Looking beyond the NHS Constitution to a meaningful Patient Promise
Launching the NHS Constitution in 2009, then Health Secretary Alan Johnson claimed the public would have, for the first time, “a clear, concise definition of their rights and responsibilities brought together in one place”.
If acted upon, the NHS Constitution has the power to shape NHS culture, providing direction to services on where to focus their efforts based on what the public expects.
It does this by setting out the core principles for the NHS, such as being there ‘for everyone’.
The Constitution also covers:
- expectations on clinicians and staff in their interactions with patients;
- responsibilities of patients when using services;
- patient rights enshrined through law;
- and pledges on quality and access to care – such as the various waiting time targets set out in the 90-page Handbook to 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.
Consultation
As part of a 10-yearly review of the NHS Constitution, the Department of Health and Social Care announced it is proposing a “limited” number of changes to the Constitution through a consultation, which runs until 25 June.
Have your say on the NHS Constitution.
In anticipation of this, Healthwatch England (HWE) commissioned polling to find out whether people were aware of the NHS Constitution and what they wanted to see regarding their rights.
Healthwatch England poll
The nationally representative poll, conducted by Savanta with 1,812 adults in England, found:
- The public has low awareness of the NHS Constitution.
- One of the rights people value the most is access to vital services, including being seen in A&E within four hours.
- People want to see new rights, such as an urgent appointment with a GP within 24 hours.
HWE believe a more fundamental overhaul – and rebranding – is needed to transform the Constitution into a meaningful contract between government, services, professionals and the public, which we would call the NHS Patient Promise.
Public views in more detail
Low awareness
The first challenge with the NHS Constitution is ‘brand recognition’ - less than one-quarter of the people we polled, 24%, had heard of it.
Awareness was even lower among people over 55, at just 12%. Even when asked more generally about awareness of their NHS rights, only one in three, 33%, people were “familiar” with them.
People told HWE they would welcome getting information about their rights from the NHS website, the NHS App, and appointment letters (the latter two of which currently contain little or no details on rights).
The public’s views on rights
The next challenge for the Constitution is that one of the key measures of its success is waiting time pledges that have long been unmet.
HWE's polling shows that existing constitutional targets on access are popular, but the NHS has not met those for A&E, cancer diagnosis, and planned operations in the last eight years.
Support for existing rights
- 77% of people want suspected cancer diagnosed or ruled out within 28 days of referral.
- 68% want to be seen in A&E within four hours.
- 65% want to receive specialist treatment in 18 weeks.
Gaps in the NHS Constitution
The existing targets are mainly focused on what happens in the hospital rather than the community, where most NHS care takes place. GP access is the single biggest issue that Healthwatch hears about, but the Constitution contains no minimum expectations on what primary care should deliver.
Our poll tested a list of potential rights currently not in the Constitution. These were based on themes reported by the public to Healthwatch, expectations in NHS England guidance and recent ideas from politicians.
Support for potential rights
- 71% want an urgent GP appointment within 24 hours
- 68% want to be able to book a GP appointment in the best way that suits them (in person, over the phone or online)
- 65% want to be able to have the type of appointment that suits them best with their GP (face-to-face, telephone or online)
- 60% want the right to request a second opinion for seriously unwell people
- 58% back having a single point of contact about their care
- 56% want to receive regular updates while waiting for care
- 55% want to have any formal complaint they make about the NHS investigated and responded to within 28 days.
The support for these shows that people don’t just want strengthened rights on access, but a Constitution that codifies overall experience of care.
More than two-thirds of the respondents, 68%, for example, said it was important that they could book a GP appointment in the way that suited them best (in person, over the phone or online); not everyone has internet access, disabled people may find it easier to communicate in person, and others may need to squeeze appointments around work.
Building on strong foundations
The Constitution correctly reflects the public's strong support for the NHS's core principles. Our polling showed the top overall ranked principles were:
- Being available to all
- Providing high-quality and safe care
- Being free to use
However, analysis of responses also shows that people from ethnic minority backgrounds ranked more highly the principle that the ‘NHS is accountable to the public, communities and patients it provides services to’ than respondents from white backgrounds.
This illustrates why a wider conversation is needed to reflect the diversity of public needs and expectations.
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.
We also need an honest, national conversation about the status of rights and pledges, which will only be meaningful if the public believes they will be adhered to. What recourse will patients have when the NHS does not meet standards, and how will the NHS Patient Promise become central to the planning, delivery, and evaluation of services?
Introducing more timely responses to complaints – for which there is no NHS-wide standard – would be a positive first step toward ensuring a mechanism for recourse. To simplify the complaints process, we would like a single service to triage complaints to ensure patients can navigate the multiple NHS providers, commissioners, regulators or safety bodies with overlapping remits.
National framework, local implementation
A consistent, national NHS Patient Promise is vital for a health service that is available to all.
However, our health system has moved towards a model of ‘local autonomy’ in which 42 Integrated Care Systems (ICSs) across England design, fund, and deliver care to meet the needs of their communities. The NHS Patient Promise would create an opportunity for commissioners and communities to discuss how to make good on rights, access pledges and mutual responsibilities.
This could be undertaken through the kind of a Citizens’ Assembly that the north London borough of Camden has adopted to inform its latest Health and Wellbeing Strategy.
This grassroots input should be supported by more explicit expectations from NHS England about how healthcare commissioners and providers should prove they are delivering on the Promise.
A new oversight framework due out this summer, which NHSE will use to score the performance of ICSs, could provide a way of ensuring that the Patient promise is being delivered.
Our asks
HWE believe a wider conversation is needed to strengthen the rights of patients. We ask:
- The government to relaunch the NHS Constitution to become the NHS Patient Promise.
- The government to run a national awareness campaign and ongoing, point-of-care promotion of NHS patient rights and pledges.
- Expansion of access pledges to cover maximum waiting times to be seen at your GP surgery.
- Patients to get the right to choose in-person, phone or online appointments at their GP surgery.
- More accountability for commissioners and providers on how they adhere to patient rights and pledges and clarity on recourse for patients if not met.
