts. Therefore, the language is used in defiance of its normally understood universal applicability. MacIntyre contends that, while there is intense public and private debate about the ethical issues of our time, such as the morality of going to war, or access to education or healthcare, these debates are ‘interminable’: that is, they never come to a conclusion, since their apparent rationality is false. McIntyre concluded that the only way to have productive discussions about healthcare, for example, was to return to the ancient concept of the virtues, as developed by the Ancient Greek philosopher Aristotle, and expanded and integrated in Catholic thought by Thomas Aquinas. This is, in my opinion, a hugely important point, and one that, from the point of view of Catholic social teaching, deserves to be more widely understood.
Aristotle used the term ‘phronesis’ (φρονησισ) to mean ‘practical wisdom’. This is a type of skill which can be acquired through good education, and which guides a person to analyse and make an accurate judgement about the right thing to do in a particular situation. It is also called ‘practical virtue’ and its practice will lead to a development of a morally good character. I wonder if the colossal impoverishment of our moral thinking, which MacIntyre describes, may not, in part at least, be due to the fact that the need to exercise phronesis, in many of the most important parts of our lives, has been taken away from us.
In other words, areas such as the care of the sick and the aged, help for the poor and the education of our children are, in the UK, overwhelmingly the monopoly of a rigid, bureaucratic state which leaves us, morally speaking, in a state of undeveloped infantilism: there are no meaningful decisions for the individual to take. If this is so, it would imply that the modern bureaucratic state impedes human flourishing or the ‘common good’ and is therefore in conflict with Catholic social teaching. This is not a point commonly found in Catholic social teaching exegesis. However, consider Centesimus annus (48):
In recent years the range of such intervention has vastly expanded, to the point of creating a new type of state, the so-called ‘Welfare State’…excesses and abuse, especially in recent years, have provoked very harsh criticisms of the Welfare State, dubbed the ‘Social Assistance State’. Malfunctions and defects in the Social Assistance State are the result of an inadequate understanding of the tasks proper to the State. Here again the principle of subsidiarity must be respected: a community of a higher order should not interfere in the internal life of a community of a lower order, depriving the latter of its functions, but rather should support it in the case of need and help to coordinate its activity with the activities of the rest of society, always with a view to the common good.
And we can relate this to paragraph 13 of the same encyclical:
Socialism likewise maintains that the good of the individual can be realized without reference to his free choice, to the unique and exclusive responsibility which he exercises in the face of good or evil. Man is thus reduced to a series of social relationships, and the concept of the person as the autonomous subject of moral decision disappears, the very subject whose decisions build the social order…This makes it much more difficult for him to recognize his dignity as a person, and hinders progress towards the building up of an authentic human community.
Pope John Paul II was writing about the general principle of socialism here, but would the point not apply to those parts of our lives where decisions have been socialised, such as healthcare in the UK, and, to a lesser extent, education? The fact that we are deprived of making moral choices guided by practical wisdom in these areas impoverishes us, in certain ways, as human persons.
Exponents of Catholic social teaching sometimes use the language of human rights, for example when advocating universal access to health-care. In my view we need to be very cautious about using such terminology, as human rights are essentially political. In the UK, in the formal sense, they date back to the Bill of Rights 1689, following the overthrow of the absolute Stuart monarch James II, which set out certain basic civil rights and laid down limits to the powers of the monarch. This, in turn, inspired the American Declaration of Independence in 1776, and the use of rights language reached global recognition with the UN Declaration of Human Rights in 1948.
The problem then arises that, since human rights are political devices, any question about human rights implies that the solution lies in political action through the government. This is not consistent with the Church’s social teaching. Indeed, the modern assertion, codified in law, of ‘rights’ to abortion, assisted suicide, and some sexual rights, are surely incompatible with traditional Catholic doctrine and in fact the magisterium has repeatedly clarified that what it means by human rights is very different from the modern secular understanding. For example, in Centesimus annus (47):
Among the most important of these rights, mention must be made of the right to life, an integral part of which is the right of the child to develop in the mother’s womb from the moment of conception; the right to live in a united family and in a moral environment conducive to the growth of the child’s personality; the right to develop one’s intelligence and freedom in seeking and knowing the truth;…In a certain sense, the source and synthesis of these rights is religious freedom, understood as the right to live in the truth of one’s faith and in conformity with one’s transcendent dignity as a person.
