Report on the effect of the NHS Constitution · the NHS Constitution. I also believe they will help the NHS better to meet them. In times of change, the Constitution provides continuity,

Report on the effect of the NHS Constitution

DH INfoRmAtIoN ReADeR BoX

PolicyHR/WorkforceManagementPlanning/Performance

ClinicalCommissionerDevelopmentProviderDevelopmentImprovementandEfficiency

EstatesIM&TFinanceSocialCare/PartnershipWorking

Document purpose Forinformation

Gateway reference 17834

title ReportontheeffectoftheNHSConstitution

Author DH

Publication date 4July2012

target audience PCTClusterCEs,NHSTrustCEs,SHAClusterCEs,CareTrustCEs,FoundationTrustCEs,MedicalDirectors,DirectorsofPH,DirectorsofNursing,LocalAuthorityCEs,DirectorsofAdultSSs,PCTClusterChairs,NHSTrustBoardChairs,SpecialHACEs,DirectorsofHR,DirectorsofFinance,AlliedHealthProfessionals,GPs,CommunicationsLeads,EmergencyCareLeads,DirectorsofChildren’sSSs

Circulation list

Description ThisreportseekstoclarifytheeffectoftheNHSConstitutiononthosewhouseNHSservicesandwhoworkintheNHS.Itconsiderswhether,andtowhatextent,theConstitutionhasmadeadifferencetopatients,staff,carersandthepublic,andexaminesthedegreetowhichitissucceedinginitsaims.

Cross reference NHSConstitutionforEngland

Superseded documents N/A

Action required N/A

timing N/A

Contact details NHSConstitutionTeamRichmondHouse79WhitehallLondonSW1A2NS02072105229www.dh.gov.uk/nhsconstitution

for recipient’s use

Report on the effect of the NHS Constitution

Presented to Parliament pursuant to Section 6(3) of the Health Act 2009

9103-TSO-NHS Constitution.indd 1 11:1104/07/2012

ContentsForeword..................................................................................................................................... 2

ExecutiveSummary...................................................................................................................... 4

1 Introduction............................................................................................................................ 6

Context................................................................................................................................... 6

Purposeofthereport.............................................................................................................. 6

ThedevelopmentoftheNHSConstitution............................................................................... 8

LegaldutiestopromoteandhaveregardtotheNHSConstitution........................................... 8

IntendedeffectoftheNHSConstitution.................................................................................. 9

2 AwarenessandunderstandingoftheNHSConstitution......................................................... 11

Context................................................................................................................................. 11

PublicawarenessoftheNHSConstitution.............................................................................. 12

StaffawarenessoftheNHSConstitution............................................................................... 16

SupportandvalueoftheNHSConstitutionamongstaff........................................................ 17

Conclusions........................................................................................................................... 18

3 RightsandpledgesintheNHSConstitution........................................................................... 20

Context................................................................................................................................. 20

Patientrightsandpledgesinpractice..................................................................................... 21

Staffrightsandpledges......................................................................................................... 31

Patientandstaffresponsibilities............................................................................................. 34

4 EffectoftheNHSConstitution.............................................................................................. 36

ProtectingtheprinciplesandvaluesoftheNHS..................................................................... 36

Empoweringpatientsandstaff.............................................................................................. 38

5 Conclusionsandnextsteps....................................................................................................40

AwarenessanduseoftheNHSConstitution..........................................................................40

SubsequentreportsontheeffectoftheNHSConstitution..................................................... 41

Nextsteps............................................................................................................................. 42

Annex1:AdvicefromtheNHSFutureForum............................................................................ 43

Annex2:ReviewoftheHandbooktotheNHSConstitution......................................................46

Annex3:Glossary......................................................................................................................48

ReportontheeffectoftheNHSConstitution

foreword

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TheNHSConstitutionbringstogetherinoneplacetheessenceofwhatmakestheNHSuniqueandspecial.Notonlydoesitgiveafocalpointtowhatthehealthserviceisallabout,itremindsusofwhattheNHSisstrivingtoachieveeachandeveryday.WhileitwasdevelopedanddraftedbeforeIbecameSecretaryofState,Isupported,andcontinuetosupport,theprinciplesandvaluesitcontains.ItsopeningparagraphisthemosteloquentexpressionofwhywealltreasuretheNHSandwhywemustsafeguarditsprinciplesandvaluesforthefuture.

IamgratefultotheNHSFutureForum,andtoitsChair,ProfessorSteveField,foradvisingmeontheeffectoftheNHSConstitution.Itsadvicehasinformedthisreport,thoughIamresponsiblefortheconclusionsexpressedhere.

AstheNHSFutureForummakesclear,theConstitutionisanenduringdocument.Ittranscendsprofessionandpolitics,commandingrespectandsupportfromallsides.WhentheConstitutionwaslaunched,itwassupportedbyMPsandPeersacrossbothHousesofParliamentandcontinuestoattractcross-partysupport.

OverthelasttwoyearstherehasbeenheateddebateabouthowwecanenabletheNHStogrowandthrive,butallpartiesremaincommittedtotheprinciplesandvaluesoftheNHSasexpressedintheConstitution.ThereformsthisGovernmenthasputinplace,includingTheHealthandSocialCareAct2012,arewhollyconsistentwiththeprinciplesoftheNHSConstitution.Ialsobelievetheywill

helptheNHSbettertomeetthem.Intimesofchange,theConstitutionprovidescontinuity,makingclearthattheprinciplesandvaluesofourNHSwillalwaysendure.

Iampleasedtoreportthat,inmostcases,theNHSisbroadlymeetingtherightsandpledgesintheNHSConstitution.Thatistobecelebrated.However,weshouldnotbecomplacent.Thereremainsscopeforimprovement–andwhereitdoes,theNHScanandmustdobetter.

AstheFutureForummakesclearinitsadvice,awarenessoftheNHSConstitutionremainslowandthereislittleevidencetheConstitutioniswidelyusedasameansofhelpingpatientsandstafftoupholdtheirrightsandthepledgesmadetothem.Thatiswhythe2012ActplacesnewlegaldutiesontheNHSCommissioningBoardandonclinicalcommissioninggroupsactivelytopromotetheNHSConstitution.IknowthatSirDavidNicholson,aschiefexecutiveoftheNHSCommissioningBoardAuthority,isalreadyexploringhowtheBoardcanfulfilthosedutiesandhelpembedtheprinciplesandvaluesoftheConstitutionacrosstheNHS.

IagreewiththeNHSFutureForumthattheNHSConstitutionprovidesanimportantmeansoftheSecretaryofStateholdingtoaccountallpartsofthesystem,includingallprovidersofNHSservices,fordeliveringonrightsandpledgesintheConstitutionandtheprinciplesandvaluesatunderpintheNHS.ThatiswhyOurNHScareobjectivesAdraftmandatetotheNHSCommissioningBoard(thedraftmandate)to


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theNHSCommissioningBoard,publishedtodayforconsultation,setsanobjectivefortheBoardtodemonstratethatpatientrightsandpledgesintheConstitutionarebeingmet.

AsSecretaryofState,IamcommittedtotheenduringprinciplesandvaluestheunderpinourNHS,andtoplayingmypartinimprovingknowledgeandunderstandingoftheConstitution.IhaveaskedtheNHSFutureForumtoconsiderhowwecanstrengthenandreinforcetheNHSConstitutionforthefuture,andconsiderhowwecanraisepublicandstaffawareness.IlookforwardtoreceivingtheadviceoftheFutureForumonpotentialchangestotheConstitutionintheautumn,afterwhichtherewillbeafullpublicconsultation.ItwillbeimportantthatanychangestostrengthentheConstitutiontakeaccountoftheoutcomesoftheFrancisinquiryintotheeventsatMidStaffordshireNHSFoundationTrust.

AstheopeningwordsoftheConstitutionstates,“theNHSbelongstothepeople”.TheprinciplesitwasfoundedonareasimportantnowastheywerewhentheNHSwascreated:healthcarefreeatthepointofuse,basedonclinicalneednotanindividual’sabilitytopay.AsSecretaryofState,itisagreatprivilege–andresponsibility–tobethecustodianofthoseprinciples.TheNHSarousesextraordinarypassionsanddevotion.Itaffectsusall.AndatitsheartaretheprinciplesandvaluesenshrinedintheNHSConstitution.

