The place of the NHS and social care in contributing to a just society
Lecture by The Most Revd Dr John Sentamu, Archbishop of York
The Paul Noone Memorial Lecture – 26 October 2019
Good evening and thank you for the invitation to deliver this year’s Paul Noone Memorial Lecture. Can I add my own welcome to God’s own county!
I’m grateful for the opportunity to speak on the subject of the NHS and Social Care in contributing to a just society.
I don’t need to tell you, but one of the greatest decisions this country ever made, one of the greatest institutions which continues to make us proud, one of the envies of countries and governments around our global village is the creation of the NHS 71 years ago.
As the largest public sector employer in the UK most of us know someone who is involved in the NHS. Here in York, the NHS Trust employs around 9,000 people, providing healthcare for approximately 800,000 people.
As someone who has benefitted from the skill and care of the doctors and nurses through a handful of medical procedures at the NHS Trust in York, St Thomas’ Hospital and University College Hospital, London, I am certainly indebted to them.
And of course my story is similar to thousands of others across the country – First class care, provided free at the point of need, regardless of wealth, status or place in society.
Every 36 hours over 1 million patients pass through hospital doors, across this country. Sometimes just for minor injuries to be dealt with immediately before the patient is dispatched to continue with day to day life or sometimes, for more complex, life threatening illnesses which require any number of specialist doctors providing the First class care, which the NHS excels in.
In 1948, the year before my birth, this country looked very different. The pressures our health and social care workers faced were different, and one of the key challenges for our beloved country today is the increase of people living in the UK and in particular, the demographic of an ageing population.
In 1911 there were 13,000 people over the age of 90. In 2011 there were 430,000 people over the age of 90.
Of course, these statistics are to be celebrated, and reflect the dramatic improvements in the living conditions and subsequently the health of the population throughout the 20th and 21stcenturies.
Life expectancy over this period increased and was, in a large part, due to improvements in living conditions. As you know only too well, among the key determinants of heath are ‘social’ determinants rather than those genetically inherited or related to the provision of health services.
40% is due to behaviour;
30% is due to genetic inheritance;
15% is due to social environment;
5% is due to physical environment;
This leaves only 10% to healthcare.
There are many notable industrialists and civic leaders of the late nineteenth and early twentieth century who recognised this, not least Joseph Rowntree, a Yorkshire man through and through who provided his employees, with a library, free education, a doctor, a dentist and a pension fund. These radical initiatives back in the 19th Century improved the health of workers and their families to no end.
In addition, the slum clearances, delivery of effective sewerage and sanitation, the Clean Air Act and the introduction of universal education, have ensured some of the greatest leaps forward in the underlying health of the nation which have in turn, led to a more just society.
Now don’t misunderstand me, the National Insurance Act of 1911, and the creation of the NHS in 1948 have undoubtedly played their part in the improvement of the nations’ health and it continues to be a jewel which governments and citizens treasure and guard jealously.
The provision of health care which is ‘free’ at the point of use; the elimination of many communicable diseases, effective treatment of previously life-threatening conditions and specialist care for those with chronic and debilitating conditions, are perhaps the most widely recognised achievements of our NHS.
But my friends, let us pause and think about the now.
With a relatively affluent and healthy UK, what can we in the UK hope for in terms of improved health for this and future generations, as we seek to create and ensure the common good in the twenty-first century?
We know there are inequalities across our country. We see inequalities which are geographical, ethnic origin inequalities, and gender inequalities.
And whilst the majority of our healthcare is provided free at the point of need – so it’s not about access but serious inequalities in health across this country still do persist.
The title of my lecture ‘Whatever you did for one of the least of these’ is a direct quote from St Matthew’s Gospel, Chapter 25.
Christians are commanded to care for the sick.
You see, it isn’t something I do because I’m an Archbishop or because I wear a dog collar.
As a follower of Jesus Christ, I am following the example of Jesus Christ. I am seeking to obey the commands of Jesus:
- to serve and care for others around me,
- to serve and care for the sick,
- to serve and care for those living in poverty,
- to serve and care for the marginalised in society,
- to serve every single person who God created in his own image and likeness.
To put it another way – I need to champion and live out the common good.
Whilst Christians can in no way claim to have a monopoly in the field of social justice, their contribution has been incalculable. There are plenty of people caring for the vulnerable in our society every day, but for the Christian, there is no choice.