It is also striking that in After Virtue MacIntyre highlights the term ‘human rights’ as something which at first sight looks like an ethical concept, but which, in fact, is not. He argues that theories of natural rights lack the kind of clear criteria for their application which are standard in major religious and ethical theories such as Aristotle’s virtue ethics.
To conclude this section, it is worth quoting Fr Robert Sirico (Sirico, 2014, pp. 86-87) who argues that it is the sheer importance of welfare that requires us to challenge the current orthodoxy:
Many have come to believe that the only way to ensure a flourishing of such support is through an elaborate state apparatus…But the question as to whether these systems ought to be rethought entirely is hardly ever raised. We are at the first stages of considering a very radical question: whether the care of the poor ought to be treated in the same way that religion in society ought to be treated: that is, as something to be kept out of politics and immunised from political intervention, not because it is a lesser social priority but rather because it is of such high social priority that we dare not permit the state to dominate this area.
The mediaeval guilds
So how might we try and implement Fr Sirico’s suggestion of rethinking the current orthodoxy of state welfare provision? Rebuilding civil society would seem a good start, in particular by a revival of mutual self-help groups, inspired by spiritual values, which we might call by their old medieval name of ‘guilds’. Of course, we cannot return to the exact model of mediaeval guilds, any more than we can return to speaking Chaucerian English. Nevertheless, it is worthwhile summarising what those organisations achieved in this area.
Some people conceive the guilds as a kind of proto trade union; others conceive them as a kind of business cartel. Both ideas are anachronistic. Trades unions grew up as a mass movement, an essentially reactive phenomenon in response to the industrial revolution. In contrast the guilds were association of freemen, of craftsmen working together to sustain each other and, through apprenticeship and training, to ensure the quality of what they produced. They were not communes: each workshop was led by a Master who worked for his own profit.
Note however that the guilds had a variety of interlocking functions: religious, economic, mutual support, and works of charity. Indeed, it is important not to forget that the guilds were primarily religious fraternities, based upon a desire to sanctify their work, and to bring honour to themselves within the community as a religious brotherhood. In Religion and Rise of Western Culture Dawson (1950) noted:
One of the most remarkable features of medieval guild life was the way in which it combined secular and religious activities in the same social complex. The guild chantry, the provision of prayers and masses for dead brethren, and the performance of pageants and mystery plays on the great feasts were no less the function of the guild than the common banquet, the regulation of work and wages, the giving of assistance to fellow-guild members in sickness or misfortune. (p. 207)
One common aim of all guilds was to arrange prayers in their guild church, particularly for the souls of deceased members. Duffy (1992) writes about England on the eve of the Reformation in his book The Stripping of the Altars:
With some variations all late medieval guilds were modelled along the (same) lines – the maintenance of lights before images and the Blessed Sacrament, the procurement of attendance of the whole guild at funerals of deceased members, and finally the exercise of sociability and charity at a communal feast associated with the saint’s day. (p. 143)
Economists tend to be negative about the guilds, seeing them as cartel-like and bureaucratic obstructions to economic growth. This was true during the development of capitalist economies from the seventeenth century onward. (It is worth noting that guilds were essentially extinct in England by 1700 but lingered on in much of Europe until the second half of the nineteenth century.) However, the opposite was true during the Middle Ages. The guilds emerged in Europe simultaneously with the revival of towns and cities, around the year 1100, in a society that had very low population density, poor transport links and a small economic surplus over subsistence levels. It was also a world with little mechanical power, where most capital lay in training human skill, i.e., the seven years it took to train an apprentice to be a craftsman. In this situation, where trade was inherently local and small-scale, the guild system assisted in the efficient allocation of capital and restricted the growth of local monopolies. As economic historian Pollard (1981) put it:
Guilds, at first, had numerous functions that favoured progress. They organized the training of apprentices, preserved standards of skill and quality, guaranteed the integrity of its members and found them a market, and above all, freed them from feudal exactions and let them share in the town government…As the centuries passed however, the system which had once been progressive increasingly came to impose rigidity on the economy until ultimately it became a fetter on progress. (p. 59)
