The topsy-turvy world of the NHS’s relationship with minority groups and their non-standard care requirements
When the NHS was last in expansion and a ‘transformation’ was underway, one of the guiding principles was called “World Class Commissioning“. It was the Blair-Brown era and the big idea (much of which is, at least in theory, intact) was that all NHS services would be designed and managed in such a way as to achieve three core objectives. These were that they would be based on scientific evidence, they would be financially sustainable and they would reflect the needs and wishes of the local population. All staff involved in commissioning had to gain eleven “competencies“, an important one being the ability to “proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health “.
From an anthropological point of view, one of the most interesting elements of this proactive engagement to shape services was the quest for “Culturally Appropriate Care” (CAC) for minority groups. Although more well known in the context of non-European settings, the concept can be a powerful influencer of health service design and delivery in any ‘super-diverse’ society.
The basic premise of the CAC movement is that, even if the medical concepts and thinking of a minority group are difficult to understand from a Western scientific standpoint, it is the responsibility of a healthcare system to work respectfully with and within their world views. In terms of the quest for ‘evidence-based healthcare,’ CAC is almost always bound to cause problems. This is because non-standard systems of health, thought and practice are often either based on non-scientific concepts or not amenable to the methodologies that science uses to investigate healthcare success. Or both.
In spite of this inevitable tension, during the late ’90s and early 2000’s a modus operandi developed in the commissioning world under which a relatively liberal attitude to minority beliefs, practices and needs grew in the NHS. There was an explosion of translation and interpreting in urban primary care in order to ease and improve access, it became commonplace to offer gender-specific consultation as well as chaperoning and community health providers began to reach out to previously unheard or unreached groups.
In terms of medical care and hospital treatment, one of the most striking examples of this open approach was the development of special surgical procedures for NHS patients whose personal beliefs lead them to reject blood transfusion. Most (but not all) blood refusers are members of the Jehovah’s Witness religion and it was that group who was instrumental in negotiating and organising blood-less surgery in the NHS.
The use of extra blood during surgery and other hospital care has long been a vital technique in western medical care and the collection (through voluntary donation) and distribution of blood and blood products is a vast and important part of the NHS. From a scientific point of view, the blood transfusion component of many treatments and operations is vital to their chances of success. Asking a doctor to deliver treatment without using extra blood is asking the doctor to deliver a ‘sub-optimal’ service. If that wasn’t the case, then why would the operation under any other circumstances be performed with a blood transfusion? Indeed the refusal of blood is seen as so potentially detrimental to the individual that (as seen in the 2017 film ‘The Children Act’) UK legal systems regularly enforce the use of transfusion in cases where blood-refuser parents attempt to decline the treatment on behalf of their children.
In spite of the obvious ‘World Class Commissioning’ problems with scientific evidence, in the case of blood-less treatment, the competing need for “continuous and meaningful engagement” with minority cultures has come out on top. The result of these processes is that, up and down the country, NHS surgeons deliver treatment programmes tailored to the expressed cultural needs of patients who disagree with blood transfusion for personal ethical reasons (usually because they are members of the Jehovah’s Witness religion). The smooth running of these arrangements and help with communication between medical staff and patients is facilitated by “Hospital Liaison Committees” staffed by senior members of local Kingdom Hall congregations. (“Kingdom Hall” is the name Jehovah’s Witnesses use for their meeting houses).
The clinical techniques that doctors resort to in lieu of their normal ‘with blood’ practices are complex, impressive and fascinating. You can see why ambitious surgeons have taken to the field enthusiastically, as it seems to appeal to both the ‘science-nerd’ and ‘hero-genius’ sides of their professional identities.
So (almost) everyone wins – the patients get their clinically sub-standard but religiously acceptable treatment. The doctors get to do technically challenging but very helpful things. And the NHS can put a great big tick in its “culturally sensitive” box. The taxpayer might feel slightly short-changed, of course, as, although the relative costs of bloodless techniques are not talked about much, they are clearly rather resource heavy in comparison to normal treatment. But then again, why shouldn’t a policy of multicultural inclusivity come with a price tag? And not many taxpayers know that the NHS offers blood-less surgery-free at the point of use, so there hasn’t been a backlash yet.
Other spiritually-inspired minority health care beliefs are rather less well catered for in the NHS, however. If you or any of your friends are of a Theosophical persuasion, for example, your beliefs about health and healing are very likely to lie in the clinical sub-cultures of Anthroposophical and Homeopathic Medicine. These kinds of approaches used to be included in NHS care. Twenty years ago, my father happily and successfully received long-term cancer care from an NHS consultant specialising in Homeopathy and Phytopathic Medicine. Recently, however, these NHS options have fallen victim to the aggressive pro-science, anti-mumbo-jumbo movement in contemporary health culture, the hegemonic ascendancy of the “science-based” strand of world-class commissioning and the concomitant decline of “continuous and meaningful engagement with the public”.
If post-election, the next expansion and transformation of the NHS actually happens, maybe we can look forward to a renaissance of cultural inclusivity. If that comes to pass, the bloodless surgery arrangements put in place by the Jehovah’s Witnesses will provide the NHS with a useful working template to follow. At present, the unequal treatment of different religious and spiritual traditions seems at odds with the overall commitment of both the NHS and the wider society to a generalised notion of fairness and equitable treatment at the hands of public bodies.