It is imperative that we ensure those in need, or as Matthew’s Gospel puts it, ‘the least amongst us are cared for’.
The care and provision for others who are in need of physical and spiritual wellbeing is essential to the purposes of God. And, can I add by extension, in order for care to be offered, it is essential that attention is given to those who are providing care – something I will come back to later.
Biblical anthropology is clear.
A human being is a whole person, by which I mean, they have mental, physical, and spiritual dimensions. Each of these, whilst separate functions, affect the other – why? Different components, yes, but as Cesar Galvez puts it, “a human being is a unit” 
A website I once visited had an interesting tick-box to fill in. It said ‘Confirm your humanity’. A rather more profound challenge than ticking the ‘I am not a robot’ box!
So why are human beings so valuable? Simply, because of the value that God places on each of us. And because of the love he showed by sending his Son to die, the only correct response is to mirror that love to everyone. Caring for God’s creation requires me to care for everyone.
Galvez goes on to say,
“The living soul is a whole. Therefore, every dimension of human life affects the other dimensions positively or negatively. So, the physical dimension affects the mental, social and spiritual dimensions, and vice versa.” 
So for the person with mental health issues, or the older person struggling to receive the correct level of care, or for the family barely able to afford a meal each day, each struggle has a profound impact on their well-being as a whole.
So how can the NHS ensure care is being given to every human being as a whole?
Well, I think the short answer is they can’t. Or at least, they can’t without the support of other agencies and professionals with unswerving underpinning from politicians and the government of the day. Now of course, this support is not a new phenomenon. The NHS has been in partnership with many agencies over the years. In addition, successive governments have rolled out new policies some more successful than others. But in fairness most noting that the approach of care which is needed for the 21st Century isn’t what it was 70 years ago and that it can’t all fall on the NHS in the traditional sense. So what can be done and what model should we be working towards, to ensure that the human being as a whole can be cared for?
Where are the lines in the sand which need to be drawn, the bigger picture which needs painting? A culture change for our entire society.
As I’ve already stated, it is imperative we care for everyone, in 7 years, let alone 70 years from now? For me this is a no brainer!
Over the next few moments, I’d like to pick up on 3 distinct, yet interconnected areas where I think the NHS and social care have a key role in contributing to a just society. Namely:-
- An ageing population.
- Mental Health.
- Collective responsibility.
The first area is an ageing population.
Like many other countries we are having to ask ourselves some hard questions around adapting to the needs of an ageing population. Not just old age, but rather an ageing population.
It wasn’t so long ago that 60-65 was described as old age. After 65, life was considered to be downhill. I turned 70 a few months ago and whilst I may not be as nimble as I once was, I don’t think I’m old!
I’m healthy and active with an inquisitive mind often working 6 or 7 days a week. But here in the UK we have a very eccentric view of the ‘good life’, or the ideal life – that is one that is lived only for a few years between the ages of 18-40.
There are now over a million people aged 65 and older who are in paid work. In fact, if we define dependency as ‘not in paid work’, then there are more dependants of ‘working age’ in the UK than there are people over state pension age who don’t work.
As humans, made in God’s image and likeness, we are made to be creative. When I was asked to speak on the Jeremy Vine Show on ‘What It Means To Be Human’, I said, “being human involves always looking beyond ourselves”.
And for an ageing population, surely that means either remaining in employment or remaining creative and productive in other ways. Retirement for some contributes to a sense of loss of worth.
But something that we do have to acknowledge is that as we get older, over time we become more dependent and more vulnerable. There is a limit to how long we can carry on the way we are.
Very few people like to think of getting old. People rarely save up to pay for long-term care. We all hope that we’ll be in the percentage of those who will never need it.
Old age of course, doesn’t necessarily mean poor. In fact, for many people who are of pensionable age, at least in monetary terms, they are not poor. Often those who are poor in later life are poor because they were poor when they were younger, unable to accumulate assets or pension rights to draw on in later life.
So how can we enable a just society for the ageing population? I put to you six thoughts.
- I believe the population of the UK are ready to buy into a system that provides a high level of care for all. Large amounts of money are injected for early years and primary, secondary and tertiary education, but so far that money has not been matched for care for older people. Of course, the debate as to whether certain care should be paid for or at least covered in part by the individual continues. This does however mean a responsibility aimed at the individual to think ahead and ‘prepare’ for ageing whilst recognising that none of us are able to know what the future holds other than one certainty – death!