Andrew Lansley CBeSecretary of State for Health


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executive Summary

TheNHSConstitutionforEnglandbroughttogether,forthefirsttime,theprinciples,values,rightsandresponsibilitiesthatunderpintheNHS.ItsetsouttheenduringcharacteroftheNHSasacomprehensiveandequitablehealthservice;anditempowerspatients,staffandthepublictoknowandexercisetheirrightsinordertohelpdriveimprovementsinquality,efficiencyandresponsivenessthroughouttheNHS.

ThisisthefirstreportbyaSecretaryofStateontheeffectoftheNHSConstitution.IthasbeenpreparednotonlytomeetthelegaldutyimposedbytheHealthAct2009,buttounderstanditspracticalimpactoverthethreeyearssinceitslaunch.Itshowsustheprogresswehavemadeandthelessonsthatcanbelearnedforthefuture.

ThisreportseekstoclarifytheeffecttheConstitutionhashadonthosewhouseNHSservicesandwhoworkintheNHS.Itconsiderswhether,andtowhatextent,theConstitutionhasmadeadifferencetopatients,staffandthepublic,andexaminesthedegreetowhichitissucceedinginitsaims.

Overwhelmingly,patientsandNHSstaffbelieveitisimportantthattheNHShasaConstitutionandthemoretheyknowabouttheConstitutionthegreatertheirsupport.AstheNHSFutureForumsaidinitsadvice,itisnotsurprisingbutneitherisitsatisfactorythatpublicawarenessoftheConstitutionremainsgenerallylowandthereislittleevidencethatpatientsuseitasameansofexercisingtheirrights.Tosome

degree,thisreflectstheapproachadoptedatthelaunchoftheConstitutionoffirstraisingawarenessamongNHSstaff.StaffawarenessoftheNHSConstitutionissignificantlyhigherthanamongthepublicbutstillfewfeelwellinformedaboutit.

ThisreportnecessarilylooksattheperformanceoftheNHSagainsttherightsandpledgescodifiedintheNHSConstitution.Inmanycases,theevidenceiseitherlimitedinscope,onlypartiallyaddressestheeffectoftheConstitution,orsimplyalludestotheeffectsoftheConstitutioninchangingbehaviourandorganisationalculture.WhatmattersmosttopatientsandstaffisthattherightsandpledgessetoutintheNHSConstitutionaredelivered.Itisthereforeimportantthataclearevidencebaseforexaminingthisisestablished.

BycodifyingtheprinciplesandvaluesoftheNHS,theConstitutionwasintendedtohelpsafeguardtheNHSasanefficientandequitablehealthsystem,andtoempowerpatients,thepublicandstaffwithintheNHStochallengetheNHS,andpromptimprovementsinNHSperformanceiftheythoughtthattheywerenotbeingmet.

ThereportshowsthatthreeyearsonfromthelaunchoftheConstitution,theNHSremainstruetoitsfundamentalprinciplesandvaluesasexpressedintheNHSConstitution.ThoseprinciplesandvaluesareasrelevanttodayastheywerewhentheNHSwasfounded,andcontinuetoenjoystrongsupportfromthe


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public.TheNHScontinuestobeauniversal,comprehensiveservice,basedonclinicalneednotonanindividual’sabilitytopay.

Ingeneral,patientsdonotusetheNHSConstitutionasabenchmarkforchallengeandthissuggeststhattheConstitutionisnotyethavingtheeffectoriginallyintended.FortheConstitutiontohaverealeffect,itwillbevitaltoraiseawarenessandembeditateverylevelintheNHS.

TheHealthandSocialCareAct2012hasstrengthenedthelegalfoundationfortheNHSConstitution:theNHSCommissioningBoardandclinicalcommissioninggroupswillhavecleardutiestopromotetheNHSConstitution.TheDepartmentofHealthwillholdtheNHSCommissioningBoardtoaccountformeetingitslegaldutytopromotetheConstitution.ItwillalsoholdtheBoardtoaccountfordeliveringontherightsandpledgescontainedwithinit.


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1 Introduction

““FFoorr tthhee CCoonnssttiittuuttiioonn ttoo ssuucccceeeedd iinn iittss aaiimmss,, iitt nneeeeddss ttoo bbeeccoommee ppaarrtt ooff eevveerryyddaayy lliiffee iinn tthhe e NNHHSS ffoorr ppaattiieennttss,, tthhee ppuubblliicc aanndd ssttaaffff.. AAcchhiieevviinngg tthhiiss wwiillll rreeqquuiirree lleeaaddeerrsshhiipp,, ppaarrttnneerrsshhiipp aannd d ssuussttaaiinneedd ccoommmmiittmmeenntt oovveerr mmoonntthhss aanndd yyeeaarrss,, ttoo rraaiissee aawwaarreenneessss ooff tthhee CCoonnssttiittuuttiioonn aannd d wweeaavvee iitt iinnttoo tthhee wwaayy tthhee NNHHSS wwoorrkkss aatt aallll lleevveellss..””

HHaannddbbooookk ttoo tthhee NNHHSS CCoonnssttiittuuttiioonn

Context

1. the NHS Constitution brought together, for the first time, the principles, values, rights and responsibilities that underpin the NHS.ItsetsouttheenduringcharacteroftheNHSasacomprehensiveandequitablehealthservice;anditempowerspatients,staffandthepublictoknowandexercisetheirrightsinordertohelpdriveimprovementsinquality,efficiencyandresponsivenessthroughouttheNHS.

2. TheNHSConstitutionhasaframeworkinprimarylegislation,establishedbytheHealthAct2009.NHSbodiesandprivateandvoluntarysectorproviderssupplyingNHSservicesarerequiredbylawtotakeaccountoftheNHSConstitutionintheirdecisionsandactions.TheintentionisthattheConstitution,andwithittheethosoftheNHS,isembeddedateverylevelwithinthehealthserviceandamongthoseorganisationsprovidingNHSservices.

3. Whileanenduringdocument,toensuretheNHSConstitutionremainsup-to-dateandofcontinuingvaluetopatients,staff

andthepublic,theSecretaryofStatemustreviewandrepublishtheNHSConstitutionatleastonceeverytenyears,andreviewandrepublishtheHandbooktotheNHSConstitutioneverythreeyears.1

4. Toensurethatitsimpactisregularlyassessedandunderstood,theSecretaryofStatemustalsoreportontheeffectoftheNHSConstitutiononpatients,staff,carersandmembersofthepubliceverythreeyears.Bylaw,thefirstsuchreportmustbepublishedandlaidinParliamentby5July2012,the64thbirthdayoftheNHS.

Purpose of the report

5. this is the first report by a Secretary of State on the effect of the NHS Constitution. IthasbeenpreparednotonlytomeetthelegaldutyimposedbytheHealthAct2009,buttounderstanditsreal,practicalimpactoverthethreeyearssinceitslaunch.Itshowsustheprogresswehavemade,aswellasthelessonsthatcanbelearnedforthefuture.

1 ThefirstreviewoftheHandbooktotheNHSConstitution,asrequiredundersection5oftheHealthAct2009,isattachedatAnnex2.


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6. ReviewingtheNHSConstitutionshouldnotbeatechnicalortick-boxexercise.Doingsoregularlyandobjectivelycanhaverealvalue,helpingtoensuretheConstitutiondoesnotsimplysitontheshelfandgatherdust,orbecomeadocumenttowhichonlylipserviceispaid.Itmakesuslookcriticallyathowtogetherpatients,staffandthepubliccanensuretheConstitutioniswovenintothefabricofeverythingtheNHSdoes–theunderlyingobjectivewhenitwaslaunched.

7. ThisreportseekstoclarifytheeffecttheNHSConstitutionhashadonthosewhouseNHSservicesandwhoworkintheNHS.IthasbeendevelopedwiththeadviceoftheNHSFutureForum,whoseletterofadvicetotheSecretaryofStateispublishedalongsidethisreport.

8. Thereportconsiderswhether,andtowhatextent,theConstitutionhasmadeadifferencetopatients,staffandthepublic,andexaminesthedegreetowhichitissucceedinginitsaims.Itfocusesontwocorethemes:

• levels of awareness of the NHS Constitution,toestablishtheextenttowhichthepublicandstaffwhoworkintheNHSareawareoftheConstitution,feelinformedaboutitscontent,andsupportitsexistence;

• the role of the Constitution in ensuring rights and pledges are delivered,toexploretheextenttowhichthe

Constitutionhashadanimpactinhelpingpatientsandstafftoexercisetheirrightsandenjoythepledgesmadetothem.

