The NHS Constitution for England brings together the principles, values, rights and responsibilities underpinning the NHS. It sets out the features of the NHS as a comprehensive and equitable health service, empowering patients, staff and the public to know and exercise their rights in helping to drive improvements in quality, efficiency and responsiveness throughout the NHS (Department of Health (DH), 2015a). In July, the Report on the Effect of the NHS Constitution (DH, 2015b) was presented to parliament. The Secretary of State is required to ensure that the impact of the Constitution is regularly assessed and understood, reporting on the effect of the Constitution on patients, staff, carers and members of the public every 3 years. The NHS Constitution was introduced as a requirement of the Health Act 2009.
There has been a stream of initiatives produced to generate public awareness regarding rights and entitlements associated with the NHS. In 1991, a UK Government document The Patient's Charter (DH, 1991) was introduced, which set out a number of rights for NHS patients. Originally introduced in 1991, under the then Conservative Government, it went through a number of iterations and was revised in 1995 and 1997. The Patient's Charter was just that: a charter for patients with little if any reference to staff, whereas the current NHS Constitution (DH, 2015c) sets out the rights to which patients, public and staff are entitled. The UK Government quietly abandoned the Patient's Charter early in 2001, the charter represented undeliverable standards and the Government had to cancel it. The NHS Constitution for England replaced the Patient's Charter in 2013 (DH, 2013).
The current NHS Constitution has been revised several times and the most recent edition came about after a DH consultation that sought views on a variety of proposed changes. Important areas that have been addressed in the NHS Constitution (DH, 2015c) include:
In addition to strengthening areas of the NHS Constitution there is also a revised Handbook to the NHS Constitution (DH, 2015a); this explains the rights, pledges and responsibilities set out in the NHS Constitution in more detail.
You may have noted that a number of the areas addressed, for example, duty of candour and dignity, respect and compassion have been included as part of the Government's response to the report into the failings that occurred at Mid Staffordshire NHS Foundation Trust as reported by Robert Francis QC (The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013). The DH have changed the Constitution to reflect that the NHS’ most important value is that patients are to be at the heart of everything that the NHS does (DH, 2013).
‘There has been a stream of initiatives produced to generate public awareness regarding rights and entitlements associated with the NHS’
The Francis report emphasised the role of the NHS Constitution in helping to create a positive and caring culture within the NHS. It suggested that the NHS Constitution was to be, or should be, the first reference point for NHS patients. The Secretary of State for Health has made it known that he is committed to playing his part to raise awareness of the NHS Constitution. This is follwing the publication of the Report on the Effect of the NHS Constitution (DH, 2015b), which noted that there is significant room for improvement. Public awareness of the NHS Constitution has declined since 2012, where even then awareness was already at a low level. ‘Progress must be made,’ announces The Secretary of State for Health. He had made it clear that he will hold to account NHS England, clinical commissioning groups and Health Education England with regards to their duty to promote the NHS Constitution.
Irrespective of all of these attempts to raise awareness, and all the money spent in attempting to do this, official reviews have recognised that public awareness is low. Along with this, evidence to suggest that patients or staff use it to exercise rights or expectations is scant. An all party parliamentary group report (All Party Parliamentary Group for Patient and Public Involvement in Patient Care, 2013) has revealed that the level of staff awareness to be ‘frankly embarrassing’. Having rights but not being aware of them is not much use.
There is a legal obligation on NHS England, clinical commissioning groups, private and voluntary sector providers supplying NHS services, to take account and promote the Constitution in their decisions and actions. The Secretary of State's clear determination to call these commissioning bodies to account would suggest that they are failing in their duty. Issues concerning enforceability of the Constitution have been raised as much of it is composed of pledges as opposed to rights. Pledges do not bring with them a legal basis, despite an expectation that they can, and should, be delivered. Strengthening of enforceability is much needed, the Constitution deserves to be seen as more than a few obligations it should receive higher status.
The NHS Constitution has been described as ‘fine words but no teeth’ (Pulse, 2012), there is a need to strengthen it with the aim to encourage patients to challenge the care they receive and staff to use it to support their quest to deliver high-quality patient-centred care.
If the NHS Constitution is to be valued, supported and used by patients and staff, carers and the public, and for it to have more significant impact, then awareness must be raised. There is also a need to ensure that it is embedded at every level in the NHS.
‘There should be an explicit requirement in all NHS contracts that providers uphold and promote the Constitution’
There should be an explicit requirement in all NHS contracts that providers uphold and promote the Constitution. If embedding the Constitution at every level in the NHS were achieved, then an important part of regulatory assessments undertaken by the Care Quality Commission and Monitor would require commissioners and providers with an incentive to provide and amass data concerning its use that at the moment is lacking.
As the NHS continues to address an enduring economic austerity, the Constitution is as important now as it has ever been. There is an ongoing reduction in resources, an ever increasing range of services that are now being seen as optional, the control of local NHS budgets are handed over to local councils and combined local authorities, with an ever increasing role for private businesses to deliver a myriad of NHS services hitherto provided by the NHS.
The NHS Constitution is meant to empower patients, public and staff by assisting each group in understanding what they might expect from the NHS. Giving the Constitution more clout could seriously ensure that the patient is truly at the heart of all that is done, for staff it should help to improve employer engagement and to help them develop better services for patients. As it is now, it has little impact, neither for patients nor for staff.