The guilds also promoted works of charity in a poor society where the destitute would otherwise have starved. These ranged from direct almsgiving, to the running of hospitals and schools. As Renard (1919) noted in Guilds in the Middle Ages, there was a genuine attempt to integrate the ideals of brotherhood into their economic role, with the ties of unity strengthened at regular intervals by guild feasts and banquets:
The merchant or craftsman found in his craft guild security in times of trouble, monetary help in times of poverty, and medical assistance in case of illness…Apart from the obligatory assistance at certain offices and at the funerals of its members, the fraternity owned a chest, that is to say a fund maintained out of the subscriptions and voluntary devotions of the members, as well as the fines which they incurred. (p. 42)
Hence the guilds were just one part of an interconnected system of Christian aid and welfare, linked as they were, to great churches and hospitals, the latter providing both alms and medicine in this period. However, while almsgiving was a major social function of the guilds, perhaps their most distinctive feature was that of a mutual self-help group. Indeed, the guild chest or fraternal treasury had a close resemblance to modern friendly societies, as there was not only help for when somebody was unable to work, but a pension for the infirm. As such they enabled ordinary workmen and their families to receive payment in case of sickness or old age. Indeed, the earliest known example of a pension scheme comes from the Guild of St James Garlickhythe in 1375:
If any of the forsaid brotherhood falls into such mischief that he hath nought for old age or able to help himself, and have dwelled as the brotherhood for 8 years and have done thereto all duties within the time, every week after he shall have of this common box 13 pence for the term of his life or he be recovered of his mischief.
Sadly, the wealth the guilds had accumulated attracted the attention of a greedy and self-willed king, Henry VIII, who confiscated their property at the Reformation. In the words of Scarisbrick’s The Reformation and the English People:
When the royal commissioners went out in 1546, and again in 1548 to survey the colleges, chantries, obit land, guilds and fraternities which the crown was about to seize, they were interested in institutions with permanent endowments of land and property – that was what the government was after. (p. 31)
A flourishing network of local hospitals, schools, and almsgiving was abolished. Henry VIII pledged to use the money to refound such institutions on a ‘purer basis’, but he totally failed to do so. Mediaeval England had some 500 hospitals, all of the assets of which were confiscated at the Reformation. However, as Whelan (1996, p. 3) observed, in The Corrosion of Charity, political influence saved the London hospitals:
Henry VIII promised to replace the monastic hospitals with other foundations, paid for by the government, but this promise remained unfulfilled. Only three of the medieval hospitals (which were as much for the care of the poor and the elderly as the sick) survived the Reformation to be re-constituted as secular organisations, all of them in London: St Bartholomew’s, St Thomas’, and Bethlehem (Bedlam). There was no further hospital building in London until the eighteenth century.
Bureaucratic incursion upon flourishing local initiatives
Earlier in this unit Rerum novarum‘s complaint about the state’s confiscation of Catholic charity foundations in the nineteenth century was noted. In the late nineteenth century this was particularly true of France and Italy, but, sadly, this is a recurrent feature of Church history. And history repeated itself yet again in the UK with the state’s nationalisation of local hospitals and, in effect, friendly societies in 1948.
Supporters of the current system of health provision rarely, if ever, seem aware that, when the current behemoth was created in July 1948, it replaced a vibrant, local, self-reliant system, though perhaps less brutally than 400 years earlier. Local initiatives which worked well had been abolished by force. Halsey (1986, p. 167) noted how ideology drove the abolition of local initiatives:
Democracy came to Britain from the bottom upwards. The urban working classes of the nineteenth century were uprooted newcomers to the growing provincial industrial towns who responded to their circumstances with extraordinary social inventiveness to give Britain in the first half of the twentieth century its most characteristic popular organizations – the co-operative store, the football club, and the Friendly Society. This urban proletariat created its own local, communal welfare societies…[But] the Labour movement dominated by the statist traditions of reform as propounded by the Webbs and the Fabians, set out to nationalize democracy and welfare; to translate fraternity, equality and liberty from the local community to the national state.