9. WhatmattersmosttopatientsandstaffisthattherightsandpledgessetoutintheNHSConstitutionarebeingdeliveredinpractice.ThisisnotageneralreportonNHSperformance;otherreports,notleastThe Year: The NHS Chief Executive’s Annual Report 2011/12andThe Health Service in England: The Secretary of State’s Annual Report 2011/2012,offerthatoverview.ButperformanceisrelevanttounderstandingtheeffectoftheConstitutiontodateandisconsideredinthiscontext.

10. the report is necessarily retrospective.ButlookingbackattheeffecttheConstitutionhashadtodatedoeshighlightlessonsthatcanbedrawnforthefuture.Forexample,ithelpsclarifythescaleofthetaskaheadintermsofraisingpublicandstaffawarenessandindicateswheremoreneedstobedone.

11. DiscussionofpotentialchangestostrengthenandreinforcetheNHSConstitution,however,arebeyondthescopeofthisreport.TheNHSFutureForumwillbeconsideringthisoverthesummerandwilladvisetheSecretaryofStateintheautumn.Therewillbeapublicconsultationonanyproposedchangeslaterthisyear.


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the development of the NHS Constitution

12. TheNHSConstitutionwasfirstpublishedon21January2009andgivenlegaleffectlaterthatyearbytheHealthAct2009.Itwastheproductofextensivediscussionswithpatients,staffandthepublicaboutwhatmatteredmosttothemabouttheNHSandfollowedapublicconsultation,overseenbyaConstitutionalAdvisoryForumcomprisingleadingexpertsandstakeholders.

13. Throughthisengagement,theConstitutionwasintendedtohaveenduringmeaningandvaluetopatients,staffandthepublicwhowouldfeelasenseofownershipofit.Fromtheoutset,ithasenjoyedwidespread,cross-partysupport.

Legal duties to promote and have regard to the NHS Constitution

14. TheHealthAct2009placesadutyonbodiesprovidingandcommissioningNHSservicestohaveregardtotheNHSConstitution.2Lookingahead,thoughbeyondthescopeofthisreport,theHealthandSocialCareAct2012appliesthisdutytothenewbodiessetupbytheAct,aswellastolocalauthorities,3sothatinplaceofPrimaryCareTrustsandStrategicHealthAuthorities,itwillapplyto

clinicalcommissioninggroupsandtheNHSCommissioningBoardand,forexample,theHealthandSocialCareInformationCentre.

15. ThereisalsoadutythatrequiresanyonewhoprovidesNHSservicesunderacontract,agreementorarrangementsmadebytheSecretaryofState,theNHSCommissioningBoard,clinicalcommissioninggroupsorlocalauthoritiestohaveregardtotheNHSConstitution.ThisissetoutintheHealthAct2009,asamendedbytheHealthandSocialCareAct2012.

16. The2012ActalsointroducesnewdutiesonclinicalcommissioninggroupsandtheNHSCommissioningBoardto:

• actwithaviewtosecuringthathealthservicesareprovidedinawaywhichpromotestheNHSConstitution;and

• promoteawarenessoftheNHSConstitutionamongpatients,staffandmembersofthepublic.

17. The2012ActalsoplacesadutyontheSecretaryofStatetohaveregardtotheNHSConstitution.ThenewdutyontheSecretaryofStatewillensurethathehastobearinmindtheprinciplesoftheConstitutionwhenheisexercisinghisfunctionsinrelationtothehealthservice.

2 HealthAct2009,Section2.http://www.legislation.gov.uk/ukpga/2009/21/contents.(AccessedJune222012)

3 ThenewdutyonlocalauthoritiestohaveregardtotheNHSConstitutionappliesinrelationtothepublichealthfunctionsoflocalauthoritiesundersection2BoftheNHSAct2006(insertedbytheHealthandSocialCareAct2012).


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Intended effect of the NHS Constitution

18. TheConstitutionwasintendedtoachievetwocoreobjectives:tosafeguardtheNHSasanefficientandequitablehealthsystem,andtoempowerpatients,thepublicandstaffwithintheNHS.

19. Toachievetheseaims,theNHSConstitutionsetsout:

• theunderlyingprinciplesandvaluesoftheNHS;

• therightstowhichpatients,publicandstaffareentitled;

• thepledgeswhichtheNHSiscommittedtoachieve;and

• theresponsibilitieswhichthepublic,patientsandstaffowetooneanothertoensuretheNHSoperatesfairlyandeffectively.

20. UnderstandinghowtheseareintendedtoworkisfundamentaltoassessingtheeffectoftheConstitution.

21. AstheoriginalImpactAssessmentoftheNHSConstitutionmadeclear:“byclarifyingthefundamentalsthatwillnotchange–throughestablishingaconsensusandarticulatinginanenduringwaytheNHS’s purpose, principles and values–progressinmeeting21stcenturychallengeswillbeeasier”.4Accordingtotheimpactassessment,notonlywouldthishelpthe

NHSdealwithemergingchallengesofrisingexpectations,technologicaladvancesandshiftsinthewayservicesweredelivered,italso“becomeseasierforthirdsectorandindependentorganisationsprovidingNHScaretoknowwhatbehaviourisexpectedofthem:itbindsallorganisationsprovidingNHScaretoacommonpurpose”.5AkeytestfortheConstitutionwas,therefore,itsabilitytoensurethatthevaluesandprinciplesoftheNHSwerefullyembeddedasanenduringpartofthefabricofthehealthservice.

22. Bysettingoutthelegal rights of patients and staff,theNHSConstitutionwasintendedtoempowerpatients,publicandstaffthroughhelpingthemtounderstandwhattheycouldexpectfromtheNHS.Likewise,byarticulatingeveryone’sresponsibilitiestoeachother,andexplaininghowpatientsandthepubliccanplaytheirpartandseetheNHSasapartner,theConstitutionwasintendedtohelpeffectachangeinbehaviour;provokingchallengeandmutualresponsibility.

23. Forpatients,theintentionwasthatthiswouldhelpequipthemtochallengeNHSservices,therebyencouragingimprovementsinquality,efficiencyandresponsivenessthroughouttheservice

4 ImpactAssessmentoftheNHSConstitution,30June2008(publishedalongsideconsultationdocuments).http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085852.pdf(Accessed22June2012)

5 ImpactAssessmentoftheNHSConstitution,21January2009.ttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093416.pdf.(Accessed22June2012)

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093416.pdf


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andapplyingpressureoncommissionerstoreduceunjustifiedvariationsinNHSservices.Forstaff,theConstitutionwasintendedtosupportfullerengagementwiththeiremployersandtoempowerthemtodevelopbetterservicesforpatientsonthebasisthatfullyengagedstaffarelikelytobemorecommittedtotheirworkandtheiremployer,andto“gotheextramile”inimprovingservices.

24. AccordingtothereportoftheConstitutionalAdvisoryForum,whichhelpedadvisetheDepartmentofHealthontheoriginalNHSConstitution,theConstitutionwasmeanttoachieveitsobjectivesthroughthefollowingmeans:

• Local leadership:TheConstitutionalAdvisoryForumwereclearthat“localleadershipandchampionsatalllevelsofthesystemwillbecriticalinthetranslationofwordsintodeeds”.Itfoundthatthereneededtobesustainedcommitmentbylocalleaders–bothamongcommissionersandNHSproviders–overmonthsandyearstopromoteandembedtheConstitution.

• Involvement of staff:Again,theConstitutionalAdvisoryForumfoundthat“theinvolvementofstaffinthedevelopmentandembeddingoftheConstitutioniscriticalbothinitselfandasabasisforengagingpatientsandthepublic.”Itsuggestedthatnon-executive

directorsofNHSbodieswerewell-placedtobecome“localambassadorsfortheConstitution.”