How can workplaces become flexible places for the ageing population to continue within but also help to acknowledge that change is inevitable? How can companies and institutions recognise the value those in their later years can offer and pass on? How can there be a greater dialogue between companies to learn from models of good practice and for that to be celebrated? How can the NHS encourage our leaders in business to address some of these issues and see the bigger picture? What partnerships can be formed?
It is important to acknowledge what the NHS is there to do and what are reasonable expectations for all those who work in the NHS and all social care providers. It is a good thing that NHS and Social Care have been linked together – though sadly later in the day.
- We need intergenerational dialogue.
The biblical model expects the wisdom that age brings is to be shared with younger generations. To put it another way, the older generation are to be mentors for the younger generation. At the most basic level, the longer you’ve been around, the more you’ve experienced, the more mistakes you’ve made, the more you’ve learnt from your mistakes and the more fitting it is for you offer advice.
Equally our young people need to or perhaps even learn to communicate with the older generations. Here in York, the Joseph Rowntree Care Home and Nursery school are adjacent to each other. That wasn’t a mistake. I’m reminded of this often when I hear and see examples of young people who through my Youth Trust have attained their Young Leaders Award who willingly want to include older generations – not doing things to them, but getting alongside.
- The appropriate care for individuals. Rather than write older people off as one group, we need to see everyone as individuals who may require different care packages. Again, as a society we have been slow to recognise just how vital this is; and even slower to implement the changes required to do so. We are beginning to see the various stakeholders come together: clinicians, social care, local communities, families and the individuals themselves to ensure a holistic approach is taken. For this to continue and be successful, a further breaking down of existing walls and a generosity of healthcare providers must be radical in their approach for the common good.
- Dementia. You don’t need me to point out one of the implications of people living longer has meant an increase in those suffering with dementia. At King’s Cross Railway Station recently, there have been posters stating 1 in 3 people born today will develop Dementia. As policies are created, we need to respect older people and not hide them away. As one friend of mine commented, ‘We need a “dementia without walls” strategy’. How are communities preparing themselves for responding to this massive change? How can we minimise the fear this appalling disease brings to both the sufferer and those who watch them suffer? What can be done by those trusted and influential figures in the community who can speak into this topic with wisdom and insight. Well my friends, I think that includes you.
- We need to think radically about wage levels in the care sector. I said in my introduction if we want to ensure that the most vulnerable are cared for well, the commitment we show to carers needs to be matched. Care staff are not paid well and whilst many are there because of a sense of ‘vocation’, we need to ensure they are paid a proper wage. The average hourly pay for a Care Worker in the United Kingdom is £7.95 an hour, well short of the Living Wage. The Long Term NHS plan recognises NHS staff continue to be under strain with workload pressures and flexibility and professional development is key to addressing some of this. They are a vital asset, often the first, last and perhaps only contact people in care received each day. Their wellbeing is just as essential. Of course, we mustn’t forget all those who care for family and friends giving up time daily to tend to them. Almost 15 billion of volunteering hours. How are we as a country adapting and ensuring those people are cared for too?
- Death. We need to be honest about death. No end of medical advances, no end of top quality care will allow any of us to cheat the most democratic institution: death. Death is not a failure. Being able to discuss and get alongside the most vulnerable in their hour of need, can be a real comfort. Hospital chaplains for example are a key part in our care system and they are to be encouraged. Delivery of spiritual care is seen as being the responsibility of all professionals in a multi-disciplinary healthcare team, but on the grounds of care, efficiency and human rights, it is essential that chaplains play a central frontline role in ensuring that appropriate spiritual and religious care is extended to all patients, clients and staff. In addition, further discussions around quality palliative care is essential. We have lost compassion and human dignity, especially where people are at the end of life or are disabled.” 
The second area is mental health.
If Dementia is one of the key challenges facing this country as the population ages, mental health is one which perhaps people are only now acutely aware of in terms of the impact it has.
In the same way that ageing is a gradual process, mental health can often be something which envelopes over time and yet unlike ageing, can be hidden from others around us for years and years. We live in a society where 1 in 4 people suffer from mental health issues.