One of the fiercest supporters of top-down democratic socialism in Harold Wilson’s government of 1964-1970 was Richard Crossman. But, in 1973, near the end of his life, he lamented the way the Labour Party had replaced voluntary action by bureaucratic fiat:
From the 1920s on, the normal left-wing attitude has been opposed to middle class philanthropy, charity, and everything else connected with do-gooding…I am now convinced that the Labour Party’s opposition to philanthropy and altruism has done it grievous harm.’ (Crossman, 1976 p. 278)
As Green (1993) showed in Reinventing Civil Society, there was a flourishing independent network of free hospitals and friendly societies that provided insurance to their members, which were forcibly incorporated into the welfare state. Of the 3,000 or so hospitals existing at that date, 2,751 were taken over by the newly created government agencies or ‘health boards’. It is striking that the 70 Catholic hospitals were the one significant group which managed to stay independent from the proposed NHS. At that time Irish (Catholic) nurses formed a high proportion of nursing staff. It is believed that Cardinal Griffin managed to overcome the resistance of NHS Minister Nye Bevan, after an intense political battle, by threatening to discourage the arrival of new trainee nurses from Ireland if Catholic hospitals were nationalised.
Yet even those who share the above criticisms seem to be inhibited from putting forward positive alternatives, as Whelan (1996, p.1) observed twenty-five years ago:
The realisation that something has gone badly wrong with welfare is now accepted by almost all shades of the political spectrum, and the reform of the welfare state is being seriously canvassed. However, many of those who are fully aware of its defects still feel obliged to defend the welfare state out of fear of what would happen if it were to be circumscribed…this is to assume that the alternative to state welfare is no welfare.
Halsey (1986, p.171) comments on how we might move forward:
Weber saw only one escape from bureaucratic tyranny – a return to small scale. Subsequent writers following this line have been dismissed as proposing economic absurdity…but at least this type of response to the modern conditions of state power and manipulative social integration, with its recognition of the failure of emotional bonds in large impersonal structures of authority, points forward rather than backward to the possibilities of solidarity through democracy.
Ethics and medicine
In this debate about Catholic social teaching and the provision of healthcare, there is one final, and vital, point to be made. It is an issue identified by St. John Henry Newman over 150 years ago in a lecture to trainee doctors on ‘Christianity and Medical Science’. This lecture forms part of the final chapter of Newman’s Idea of a University (Newman, 1873). In this lecture, Newman warned his audience that, as doctors, they might quite legitimately make decisions based on their professional expertise, but which were illicit when looked at from a higher, moral or religious, level. He makes the point that, when there is political unrest, a general might recommend aggressive military intervention to suppress it which is logical from his own viewpoint. However, his political superior might reject this advice on the basis of his higher-level thinking of ‘statecraft’, to which military judgement is just one factor to be taken into account. A doctor taking decisions about medical interventions also needs to look to higher authority.
Newman goes on to give the example of a nun, also a nurse, who is urged by doctors to leave a place where plague has broken out. Their advice is medically sound, but if the nun, who has devoted her life to caring for the sick, decides to stay, being happy to risk her life in this way, her decision is a moral one at a higher level than the purely technical advice of the doctors. Newman states (chapter 10, part 3): ‘The medical man was right, yet he could not gain his point. He was right in what he said, he said what was true, yet he had to give way’.
He continues:
A patient is dying: the priest wishes to be introduced, lest he should die without due preparation: [but] the medical man says that the thought of religion will disturb his mind and imperil his recovery…I think the priest ought to have that decision, just as the politician, not the commander-in-chief, would have the decision, were politics and strategics to come into collision.
Newman is warning about the risk of what might now be called ‘managerialism’: in other words, the possibility that medical decisions are taken on a purely technical basis, with ethical and religious considerations being shunted to the sidelines. The horrific murder of Catholic MP David Amess in October 2021 is a case in point. A priest came to the scene to administer the last rites to the dying man, but he was prevented by police from doing so on the grounds that it was a crime scene.
This is always a risk in any profession, but one that is perhaps particularly apparent when medical treatment is essentially a government monopoly, and one that is therefore permeated by the implicit political ideology of the time. Religious viewpoints can sometimes seem to be seen as an irrelevant impediment to efficient and cost-effective medical care in such an environment. Furthermore, in such a monopoly, people are prevented from seeking institutions that would provide care in a way that accords with their conscience.