• effective communication:TheConstitutionalAdvisoryForumconcludedthat“acriticalsuccessfactorforensuringtheConstitutiontakeseffectwillclearlybetheapproachtakenatlocalandnationallevelstocommunicatingitscontentsandtheirmeaning.”TheForumemphasisedtheimportanceoftheConstitutionbeingaccessibletoallandofusingarangeofformatsandcommunicationschannelstoraiseawareness.6

25. ThisreportfirstconsiderstheextenttowhichthepublicandNHSstaffareawareoftheNHSConstitution.ThisisthesubjectofChapter2.Chapter3considerstheroleoftheConstitutioninensuringthatrightsandpledgesaredeliveredinpractice.Chapter4offersconclusionsabouttheeffectoftheConstitutionthreeyearsonfromitslaunchin2009.ThefinalchapterdrawstogetherthekeyconclusionsofthereportandsetsoutnextstepsforstrengtheningandreinforcingtheConstitutionforthefuture.Annex2providesareviewoftheHandbooktotheNHSConstitutionasrequiredundersection5oftheHealthAct2009.

6 ReportoftheConstitutionalAdvisoryForumtotheSecretaryofStateforHealth,December2008,pp27-28.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_091761.pdf(Accessed22June2012)


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2 Awareness and understandingof the NHS Constitution

Summary

• PublicawarenessoftheNHSConstitutionisrelativelylow(27%)andpatientsarenotyetusingtheConstitutionasameansofexercisingtheirrights.However,intheEastofEngland,wheretherehavebeenconsiderableeffortstoembedtheNHSConstitutionintotheorganisation,publicawarenessissignificantlyhigherthanaverage(41%).

• StaffawarenessoftheNHSConstitutionissignificantlyhigherthanamongthepublicbutfewfeelwellinformedaboutit.

• Overwhelmingly,NHSStaffbelievethatitisimportantthattheNHShasaConstitutionandthisrisesfrom72%to90%forthosewhofeelmostknowledgeableaboutit.

• FortheNHSConstitutiontohaverealimpactandbetrulyvalued,supportedandusedbypatients,staff,carersandthepublic,itwillbevitaltoraiseawarenessandembeditateverylevelintheNHS.

Context

26. TheNHSConstitutionwasintendedtoempowerpatients,publicandstaffbyhelpingeachgrouptounderstandwhattheycouldexpectfromtheNHS.Forpatients,theideawasthatthiswouldprovokechallenge(therights)andsharedresponsibilitiesforNHSservices.Forstaff,therightsandresponsibilitieswereintendedtoimproveengagementwiththeiremployersandtoempowerthemtodevelopbetterservicesforpatients.

27. ThenationalapproachtocommunicatingtheNHSConstitution,andtoachievingtheintendedgoalofpatientandstaffempowerment,adoptedbythepreviousGovernmentwastofirstpromoteitsvaluesandkeymessagestoNHSstaffbeforepromotingittothepublic.Byfirst

makingstaffaware,theintentionwastoenablethemtounderstandandapplytheprinciplesandvaluesoftheNHSConstitution,whilealsofeelingconfidenttodiscussitwiththepublicandtheirpatients.TheGovernmentagreesthatthisstrategyoffirstraisingawarenessoftheConstitutionamongstaffwasthecorrectapproach.

28. AnidentityfortheNHSConstitutionwascreatedtogiveasenseofcohesionaroundallcommunications,andthiswastestedthoroughlywithstaffandpublicfacingfocusgroups.

29. ThisidentitywasappliedtoNHSfacingmaterialstosupportlocalengagementaspartofacommunicationstoolkitincludingartworkfiles,documents,filmsandane-learningtool.Publicfacingcommunicationactivityfollowedandthis


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includedashortfilmfortheLifeChannel(runinGPsurgeries),adigitalmediacampaign,aPRandmediacampaignandcommunicatingthroughpartnershipswithstakeholders.

30. SomeorganisationswentfurtherthanthenationalapproachandthecasestudyfortheEastofEngland(pages14and15)showstheeffortsmadetointegratetheNHSConstitutionintoitsorganisationalculturethroughleadershipandassertiveaction.TheEastofEnglandStrategicHealthAuthorityapproacheditsdutytohaveregardtotheConstitutionbyensuringthatitwasafocusforeverythingtheorganisationdid.TheeffectofthishasbeennotonlytomakestaffmoreawareoftheNHSConstitutionbutconsequently,membersofthepublictoo.

Public awareness of the NHS Constitution

‘If the NHS Constitution is to be a living document with real power and ability to improve care then patients and the public must first be aware of it’

Patients Association, 15 June 2012

31. ThereareseveralfacetstotheawarenessoftheNHSConstitutionamongpatients,staff,carersandthepublic:

• awarenessthatthereisaNHSConstitution;

• understandingwhattheNHSConstitutionmeansforthem;

• knowinghowtousetheNHSConstitutionsotheyfeelempowered;and

• valuingtheNHSConstitutionsoitbecomesfullyembeddedwithineveryleveloftheNHS.

32. InordertogaugeawarenessandattitudesofNHSstaffandmembersofthepublictotheNHSConstitution,theDepartmentofHealthcommissionedindependentresearch.Threewavesofresearchwerecarriedoutin2009,2010and2012usingthesameapproachandmethodology,whichhasallowedustotrackanychangesovertime.Assuch,NHSstaffinthisreportreferstomedical/professionalstaffandadministrativeassistants.However,ontheadviceoftheNHSFutureForumworkinggroupontheNHSConstitution,theDepartmentcommissionedadditionalresearchofNHSpaybands1-4,focusingonnursingauxiliariesandhealthcareassistantswhohaveasignificantamountofpatientcontact.Asthisresearchwasconductedin2012only,anycomparisonsmadebetweennursingauxiliariesandhealthcareassistantsareonlymadebetweenotherprofessionalgroupsfor2012ratherthantheNHSstafffigureorpreviousyears.


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33. Researchcarriedoutin2012revealsthatpublic awareness of the NHS Constitution remains relatively low.Giventhedecisiontofocusfirstonincreasingawarenessamongstaff,thisisnotsurprisinganditisimportantthattheheadlineawarenessfiguresareseeninthiscontext.TherehasbeenasmallriseintheawarenessoftheConstitutionamongthepublicsinceitslaunchhowever,in2012lessthanafifthofpeoplehaveheardoftheConstitutionbynameandaquarterwereawareofitbyitsdescription.7

34. Morethantheheadlineawarenessfigures,however,akeytestoftheeffectoftheNHSConstitutionistheextenttowhichpeopleareusingitasameansofupholdingtheirrightsandthepledgesmadetothem.Thesurveydemonstratedthatlessthan1%ofpatientscitedtheNHSConstitutionasasourceforfindingoutinformationaboutwhattheycouldexpectfromtheNHS,theirrightsaspatients,orwhattodoiftheydidnotgetwhattheyexpected.PatientsaremostlikelytoaskaGP/Healthprofessional8orgototheNHSChoiceswebsite9forinformationandaround5%ofthepublicmentionedGoogleasasourceforinformation.

35. Amongstaff,only1%reportedthatapatienthadaskedthemabouttheNHSConstitution,andjust3%hadencounteredapatientexercisingtheirrightsthroughtheConstitution.ThisisconsistentwiththelowlevelofknowledgeabouttheNHSConstitutionamongthepublic.

36. Thereisregionalvariationinthelevelofpublicawarenessrangingfrom16%intheSouthCentralregionto41% in the east of england SHA region where public awareness is significantly higher than average.TherehasalsobeenasignificantincreaseinawarenessovertimewithintheEastofEnglandregion;in2009,24%wereaware.Itisnoteworthythatin2010,NHSstaffintheEastofEnglandweremoreawareoftheNHSConstitution(61%)thanaverage(50%).Thisreflectedgreatereffortstoraisestaffawareness(seepages16and17)withtheawarenessresearchshowingthatstaffweremorelikelythanaveragetohaveencounteredtheNHSConstitutioninsomeway,particularlythroughinternalcommunicationse.g.astaffmeeting(21%comparedwith13%onaverage).

7 ThedescriptionprovidedabouttheNHSConstitutionwas“In2009,forthefirsttimeinthehistoryoftheNHS,anNHSConstitutionwascreated.Thisdocumentreflectswhatmatterstostaff,patientsandthepublic.ItsetsoutwhatstaffandpatientscanexpectfromtheNHS.Italsodescribestheresponsibilitieswhichthepublic,patientsandstaffhavetowardseachothertoensurethattheNHSoperatesfairlyandeffectively”.

8 ThepublicaremostlikelygotoaGP/healthprofessionaltolookfordifferenttypesofinformationabouttheNHS(44%);whattheycanexpectfromtheNHS(44%);aboutwhattheirresponsibilitiesareasapatient(35%);andwhatyoucandoifyoudon’tgetwhatyouwantfromtheNHS(28%).