In their excellent book, The Spirit Level, Kate Pickett and Richard Wilkinson ask the following question:-
“How is it that we have created so much mental and emotional suffering despite levels of wealth and comfort unprecedented in human history?” 
Now I recognise that mental ill health is complex and personal. Sweeping statements are often dangerous so I will try and avoid those.
I was encouraged to read in the NHS Long Term Plan considerations for both Adult and Child Mental Health illness. Not least a renewed commitment to grow investments in mental health services over the next five years.
Along with welcomed investment, creativity and new ways of working are needed to ensure appropriate care can be given in a timely way.
New roles are being developed across education institutions, with mental health practitioners employed to work with pupils and schools to improve mental health and recognise early symptoms. This is a very welcome addition.
However, the lack of awareness and understanding around mental health should not be underestimated and the stigma which is attached to it can be debilitating for many, restricting a need for openness and support with family, friends and peers.
The social isolation caused by acknowledging mental health struggles is immense.
Earlier this month we had mental health awareness day in the UK and whilst some may argue such initiatives are counter-productive, I believe it is through these initiatives alongside high profile people such as The Dukes of Cambridge and Sussex, to name a few, speaking out that we begin to break down the stigma.
A further area which concerns me is the access to mental health care and the treatment of those from BAME communities.
Evidence demonstrates that people from Black and Minority Ethnic communities are less likely to seek help at an early stage of illness, due to ‘a combination of lack of knowledge, stigma, inappropriate models of diagnosis and poor experience of mental health services.’ 
For Black men, it simply isn’t the ‘masculine’ approach to admit any mental health symptoms. For Asian men and women, it is about the shame which is brought on the family, and Asian women, are the least likely to be treated for mental health illness.
In all cases, the key is ensuring that access to clinicians, accurate diagnosis and appropriate medication is sought. Let me expand.
- Because of the stigma which is attached, it passes down generations. There is a need for those within the BAME community to speak out and be advocates for championing mental health. If the shame of speaking out can be eradicated, we can begin to ensure for future generations treatment for mental health is sought in a timely manner.
- But there are also cultural barriers where better education and trust needs to exist. This is a two-way thing, between individuals and the care providers to individuals. It is a blight that unfair treatment towards ethnic minority individuals over time due to a lack of cultural understanding and in some cases racism, has led to more BAME individuals being subject to compulsory powers initiated under the Mental Health Act. This has only led to a sense of fear amongst individuals and communities. And my friends, let me tell you, this still exists today. An improved knowledge and understanding of cultural differences is long overdue along with swift action where any hint of racism exists.
- However, BAME individuals and communities need to be reminded, as I mentioned earlier, that health is about the well-being of the whole person and the consequences of living with mental illness and not seeking treatment has an extremely damaging impact on the individual and the wider family.
- I also want to highlight the role religious organisations can play alongside third party organisations to be proactive in educating, getting alongside and encouraging openness around Mental Health for BAME individuals. Churches are often seen as independent bodies and therefore have the potential to be ‘an honest broker.’ Through their networks they can help design and deliver culturally appropriate and accessible services in collaboration with health practitioners.
The trust instilled by communities in their religious leaders must not be underestimated. The language which we sometimes hear used, such as healing of body, mind and spirit are phrases Christians and other religious groups will tend to use often. Anecdotal evidence suggests that psychiatrists are sceptical and rather dismissive of this language. We need people to be reminded, the spiritual is part of the whole and needs to be treated as such.
Of course, mental health touches all of us, irrespective of ethnic origin or gender and many of us will be supporting or working alongside colleagues who suffer from mental health.
Of the 4,500 adults recently questioned, 13% experienced suicidal thoughts because of concerns about body image; and 10% of UK women have deliberately hurt themselves because of their body image. These are sobering statistics.
But there are good news stories as well. Help is generally sought more quickly for treatment, and treatment can often allow people to lead normal lives, and the stigma is beginning to lift.
In a time which can often seem so dark for an individual, can I encourage you to be the light, hope and help for those who need it most.
The third area is collective responsibility for our health and well-being.
Thirdly and finally, one important question has to be asked which relates to where responsibility lies for individual well-being? The NHS and social care certainly have their part to play, but as I said in my introduction, there are other factors which affect the health of an individual and it’s important to ensure a holistic approach is taken.