Newman’s thinking was reiterated by Cardinal Griffin in 1946 when he issued a public statement on the Bill to take over voluntary hospitals without compensation:
Voluntary hospitals should have the right to contract out of the scheme. Many of the voluntary hospitals in this country have been founded for a specific purpose. That is, to enable patients using hospitals to observe the customs and principles of their own faith. That is a vital issue in the treatment of disease and sickness where medical practice may sometimes conflict with the moral principles of patients. To secure these rights it is essential that appointments to the hospital should safeguard the principles of the patients for whose benefit the hospital has been endowed.
Though a small number of such hospitals remained, including some Catholic hospitals, the method of financing healthcare in the UK prevents the effective use of such organisations except by the most-well-off in society: hardly an “option for the poor”.
Conclusion: reforming UK healthcare
If the above analysis is correct, it seems obvious that UK healthcare provision is in need of significant reform and the introduction of competition. This does not mean the introduction of a US-style healthcare system. One important step might be to copy Australia which, in 1975, separated payment for healthcare from provision of healthcare. Essentially the government gives everyone a medicare card that can be presented to any accredited healthcare provider, with medical procedures paid for at a set rate. France and Germany, also provide examples of how to maintain plurality of provision, and hence competition. In Germany a substantial proportion of medical provision is by religious institutions.
There also seems a clear need to simplify the current Byzantine complexity of NHS bureaucracy, with its clear risk that staff might feel obliged to prioritise paperwork above patient care. The principle of subsidiarity is not just a political principle. Organisations should ensure that their employees have the appropriate degree of autonomy. For example, during the pandemic 40,000 retired doctors and nurses applied to come back to work. However, only 5,000 of these were successful, with many deterred by bureaucratic requirements to provide 21 different pieces of evidence, later cut to “only” 15, to support their application[6].
However, as well as practical reforms, there needs to be philosophical changes in the way we view healthcare. Newman’s views, discussed above, rely upon the belief, largely taken for granted in his day, that there is a hierarchy of knowledge. In other words, that theology and philosophy were at a higher level than purely technical subjects such as medicine or warfare. However, from the beginning of the twentieth century, this traditional viewpoint tended to fade away as the sheer complexity and volume of academic study led to increased specialisation.
Is there any way in which this hierarchy of knowledge can be re-introduced given the intense academic specialisation of our era? MacIntyre (2009) notes that universities were founded in the middle ages to enable philosophical and theological discussion about Catholic thought and its implications for contemporary life. That they were grounded in Catholic theology helped ensure that they provided an integrating principle in which subjects could be discussed in relation to each other. MacIntyre argues that, even today, or perhaps most particularly today, Catholic philosophers are needed to provide an intellectual unifying principle which is the only way to enable a genuine and productive moral debate to proceed: As he put it:
“One of the tasks of Catholic philosophers now, therefore, has to be that of following the injunction of John Paul II in Fides et Ratio to do philosophy in such a way as to address the deeper human concerns that underline its basic problems, without sacrificing rigour or depth.” (p. 176)
Let those of us who study Catholic social thought and teaching take encouragement from MacIntyre’s words and use them to analyse and to challenge the ills of contemporary society such as current modes of healthcare provision.
References
Arnold M., Rutherford M. J., Bardot A., Ferlay J., Andersson T. M., Myklebust T. Å., Tervonen H., Thursfield V., Ransom D., Shack L., Woods R. R., Turner D., Leonfellner S., Ryan S., Saint-Jacques N., De P., McClure C., Ramanakumar A. V., Stuart-Panko H., Engholm G., Walsh P. M., Jackson C., Vernon S., Morgan E., Gavin A., Morrison D. S., Huws D. W., Porter G., Butler J., Bryant H., Currow D. C., Hiom S., Parkin D. M., Sasieni P., Lambert P. C., Møller B., Soerjomataram I., Bray F. (2019), Progress in cancer survival, mortality, and incidence in seven high-income countries 1995-2014 (ICBP SURVMARK-2): a population-based study, Lancet Oncol. November 20(11):1493-1505.
Booth P. M. (2014), “Understanding Catholic Social Teaching in the light of economic reasoning”, in Booth P. M. (ed), Catholic Social Teaching and the Market Economy, London:St. Pauls.