9 TheNHSchoiceswebsiteisalsofrequentlymentionasasourceofinformationabouttheNHS(36%);whattheycanexpectfromtheNHS(36%);aboutwhattheirresponsibilitiesareasapatient(29%);andwhatyoucandoifyoudon’tgetwhatyouwantfromtheNHS(26%).


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east of england case studyResearch shows that awareness of the NHS Constitution in the east of england is significantly higher among NHS staff and the public than in the rest of england – 41 per cent of the public were aware of the NHS Constitution in the east of england compared with 27 per cent nationally. We asked the east of england Strategic Health Authority what approaches it took to build on the national communications approach to promote and embed the NHS Constitution among its staff and population.

‘TheNHSConstitutiontookholdintheEastofEnglandbecauseitwaspromotedfromtheverytopofourorganisations.TheleadershipfromourChairsandNon-ExecutiveswaspassionatebecausetheyunderstoodtheNHSConstitutiontobecorebusiness–improvingthequalityofservicesforpatientsbysupportingourstafftodothebestjobpossible.ThispassionwassupportedandbroughtalivebythecommunicationsandengagementteamswhowereambitiousandinnovativeintheirapproachandalignedtheConstitutiontoexistingcampaignsandmessages.TheNHSConstitutionalsoveryquicklybecamethetapestryhangingbehindBoarddiscussionssoitsvisibilityandrelevancewasreal.’

Dr ed Garratt , former head of communications for NHS east of england.

engaging the Public

Fromthestart,theaimwastobringtheConstitutiontolife,helpingmembersofthepublicandallNHSstafftounderstandwhattheConstitutionmeanttothem.

NHSorganisationsacrosstheEastofEnglandmadetremendouseffortstoengagetheirlocalpopulationsandwhereverpossiblereferredtotheNHSConstitutionaspartofthisengagementprocess.Forexample,whenmixedsexaccommodationwaseliminatedintheregion,patientsandthepublicwereremindedoftherightwithintheConstitutiontobetreatedwithdignityandrespect.Also,guidancegiventoGPstohelpthemcommissionspecialisedservicesforpatientswitheatingdisordersmadeclearthatpatientshadarightundertheConstitutiontobeseenwithin18weeksofreferral.

InHertfordshire,allNHSorganisationsworkedjointlyontheNHSConstitution,activelyengaging17‘seldomheard’groupsincludingblackminorityethnic(BME)communities,prisonersandcarersaboutit.Inaddition,NHSMidEssexdistributedcopiesoftheConstitutiondocumentthroughoutthePCTarea,suchasinlibraries,counciloffices,andGPsurgeries.


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PublicengagementeventswereusedasopportunitiestodiscussandpromotetheNHSConstitution.NHSSouthWestEssex,forexample,targetedtheirlocaluniversity/collegefreshers’weekinBasildon.NHSGreatYarmouthandWaveneyincludedtheConstitutioninastayinghealthycompetitionforallschoolsinGreatYarmouthBoroughCouncilandWaveneyDistrictCouncilAreas.Inaddition,PCTssuchasNHSGreatYarmouthandWaveney,NHSNorfolkandLutonPCTengagedwiththeirlocalcommunitiesabouttheConstitution.*TrustChairsalsospokeatYouthCouncilsandPensionersAssociationsaroundtheregion.

*TheWaveneyCommunityCohesionPartnership;NorfolkPhysicalandSensoryImpairmentStrategyWorkingGroup,SuffolkDisabilityActionGroup;GreatYarmouthDisabilityForumtheNorfolkCoalitionforDisabledPeople;NorfolkOlderPeoplesForum;BroadlandDisabilityForum;andtheNorwichandDistrictCarersForum.

engaging Staff

TheNHSConstitutionwasplacedattheheartofallNHSorganisationsinEastofEngland.SeniorleadersintheregionusedeveryopportunitytoactaschampionsoftheNHSConstitutionandstaffatalllevelswereencouragedtoreadanddigestthedocumentandthinkaboutwhatitmeantforthemwhenmakingdecisionsandintheirdaytodaywork.Thisinturngavethemtheconfidencetotalktopatientsaboutittohelpraiseawareness.

Atboardlevel,alldiscussionsanddecisionstookaccountoftheNHSConstitution.DetailsofhowtheConstitutionwastakenintoaccountwereineveryboardpaperanditsprinciples,rights,pledgesandresponsibilitieswereusedtohelpreviewongoingexistingwork.TheSHAChair(SirKeithPearson)heldPCTChairstoaccountviatheirperformanceappraisalsforpromotingtheNHSConstitutionwithintheirorganisations.SeniorleadersalsotookopportunitiestobeambassadorsfortheNHSConstitution,promotingitwhentalkingwithexternalorganisations.

AtHinchingbrookeHospital,seniormanagersrecognisedthevalueoftheNHSConstitutionforstaffengagementinthecorevaluesoftheorganisation.ItusedtheConstitution’srights,pledges,responsibilities,andexpectationsastheframeworkforitsstaffengagementprojectandtherefreshofitsstaffcharter.Examplesincludedmoredirectorvisibilityandrunningaprogrammeofdirectorinvolvementindepartmentalteambriefings,withadirector/chiefexecutive“buddying”adepartment.ThehospitallaunchedsomeoftheideaswitharefreshedstaffcharterusingtheConstitutiontomakeitmoremeaningful.”

InnovativeapproachestocommunicationwerealsousedtohelpincreasethevisibilityoftheNHSConstitutionandraiseawareness.Forexample,theydevelopedadedicatedEastofEnglandNHSConstitutionwebsite,(audio)blogs,Facebookpages,andmembersofstaffincorporatedlinkstotheConstitutionintheiremailsignatures.Insteadofthetraditionalapproachtoconsultation–forexample,throughpublicmeetings–NHSMidEssexcreatedanaudioblogtomakethefeedback‘reallife’and‘meaningful’,andwidelyavailablewww.midessex.nhs.uk.


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Staff awareness of the NHS Constitution

37. Among NHS staff, awareness of the NHS Constitution is significantly higher than among the public.Thisreflectstheoriginalcommunicationsstrategyofraisingawarenessamongstaffbeforedoingsoamongpatients.NHSstaffarenowsignificantlymoreawareoftheNHSConstitutionwhenpromptedwithitsname.Thishasincreasedfrom31%in2009to45%in2012.WhenprovidedwithadescriptionoftheConstitution,NHSstaffawarenessrosetoaroundhalf(54%);thishasincreasedonlyslightlyfrom47%in2009.TheseresultsshowthatwhilstthecombinedawarenessoftheNHSConstitutionremainssimilarto2009,theNHSConstitutionnameisbecomingmorefamiliarwithstaff.

38. Awareness differs between different staff groups.Administrativestaffhavingthelowestawareness(34%),justoverhalfofnursingauxiliary/nursingassistants(52%)andhospitalnurses(58%)areawareandmanagershavethehighestawarenessat87%.there have been however, significant increases in awareness amongst a number of different occupationsincludingGPs(78%awarein2012),practicenurses,hospitalnurses,dentistsandmanagers.Throughoutallthesurveysonawareness,managerswereconsistentlymorelikelythanotheroccupationstobeawareoftheNHSConstitution(87%ofmanagerscomparedwith54%ofallNHSstaff).However,thisdoesnotprovethattheNHSConstitution

isbeingusedbythesegroupsandraisesquestionsaboutwhether,andtowhatextent,theNHSConstitutionisusedbyorganisationsinconductingtheirbusiness,forexampleinstaffinductions,educationandtraining.

39. In2012,thesourcesfromwhichNHSstaffheardabouttheNHSConstitutionhadnotchangedsignificantly.Staffprimarilygainedinformationthroughthemainstreamandmedicalpress–thiswasparticularlytrueforGPs.Incontrast,managersweremorelikelytohaveheardfromemailsandbulletins(20%)andtheDHwebsite(13%).

40. ItisonethingtoknowthattheNHSConstitutionexistsortohaveheardofitbutanothertobeknowledgeableaboutitscontents,howtouseit,andwhattodo–andwhotospeakto–ifrightsandpledgesarenotbeingdelivered.ThisiskeyifstaffaretobeabletousetheConstitutioneffectivelyasameansofupholdingtheirrightsandthepledgesmadetothem.

