There is a lot going on right now in terms of government consultations, initiatives and patient safety reports, both published and planned. All this activity eventually needs to settle and take root. It is in one sense good to see all this activity, it adds vibrancy to debates and discussions. However, in another sense there are dangers – the danger of overlap, of reinventing the wheel, the constant repetition of messages, a neverending cycle of new initiatives, all of which can have negative consequences in terms of patient safety culture development.
It might now be the time to start asking for some consolidation and rationalisation of activity, particularly in relation to changing regulatory and governance structures but not restricted to that. Nurses, doctors, and others already work within a complex healthcare regulatory and governance environment. We need to avoid turning the field of patient safety into a ‘conveyor belt’ of policy making. All this is much easier said than done given the vast number of stakeholders in this area.
In this column I will be discussing The NHS Constitution (Department for Health and Social Care (DHSC), 2023a), and its pending 10-year review (DHSC, 2024). This consultation review is also taking place alongside other recent consultations including those on Never Events and the Duty of Candour. They will all need to be digested and applied by all those involved with patient safety policy development and practice. It is a busy time on the healthcare regulatory and governance front.
An NHS ‘mission statement’: The NHS Constitution
Many organisations have mission, vision or value statements and drafting them is an art. There is a service industry devoted to this:
‘A mission statement is a declaration of what your company does and why it exists. This message is designed for internal and external audiences; it should ignite interest in the organization as it builds its brand.’
These kinds of statements are excellent ways of conveying key information about what an organisation is about and how it sees itself. Some idea of the character, personality, aims, mission, values and brand of the organisation can be seen. They act as a national and global window on the organisation to the public and stakeholders.
In looking at these statements generally across several organisations, I can see that they are helpful but are generally drafted in an aspirational way. In essence they can be seen as clever marketing tools. The language is flexible and vague enough to allow for interpretation and flexibility of meaning. The corporate ‘flavour’ is being conveyed.
The NHS Constitution (DHSC, 2023a) does this to a significant degree. It can be viewed as the NHS in England's mission statement. It is a comprehensive document containing principles that guide the NHS, NHS values, patient and staff rights and so on. In the introduction it is stated that the NHS belongs to the people:
‘It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives.’
DHSC, 2023a: 3
Principles and values
There are seven key principles stated that guide the NHS in all it does (DHSC, 2024a):
- The NHS provides a comprehensive service, available to all
- Access to NHS services is based on clinical need, not an individual's ability to pay
- The NHS aspires to the highest standards of excellence and professionalism
- The patient will be at the heart of everything the NHS does
- The NHS works across organisational boundaries
- The NHS is committed to providing best value for taxpayers’ money
- The NHS is accountable to the public, communities, and patients that it serves.
These are underpinned by core NHS values, which are set out as: working together for patients, respect and dignity, commitment to quality of care, compassion, improving lives and everyone counts.
Rights and pledges
There are specifics about rights and about pledges, which are more aspirational. There is an important distinction between the two terms, which is further explained in The Handbook to the NHS Constitution (DHSC, 2023b). This states that a right is a legal entitlement protected by law and is already in place. This is distinct from the term ‘pledge’:
‘This constitution also contains pledges which the NHS is committed to achieving, supported by management and regulatory systems. The pledges are not legally binding because they express an ambition to improve, going above and beyond legal rights.’
DHSC, 2023b: 4
Reference is made to responsibilities, expectations on patients, staff and the public to helping the NHS work effectively, ensuring that NHS limited resources are used fairly.
An aspirational NHS?
In my view, The NHS Constitution paints a fairly rosy and upbeat portrayal of the NHS – more aspirational than one founded in everyday reality. The key point is that the Constitution creates expectations for everybody and some of these may in practice work out to be too optimistic and not founded in the everyday reality of the NHS. Therefore, public, patient and staff disappointment and disenchantment can set in and the whole concept of The NHS Constitution falls into disrepute.
An example here would be of a pledge relating to patient safety, which appears under the heading of complaints and redress:
‘ensure that when mistakes happen or if you are harmed while receiving health care you receive an appropriate explanation and apology, delivered with sensitivity and recognition of the trauma you have experienced, and know that lessons will be learned to help avoid a similar incident occurring again.’
DHSC, 2023a:13
We know from several past reports of investigations into patient safety crises that this is not always the case, and that the NHS has a poor track record in learning lessons from past adverse healthcare events. Another pledge example would be:
‘Provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution.’
DHSC, 2023a: 8
Many struggle to obtain GP appointments and reading this pledge will be uncomfortable reading for some. Other pledges include offering easily accessible, reliable, and relevant information in an understandable form, identifying and sharing best practice in quality of care, and so on.
The 10-year review
Legislation requires that The NHS Constitution be reviewed every 10 years and this is the time for its review. This will take place in the form of an open consultation (DHSC, 2024a). The government said it plans to publish an updated Constitution during 2024 and a revised accompanying handbook.
The consultation outlines the proposed changes to The NHS Constitution that the government intends to make. Proposed changes will be on areas such as responding to deterioration, health disparities, environmental responsibilities, patient responsibilities, research, leadership, sex, and gender reassignment and on other areas.
Healthwatch critique
A recent blog from Healthwatch (2024) offered a stinging critique of The NHS Constitution:
‘But 15 years later, amid struggles to get timely care and public satisfaction with the NHS at its lowest ever level, the Constitution is far from the “enduring” public touchstone envisaged.’
Healthwatch commissioned a poll to find out the extent to which the public knew about The NHS Constitution and what rights they wanted to see in it. The results are not surprising to those involved in patient safety policy making and practice.
The blog states that 1812 adults in England were polled and less than onequarter 24% had heard of the NHS Constitution. Awareness was even lower, the blog states, among people over 55, at just 12%. The blog discusses gaps in The NHS Constitution stating that it contains no minimum expectations on what primary care should deliver. In support for potential rights in a revised Constitution, Healthwatch states that 71% of those polled want an urgent GP appointment within 24 hours; 60% want the right to request a second opinion for seriously unwell people; 55% want to have any formal complaint they make about the NHS investigated and responded to within 28 days. There are other rights calls discussed in the blog, and it sets out in detail key changes needed for The NHS Constitution to make it more fit for purpose.
What's in a name?
A key point made by Healthwatch is the name, The NHS Constitution, and I have often thought about this. The name is wrong, it is too technical, obscure, and far removed from the experiences of most people. We need a better, more public-friendly name for the document:
‘A simple area to start with would be terminology. Abandoning the technocratic language of a “Constitution”, the document should become a genuine “NHS Patient Promise” that includes commitments more reflective of the public's daily experience of the NHS and cultural changes necessary to build a health service that belongs to us all.’
Conclusion
There is a lot going on in the NHS regarding health regulation, governance and patient safety and there is no sign of this high level of activity ever abating. This has been the situation for several years and it no doubt will be set to continue.
Presently this high level of activity is particularly noticeable with all the government consultations in the pipeline. At some point and, I would argue, much sooner rather than later, we do need to try to pause, reflect, consolidate, and rationalise what is going on with NHS patient safety, health regulation and governance as much as we can.
This I accept is much easier said than done given the importance of the subject area and the myriad number of stakeholders in the area. The review of the Constitution is a good opportunity to make long-term sustainable changes that will have a positive impact towards developing a proper NHS patient safety culture. Presently, as we have seen, there are major problems with it. The review of it will allow for some degree of reflection, consolidation and reset. It is, however, yet another review in a crowded area. An area that sees an ever-increasing amount of activity in terms of reports, consultations, initiatives, and changes. There are attendant dangers to this high level of activity.