Charles, R. (1998), Christian Social Witness and Teaching: The Catholic Tradition from Genesis to Centesimus Annus, Leominster: Gracewing.
Crossman, R.H.S. (1976), “The Role of the Volunteer in a Modern Social Service”, in Halsey A. H. (ed), Traditions of Social Policy, Oxford: Blackwell.
Dawson C. (1950), Religion and Rise of Western Culture, London: Sheed & Ward.
Duffy E. (1992), The Stripping of the Altars, New Haven, USA: Yale University Press.
Green D. (1983), Reinventing Civil Society, London: Institute of Economic Affairs.
Gregg S. (2014), “Catholicism and the case for limited government”, in Booth P. M. (ed), Catholic Social Teaching and the Market Economy, London: St Pauls.
Gregg S. (1999), Challenging the Modern World- Karol Wojtyla/John Paul II and the development of Catholic Social Teaching, Maryland: Lexington Books.
Halsey A.H. (1986), Change in British Society, 3rd Edition, Oxford: Oxford University Press.
Lawson N. (1992), The View from No. 11: Memoirs of a Tory Radical, London: Bantam Press.
MacIntyre A. (1981), After Virtue – a study in moral theory, London: Duckworth.
MacIntyre A. (2009), God, Philosophy, Universities, London: Continuum.
Newman, St John Henry (1873), The Idea of a University Defined and Illustrated – in nine discourses delivered to the Catholics of Dublin.
Pollard, S. (1981), Peaceful Conquest – The Industrialization of Europe 1760-1970, Oxford: Oxford University Press.
Renard G. (1919), Guilds in the Middle Ages, London: Bell.
Scarisbrick J. J. (1984), The Reformation and the English People, Oxford: Blackwell.
St. Pope John Paul II, (2005), Memory and Identity, London: Phoenix.
Sirico R. (2014), “Rethinking welfare, reviving charity: a Catholic alternative”, in Booth P. M. (ed), Catholic Social Teaching and the Market Economy, London: St. Pauls.
Weber M. (1947), The Theory of Social and Economic Organization, New York: Oxford University Press.
Whelan R. (1996), The Corrosion of Charity- from moral renewal to contract culture, London: Institute of Economic Affairs Health and Welfare Unit.
Papal encyclicals and other Church documents referred to in this section
John Paul II, 1991, Centesimus annus, encyclical letter:
Vatican II, Gaudium et spes, 1965, Pastoral Constitution on the Church in the World:
John XXIII, 1961, Mater et magistra, encyclical letter:
http://www.vatican.va/content/john-xxiii/en/encyclicals/documents/hf_j-xxiii_enc_15051961_mater.html
Pope Pius XI, 1931, Quadragesimo anno, encyclical letter:
Leo XIII, 1891, Rerum novarum, encyclical letter: [7]
Questions for discussion
If the outcomes of the NHS matched those in the health systems of the rest of the world, do you think Catholic social teaching would lead us in the direction of preferring other approaches to healthcare provision?
How does our system of healthcare provision reflect the principles of subsidiarity and solidarity?
In a highly secularised society, is it likely that even Church healthcare institutions would be immune from pressure to perform procedures and treatments that the Church regards as immoral?
What other healthcare systems around the world might better reflect the principle of subsidiarity?
How did the Church respond to the calling to care for the sick in earlier ages?
Footnotes
[1]See: https://www.kingsfund.org.uk/blog/2018/05/nhs-international-spending
[2] https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019
[3]Care Quality Commission, Royal Shrewsbury Hospital Quality Report: Date of inspection visit: 16th April 2019, Date of Publication 6th December 2019.
[4]It is also notable that the vaccination taskforce was working to achieve a single goal (mass vaccination). Central planning of any activity is far easier (and sometimes appropriate) when there is one single, easily-defined goal.
[5]It is worth noting that this happened on a huge scale in the reformation. And, though the Catholic hospitals remained in Church hands at the founding of the NHS, other charitable hospitals were nationalised.
[6] Retired doctors must fill in 15 forms before being able to give jab, Daily Telegraph 9 January 2021.
[7] This chapter uses the original, Manning translation of 1891.