41. TheresearchalsolookedathowinformedstafffeltabouttheNHSConstitutionanditskeyelements.In2012,threeyearsaftertheNHSConstitutionwaslaunched,onlyaroundoneintenstaffsaidtheyfeltveryorfairlywellinformedabouttheNHSConstitution.Asinpreviouswavesofresearch,managersweremorelikelytosaythattheywerewellinformed(36%ofmanagerscomparedwith11%ofhospitaldoctorsand8%ofnursingauxiliaryandhealthcareassistantsandpracticenursesin2012).


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42. Theresearchshowsthatemailsandbulletins,conversationswithcolleagues,anetworkorteammeeting,ortheDHwebsitearethemosteffectivemethodofcommunication.In2010,staffthatweresurveyedintheEastofEnglandweremorelikelytohaveencounteredtheNHSConstitutionthroughoneoftheinformationstreamsaboveandalsomorelikelythanaveragetofeelinformedabouttheNHSConstitution(26%,comparedwith14%onaverage).

43. Whilst few staff feel they are well informed about the NHS Constitution a greater proportion are aware of its main elements.Whenpromptedwithadescription,nearlytwofifthsofstaffwereabletorecallallthemainelementsoftheNHSConstitution,withasignificantincreaseineachoftheseelements(exceptpatients/staffrights)comparedwithpreviousyears.AwarenessofGPs,practicenurses,hospitalnurses,hospitaldoctors(formostelements)andmanagersallincreasedsignificantly.Notably,since2009awarenessofthemainelementshasnotincreasedindentists,pharmacistsandadministrativestaff.TheproportionofstaffwhoareawareofthekeymessagesoftheNHSConstitutionhasalsoincreasedslightlysince2009,withasignificantincreaseintheproportionofNHSstaffawarethattheNHSConstitutionsecuresthefoundingprinciplesoftheNHS(from23%in2009to32%in2012),whichwasdrivenmainlybymanagers.

Support and value of the NHS Constitution among staff

44. overwhelmingly, NHS staff believe that it is important that the NHS has a Constitution and this rises from 72% to 90% for those who feel most knowledgeable about it.SupportamongNHSstafffortheNHSConstitutionhasfallensince2009,from63%to55%in2012butthisisaresultofstaffrespondingmoreneutrallythattheyneithersupportnoropposeit.

45. over 70% of NHS staff agree that it is important that the NHS has a Constitution compared with 90% of staff who consider themselves very or fairly knowledgeable about it.Justoverhalf(52%)ofallNHSstafffeltthattheNHSConstitutionwouldhaveapositiveimpactonpatientexperienceoftheNHScomparedwith78%ofNHSstaffwhofeltknowledgeableaboutit.Since2009,NHSstaffhavebeenmorelikelytosaythattheNHSConstitutionwouldhaveapositiveimpactonpatients(52%)comparedwiththeimpactonthem(41%).In2012,nursingauxiliaryandhealthcareassistantswerethemostlikelystaffgrouptosaytheNHSConstitutionwouldhaveapositiveimpactonpatientexperience(65%)comparedwithGPswhowerethelowestat30%.Again,staff who felt knowledgeable about the NHS Constitution were more likely than average to say that it would have a positive impact on them (68%).


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46. ThedeclineinsupportfortheNHSConstitutionwasdrivenbyanincreaseintheproportionofNHSstaffwhoansweredneutrallythattheyneithersupportnoropposeit(from25%in2009to34%in2012).Hospitalnurseswerethemainprofessionthatcontributedtothischange.Asin2009,theyweremorelikelythanaverage(77%ofhospitalnursescomparedwith56%ofallNHSstaff)tosaythesupportedtheNHSConstitution,butby2010werenomorelikelythanallNHSstafftosupportit(54%ofhospitalnursescomparedwith56%ofallNHSstaff).

47. TheevidencesuggeststhatagreaterawarenessoftheNHSConstitutionanditscontentscanincreaseoverallsupport.Forexample,in2012GPsandhospitaldoctorsweresignificantlymorelikelytobeawareoftheConstitution.Theywerealsomorelikelytobesupportiveofit.

Conclusions

48. Threeyearsonfromitslaunch,thedrivetoraiseawarenessoftheNHSConstitutionamongstaffandthepublicneedstocontinue.WhilstitisencouragingthatcertainstaffgroupssuchasmanagersareveryawareoftheNHSConstitution,itisunsatisfactorythattherearelargevariationsbetweendifferentoccupationswithlowerawarenessinsomegroupsthathavethegreatestpatientcontact.

49. Itisperhapsnotsurprisingthatawarenessamongthepublicislowgiventheapproachtofirstraiseawarenessamongstaff.However,wherehigherlevelsofstaffawarenesshasbeenachieved(e.g.EastofEngland),theNHSConstitutionissupportedandvaluedbystaffwiththeaddedeffectofincreasingawarenessamongstthepublic.

50. Whilstitisencouragingthatawarenessamongpatientsandstaffisincreasingyearonyear,thereneedstobemorefocusonraisingawarenessamongallstaffwhatevertheiroccupationandincontinuingtofocuseffortstoraisepatientandpublicawarenessoftheNHSConstitution.

51. AwarenessamongNHSstaffandthepublicisimportantbutthisisonlyonefactor–patientsandstaffalsoneedtobeabletousetheConstitutionasameansofupholdingtheirrightsandthepledgesmadetothem.WhatcomesthroughfromthisresearchisthatalthoughawarenesslevelsarerisingamongNHSstaffandthepublic,thereislittleevidencethatpatientsandstaffareusingtheNHSConstitutionindiscussionsaboutthepatientscareorthestaffmembersemployment.ThisalsoechoestheadviceoftheNHSFutureForum.

52. AllNHSorganisations,astheycarryouttheirdutiestohaveregardtotheNHSConstitution,haveagreatopportunitytotakeadvantageofthelessonslearnedfromthisresearch.Inparticular,thereareclearbenefitsofintegratingtheConstitution


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throughouttheNHSandusingittofocusitsworkwiththepublicandpatientsandtheirstaffateverylevel,astheworkcarriedoutintheEastofEnglanddemonstrates.

53. TheHealthandSocialCareAct2012placescleardutiesontheNHSCommissioningBoard,andonclinicalcommissioninggroups,topromotetheNHSConstitution.ThismeanspromotingawarenessoftheConstitutionamongpatients,staffandthepublic.ItalsomeansthattheBoardmustexerciseitsownfunctionsinawaythatpromotestheConstitution.Rightly,itwillbefortheNHSCommissioningBoardtodeterminepreciselyhowitwillfulfiltheselegalduties.

54. AstheNHSFutureForummakesclearinitsadvice,theNHSConstitutionprovidestheSecretaryofStatewithameansofholdingtoaccountallbodiesinvolvedinthecommissioningandprovisionofNHSservicesfordeliveringonboththerightsandpledgesintheConstitutionandtheprinciplesandvaluestowhichtheNHSadheres.TheDepartmentofHealthwillholdtheNHSCommissioningBoardtoaccountformeetingitslegaldutytopromotetheNHSConstitution.ItwillalsoholdtheBoardtoaccountfordeliveringontherightsandpledgescontainedwithinit.

55. ThiswillbeachievedthroughtheGovernment’sdraftmandatetotheNHSCommissioningBoard(thedraftmandate),whichsetsouttheGovernment’sobjectivesfortheBoard.Thedraftmandate,on

whichapublicconsultationhasnowbeenlaunched,setsanobjectivefortheBoardtodemonstratethattherightsandpledgesintheNHSConstitutionarebeingmet.

56. Inlinewiththedutiesinthe2012Act,theDepartmentexpectstheNHSCommissioningBoardtomakeclearinitsbusinessplanhowitwillachievetheobjectivesinthedraftmandate,includinginrelationtotheNHSConstitution.Likewise,itexpectstheBoardtomakeclearinitsannualreporthowithasfulfilledthoseobjectives.Atthesametime,theDepartmentwilllooktotheNHSCommissioningBoardtoholdclinicalcommissioninggroupstoaccountforfulfillingtheirlegaldutiestopromotetheNHSConstitution.