Firstly, we need to continue to move to a more equal society. In the 21st century, inequalities, often inflicted on rather than brought on continue to be engrained in the lives of so many people. And this affects the health of individuals.
In his book, The Health Gap, Michael Marmot highlights statistics which show that the greater the disadvantage and inequality (within society) the worse the health becomes.
‘Inequality often means disempowering, it deprives people of control over their lives. Their health is damaged as a result. The greater the disadvantaged, the worse the health.’ 
In 2013 the Office of National Statistics showed that people born in Manchester can expect, on average, to live 5 years less if they are men and 3.7 years less if they are women than the average English person.
Men born in Kensington and Chelsea – the area with the highest life expectancy in England, can expect to live 10 years longer than men from Manchester.
But even within communities, there are often differences. Those from the poorest communities here in York can expect to live about 7 years less than their counterparts in the most affluent areas of the city. 
In the 21st Century, these statistics should make us restless and we should be demanding that appropriate attention is given to reducing these rather than accepting the status quo.
We have to remember that there are often steps in the process which lead or could indeed prevent admission to hospital. Therefore, the system is reliant on every other step succeeding. This starts from tackling inequality from the outset and as I have already mentioned, providing a holistic approach as services are co-delivered.
In a free and demand-led health system, we must ensure that the benefits are equitable and not disproportionate, possibly experienced by those who are most confident about seeking health care.
The continuation of greater integration in the delivery of health and social care will, hopefully, lead to a reduction in hospital admissions and ensure that people will be discharged after a short spell in hospital, and receive appropriate social care determined by all concerned.
The NHS Long Term Plan recognises the lack of equality and states that funding for key national and local programmes will be given on the proviso that they set out specific measurable goals and mechanisms by which they will contribute to narrowing health inequalities over the next five to ten years.
But beyond what organisations and institutions can offer, people’s well-being should be first experienced in family and community settings. We seem to have lost much that is good about community life – and fewer of us are getting involved in such worthy volunteering schemes.
And because family and community settings are crucial I believe that these smaller units can act to make incremental differences to a bigger picture. If individuals and groups implement changes and champion them – they catch on, and society at large, including governments, are more likely to come into line.
What about key people in the local life of our streets and towns whose conversations and attitudes shape public opinion? Such people one writer argues would be important in changing attitudes to health, illness and death. 
And key for me is a question as to how churches, religious groups and the third sector can support this? Michael Wilson in his book, Health Is For People, goes on to say,
‘Health planning is not just the responsibility of the professions who work to keep us well, but belongs widely to society. To discuss health there must be present, in addition to doctors and nurses, housewives, artists, ministers of religion, teachers, environmentalists, architects, economists and so on.’ 
And through that cohesion imagine the difference where our communities are underpinned by a consensus that everyone should, by right, have access to the opportunities which enable individuals to achieve their full potential in life and that no one who is unwell should go untreated.
And yet, whilst health should be a collaborative effort, we mustn’t forget and where necessary ‘teach’ the role that the individual has.
‘What our individual responsibilities are to one another? What our responsibilities are to us personally?’
Each of us is the custodian of our own body and soul. Some of the choices around the food we eat, the exercise we take, directly affects our health and others’ health and well-being.
To use just one example, the surge in type 2 diabetes, has increased the costs to our NHS and social care often because of a direct impact of our ‘lifestyle’ choices.
We are also responsible for our health as individuals as we contribute to the cost of the NHS and some parts of social care through the taxes we pay allowing care to be free at the point of need.
But I wonder, as Kersten England does, whether this human right – healthcare at the point of need has been contaminated by customer rights, which can be exercised without proper care towards others.
‘Taxation comes to be seen as payment against services to be received as a customer rather than an investment by citizens – in proportion to their ability to contribute – in the creation of the common good.’ 
The common good is not ultimately created in the payment of monies for the provision of services to the State. No my friends, ‘it is created through individual acts of human kindness, care and compassion for others known and unknown.’
The story of a compassionate and neighbourly Samaritan in Luke’s Gospel, Chapter 15, is a wonderful example of this.
You’ll know the story –the person who was least likely to have helped the man who had been robbed and left lying by the roadside severely wounded, came over, took pity on him, ensured he ended up somewhere which could offer the most appropriate care and paid for the cost of the care, upfront. Without requiring anything in return.
If this isn’t the common good at work my friends, I don’t know what is? The parable Jesus told was about human relationships. This isn’t a case of a singular goodness, but of a common humanity. The fabric of people’s lives is woven by their relationship with others and with God’s world. And what does Jesus say to the teachers of the law at the end of that parable?
“Go and do likewise”.
Creating an equal society where inequalities amongst us disappear – Yes!
An individual responsibility where we take care of others and ourselves – Yes!
A collective, inter-dependant community approach, bubbling up and driving a change for the future – Yes!
In the three areas that I’ve highlighted this evening:
- an ageing population;
- mental health; and
- collective responsibility,
we need to recognise that educating and planning for the long term is key.
As individuals and a society, we tend to overestimate what we think we can achieve in a year or accomplish in a decade.
I’m reminded of the following story:
On the Swedish island Visingsö, there is a mysterious forest of oak trees: mysterious because oak trees aren’t indigenous to the island and its origin was unknown for more than a century. Then in 1980, the Swedish Navy received a letter from the Forestry Department reporting that their requested ship lumber was ready. The Navy didn’t even know it had ordered any lumber. After a little historical research, it was discovered that in 1829, the Swedish Parliament, recognising that it takes oak trees 150 years to mature and anticipating a shortage of lumber at the turn of the twenty-first century, ordered that 20,000 oak tress be planted on Visingsö and be protected for the Navy.
That is thinking long, as opposed to short-termism.
As an aside, you might be interested to know, the lone objector to this plan in 1829 was the Bishop of Strangnas. He didn’t doubt that there would still be wars which the Navy would have to fight at the end of the twentieth century, but he was the only one who anticipated that ships might be built of other materials by then!
So for us today, what does this long term thinking look like for the NHS and Social Care? If governments and others who carry influence were prepared to think long, think boldly, think across party politics for the sake of the common good, we would be investing for the children yet unborn.
Nobody really believes that the areas I’ve touched on can be completely turned around in a year. But unlike the Swedish Navy we will hopefully not need to wait 150 years either.
Although ageing population, mental health and collective responsibility are all distinct nevertheless they should not be separated.
Why? Because the health of the individual, whatever age or stage, whatever condition they find themselves in requires a holistic approach to their well-being.
And, thereby, ensuring that the common good is for all and putting compassion, humility and justice, and the dignity of each person at the forefront of our actions.
In God’s world there are no strangers – just neighbours with diverse gifts and needs, whom we meet as we journey along life’s road.
And in no small part, the NHS and Social Care continue to be instrumental in journeying along that road in the same way as it was in 1948.
Let me leave you with one final quote from Michael Wilson’s book, Health Is For People,
“Health is not for the rich to give the poor. Health is a quality of life they make together. Neither can possess health apart from the other, nor steal health from the other without robbing himself. Rich and poor, doctor and patient, oppressor and oppressed make one another. We make health possible for one another.” 
Amen to that!
 Cesar Augusto Galvez – Biblical Perspectives on Health for the Contemporary World, April 2010, Vol.13, No.1. pp. 20-29.
 IBID, p. 22
 Ageing: Blessing or Burden? On Rock or Sand: Firm foundations for Britain’s future, ed. John Sentamu (Jan 2015). p. 175
 IBID p. 175
 Symposium at Bishopthorpe November 11th 2011
 P3 Symposium notes 28 July 2011
 The Spirit Level: Why Equality is Better for Everyone (Kate Pickett and Richard Wilkinson) (2010) p. 3
 P4 UKME mental health care toolkit
 The Health Gap: The Challenge of an Unequal World, Michael Marmot (2016), p. 7
 On Rock or Sand: Firm foundations for Britain’s future, ed. John Sentamu (Jan 2015). p. 135
 Health Is For People, Michael Wilson (DLT 1975) p. 103
 IBID P104
 On Rock or Sand: Firm foundations for Britain’s future, ed. John Sentamu (Jan 2015). p. 154
 IBID p. 155
 IBID. p. 155
 On Rock or Sand: Firm foundations for Britain’s future, ed. John Sentamu (Jan 2015). p. 155
 Material from the Circle Maker Mark Batterson. P137-138
 Health Is For People, Michael Wilson (DLT 1975) p 111