57. ButitisnotonlytheNHSCommissioningBoardthathasresponsibilitiesinrelationtotheNHSConstitution.ItisalsoimportantthatclinicalcommissioninggroupsfulfiltheirdutiesinrelationtopromotingtheConstitution.ItisalsovitalthatallprovidersofNHSservices,includingNHSFoundationTrusts,NHSTrustsandindependentsectorproviders,andregulatorsincludingMonitorandCQCtakeaccountoftheNHSConstitutionincarryingouttheirfunctions,asrequiredbylaw.AllbodiesinvolvedincommissioningandprovidingNHSserviceshavearoletoplayinembeddingtheConstitutionateveryleveloftheirorganisations.


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3 Rights and pledges in the NHS Constitution

Context

58. Rights in the Constitution are legal entitlements, protected by law.Asa‘declaratorydocument’,theConstitutioncodifiesexistingrightscontainedinexistinglegislation,drawingthemtogetherinoneplace.Itdoesnot,itself,createnewrightsorreplaceexistingones.TheseincluderightsconferredexplicitlybylawandrightsderivedfromlegalobligationsimposedonNHSbodiesandotherhealthcareproviders.TheHandbooktotheNHSConstitutiondescribesthelegalbasisofeachright,helpingpatients,staffandthepublictounderstandhowtochallengeiftheirrightsarenotbeingdelivered.

59. Forpatients,theserightsinclude,forexample,therighttoreceiveNHSservicesfreeofcharge,apartfromcertainlimitedexceptionssanctionedbyParliament,andtherighttobetreatedinatimelymanner,withaprofessionalstandardofcare,byappropriatelyqualifiedandexperiencedstaff.Theyalsoincludeotherssuchastherighttobetreatedwithdignityandrespect,therighttobeinvolvedindecisionsabouttheircare,andtherighttohaveanycomplaintmadeaboutNHSservicesdealtwithefficientlyandproperlyinvestigated.Forstaff,theserightsinclude,amongothers,therighttohaveagoodworkingenvironment,tohaveafairpay

andcontractframework,tobeinvolvedandrepresentedintheworkplace,tohavehealthyandsafeworkingconditions,andtobetreatedfairly,equallyandfreefromdiscrimination.

60. Pledges in the Constitution are aims which the NHS is committed to achieve.Unlikerights,pledgesarenotlegallybinding,anddonothavealegalunderpinning.Theirenforcementmethodinsteadrestsonregulatoryorcontractualperformancemanagementoforganisations.Theygobeyondthelegalrightsestablishedinlegislation,butthereisaclearexpectationthattheycan,andshould,bedelivered.

61. Forpatients,thepledgesintheConstitutioninclude,forexample,commitmentsbytheNHStomakedecisionsinaclearandtransparentway,tocontinuousimprovementinthequalityofservices,andtomakethetransitionassmoothaspossiblewhenpatientsarereferredbetweenservices.Forstaff,thepledgesinclude,amongothers,commitmentsbytheNHStoprovideallstaffwithclearrolesandresponsibilitiesandrewardingjobs,toprovideallstaffwithpersonaldevelopmentandaccesstoappropriatetraining,andtosupportallstaffinraisingconcernsattheearliestreasonableopportunityaboutsafety,malpracticeorwrongdoing.


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Patient rights and pledges in practice

62. Thisreportwasneverintendedtoprovideadetailedexaminationofthe“stateoftheNHS”–butitisrelevanttoexaminetheextenttowhichtherightsandpledgesintheNHSConstitutionarebeingdeliveredinpractice.TheDepartmentofHealthhasalsopublishedanumberofdocumentsinparallelwiththisreport,includingtheNational Health Service and Public Health Service in England: The Secretary of State’s annual report 2011/12,andThe Year: The NHS Chief Executive’s Annual Report 2011/12,whichexaminetheperformanceoftheNHSinmoredetailthanthisreportintendstodo.

63. Ratherthanreplicatethesedocuments,thisreportexaminestheevidencethroughtheframeworkofthesevendomainsinpublicandpatientrightssectionoftheNHSConstitution.Whilewehavenotexaminedindetailhoweveryrightandpledgehasbeendelivered,thereportdoesexaminehowtheNHSisaddressingeachdomain,andoffersahighlevelperspectiveonwheretheNHSisdoingwell,andwhereitcouldbeimproved.

the sources of information available

64. WhenfocusingonhowtheNHSisperformingagainstthepatientrightsandpledgescodifiedintheNHSConstitution,thereisarangeofdifferentsourcesof

informationavailable.Theseinclude,amongothers:

• Nationalsurveyresultsanddatathatrevealhowpatientsfeelaboutthecaretheyreceiveandtheirinvolvementindecisionsthataffectthem,suchastheinpatientandoutpatientsurveysbytheCareQualityCommission,theGPpatientsurvey,andthenationalCancerPatientExperienceSurvey;

• PatientReportedOutcomeMeasures(PROMs),whichassesspatients’perspectivesontheeffectivenessoftheircareandtreatment;

• TheNHSAtlasesofVariation,whichareintendedtohighlightvariationbetweenlocalities,andshowbothwherelocalitiesareperformingwell,andwherethereisscopeforimprovement;

• AnnualreportsaboutwrittencomplaintstotheNHSpublishedbytheNHSInformationCentreforHealthandSocialCare;

• ReportsoftheHealthServiceOmbudsmaninrelationtopatientcomplaints;

• ReportspublishedbytheCareQualityCommissiononthestateofhealthcareandadultsocialcareservices;and

• Reportsandresearchpublishedbyawiderangeofcharities,patientgroups,thinktanksandotherstakeholdersonNHSperformanceandpatientexperience.


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65. However,insomeareastheevidenceisofteneitherlimitedinscope,onlypartiallyaddressestheeffectoftheConstitution,orsimplyalludestotheeffectsoftheConstitutioninchangingbehaviourandorganisationalculture.Asaresult,establishingaclearevidencebaseforexaminingtheeffectoftheConstitutioninhelpingtodelivertherightsandpledgesischallenging,andanyconclusionsshouldbereadinthatlight.InmanycasestheevidenceofhowwelltheNHSisdeliveringisalsomixed,anditiscurrentlyimpossibletodrawageneralconclusionontheeffectivenessoftheNHSconstitutionduetoalackofindicators.Aswemightexpect,differentorganisationsarefulfillingpatients’expectations,assetoutintheConstitution,indifferentwaysandtoagreaterorlesserextent.

Access to health services

“Across both health and social care, most action has been taken to address race equality, followed by disability and religion and belief…a higher percentage of NHS trusts have taken action on all equality strands, except religion and belief, compared to adult social care services.”

the Health Service ombudsman, february 2011

66. TherightsaroundaccesstohealthservicesenshrinedintheNHSConstitutiongototheveryheartofwhatourNHSisallabout:acomprehensiveserviceavailabletoall,basedonclinicalneednotanindividual’sabilitytopay.AccessintheConstitutionisdefinedbothintermsoftheabilitytogainaccesstoservices,butalsothetimelinessofcare.DeliveringthesecommitmentsshouldbedeeplyembeddedintothecultureoftheNHS,withtheConstitutionreflectingexistingcommitmentsandpractice.


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67. TheNHShascontinuedtomaintainitsgoodperformanceonaccessatatimeofsignificantfinancialpressure.IthasmettheQIPP(Quality,Innovation,ProductivityandPrevention)performancemeasuresfor2011/12,withoutunderminingaccess.WaitingtimesintheNHSremainlowandstable.

68. TheNHSisconsistentlymeetingthe18weekmaximumwaitbetweenreferralandtreatment,withover90%ofpatientsadmittedtohospital,and95%ofnon-admittedpatientsstartingconsultant-ledtreatmentwithin18weeks.Thenumberofpatientswaitinglongerthan18weekstostarttheirtreatmentisalsodowntoitslowesteverlevel.10

69. Accesstoemergencyservicesalsoremainsabovethenationalstandard,with95.8%ofpatientsspendinglessthanfourhoursinAccidentandEmergencydepartments.11Thiscontinuestoexceedthenationaloperationalstandardat95%.

70. TheNHSisalsomeetingtheaimofpatientswaitingnolongerthantwoweekstoseeacancerspecialist,comparedwiththeoperationalstandardof93%.Inthelastquarterof2011-2,96.3%ofpatientswaitedamaximumoftwoweeksforafirstoutpatientappointmentwhenreferredurgentlywithsuspectedcancerbyaGP.10

Thisisanincreasefrom96.0%ofpatientsinthesamequarterof2010-11.10

71. However,whiletheNHSdoeswellasawhole,thereissomeevidenceofvariation,andareaswheretheNHScouldimprove.The“twoyearson”datafollowingtheFair Society, Healthy LivesreviewsuggestedthattherearestillsignificanthealthinequalitiesacrossEngland.12Thereisscopeforfurtherimprovementinthisarea,andreducinginequalitiesandpromotingequalitieswillbeacentralpriorityfortheNHSCommissioningBoard,reflectedinthedraftmandate.

Quality of care and environment

“Many of the hospitals we visited showed a genuine commitment to delivering person-centred care, with registered nurses, doctors, other care professionals and healthcare staff pulling together to treat people they cared for with passion and respect….leaders in hospitals must create a culture in which good care can flourish.”

Care Quality Commission, october 2011

72. Qualityofcareisoneofthemostcriticalaspectsinprovidingasuccessfulanddependablehealthservicetothepublic,anditshouldbeattheheartofeverything

10 NationalHealthServiceandPublicHealthServiceinEngland:TheSecretaryofState’sannualreport2011/12.

11 Thequarter42011-12.

12 ‘TwoYearsOn’Data,UCLInstituteofHealthEquity.http://www.instituteofhealthequity.org/Content/FileManager/pdf/2-year-on-press-release-final.pdf(Accessed22June2012)


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theNHSdoes.ProvidingahighqualityservicetopatientsistheresponsibilityofeveryoneworkingintheNHS,andrequiresaconsistentandrelentlessfocusonimprovingboththestandardsofcare,andthemannerinwhichitisdelivered.Aswiththerightsaroundaccess,deliveringthecommitmentsaroundqualityshouldbefundamentaltohowtheNHSoperatesasanorganisation.Inordertoensurethisisthecase,thedraftmandatesetsobjectivesaimedatimprovingquality.

73. Asaresult,therightsandpledgesintheNHSConstitutionshouldreflectexistingcommitmentsandbestpractice,whichhighperformingNHSorganisationsarealreadymeeting.The2011staffsurveysuggested87%ofstaffinthe2011surveyfeltsatisfiedwiththequalityofcaretheyprovidetopatients,whileCQCreportedthatmanyhospitalsshowedagenuinecommitmenttodeliveringperson-centredcare,treatingpatientswithpassionandrespect.13Inthe2011patientsurvey,92%ofadultinpatientsratedtheircareasexcellent,verygoodorgood;althoughitisdisappointingthatthemajorityofpatients(87%)werenotaskedtogivetheirviewsduringtheirhospitalstay.12

74. Anespeciallyimportantaspectofprovidingahighqualityserviceisprovidingaclean,safeenvironmentforpatientsandstaff.

Therehasbeenconsistentimprovementinthisarea,withgrowingnumbersofpatientsdescribinghospitalsasveryclean,andverysubstantialreductionsinMSRAandC.difficileinfections(25%reductionofMRSAbloodstreaminfectionsin2011/12comparedwith2010/11).14

75. However,theNHS Atlas of Variationshowsthatthereisstillawidedegreeofvariationinqualitybetweenservices.Therearealsosomeunacceptableexamplesofpoorservice.TheFrancisinquiryintocareatMidStaffordshireNHSFoundationTrust,andtheinquiryintocareatWinterbourneViewcarehomearebothexaminingexamplesofunacceptablypoorqualitycare,andtheGovernmentwillconsidertheirrecommendationstominimisetheriskofsimilareventshappeningagain.

76. Aswegoforward,asLordDarzihassaid,qualitymustbeoneofthekeyorganisingprinciplesfortheNHS.AllNHSorganisationsmustensurethattheyconstantlyprovideaclean,highqualityservicesthatrespecthumandignitytoalltheirpatients.TheNHSCommissioningBoardwillhaveacontinuingdutyinlegislationtoimprovethequalityofcare,andthedraftmandate(andwithinit,theNHSOutcomesFramework)includesobjectivesaimedatimprovingthequalityofservices.

13 CareQualityCommissionInpatientSurvey2011-http://www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/inpatient-survey-2011(Accessed22June2012)

14 TheYear:TheNHSChiefExecutive’sAnnualReport2011/12.


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Nationally approved treatments, drugs and programmes

77. TheNHSConstitutioncontainsanumberofrightstoensurethatpatientsareabletoaccessarangeofnationallyapprovedtreatments,drugsandservices,aswellasvaccinationandscreeningservices.

78. TheevidencesuggeststheNHSisdeliveringitscommitmentstoprovideaccesstoNICEapproveddrugsandtreatments.Foramajorityofmedicinesthathavebeenstudied,usageacrosstheNHSmetorexceededthelevelpredictedbyNICE,suggestingthatpatientsaregenerallyabletoaccesstherighttonationallyapproveddrugstomeettheirneeds.15

79. However,itisnotpossibletodeterminetherelationshipbetweentherightsintheNHSConstitutionandindividualtreatmentdecisions,asthedataissomewhatlimited.WhiletheNHSasawholeismeetingitsresponsibilities,theGovernmentiscommittedtoensuringthateverypatienthasaccesstonationallyapprovedtreatments,drugsandprogrammeswhereclinicallyappropriate.Thedraftmandateincludesanobjectiveto“upholdandwherepossibleimproveperformanceontherightsandpledgesforpatientsintheNHSConstitution”,andcontainsa

specificreferencetodeliveringtherighttodrugsandtreatmentsthathavebeenrecommendedbyNICE.

80. Furthermore,infutureboththeNHSCommissioningBoardandclinicalcommissioninggroupswillcontinuetohavedutiesinrelationtonationallyapproveddrugsandtreatmentsthatreflectthosedutiescurrentlyonPrimaryCareTrusts.ThiswillensurethattheprogresstheNHShasmadeinthisareawillnotbelost.

81. TheNHSisalsoensuringaccesstovaccinationsanddeliveringonitspledgetoprovidenationalscreeningprogrammes.Accessto,anduptakeof,screeningprogrammeshassteadilyincreased,alongsideincreasingdistributionoftrainingandbestpractice.WhererecommendedbytheJCVI,theDepartmentofHealthhasprovideddetailedguidancetocommissionerstosupportspecificvaccinationprogrammes.

15 UseofNICEappraisedmedicinesintheNHSinEngland–ExperimentalStatistics(2009)The Information Centre for Health and Social Care.http://www.ic.nhs.uk/pubs/niceappmed(Accessed22June2012)UseofNICEappraisedmedicinesintheNHSinEngland–2009,Experimentalstatistics(2011)The Information Centre for Health and Social Care.http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions/use-of-nice-appraised-medicines-in-the-nhs-in-england--2009-experimental-statistics(Accessed22June2012)

http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions/use-of-nice-appraised-medicines-in-the-nhs-in-england--2009-experimental-statistics


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Respect, consent and confidentiality

“I have yet to see convincing evidence of a widespread shift in attitude towards older people across the NHS that will turn the commitments in the NHS Constitution into tangible reality…The NHS must close the gap between the promise of care and compassion outlined in its Constitution and the injustice that many older people experience.”

the Health Service ombudsman, february 2011

82. TheNHSshouldalwaystreateveryonewithrespectandcompassion.TheNHSConstitutioncontainsanumberofrobustrightstoensurethatpatientsarealwaystreatedwithrespectanddignity.WhiletheNHSifoftengoodatprovidingcompassionatecare,thereisstillvariationandscopetoimprove,evenwithinthesameorganisationorthesameservice.

83. AsubstantialmajorityofpatientsreportthattheNHShastreatedthemwithrespect.Forexample,98%ofpatientsusingcommunitymentalhealthservicesfelttheyweretreatedwithdignity.16Thisisencouraging.However,itisclearlyunacceptableforaminority,howeversmall,tofeellikeindividualNHSorganisationsorstaffhavenotmettheirbasicrighttobe

treatedwithdignityandrespectsetoutintheNHSConstitution.

84. TreatingpatientswithdignityandrespectwillbeavitalpartofachievingimprovementsagainsttheoutcomesintheNHSOutcomesFramework,whichisatthecoreofthedraftmandate,andtheGovernmentwillbeholdingtheNHSCommissioningBoardtoaccountforhowtheNHSperformsagainstthese.

85. Itisespeciallytroublingthat,onrareoccasions,thecareofvulnerablegroupssuchasolderpeoplehasfallenshortofthevisionsetoutintheNHSConstitution.TheHealthServiceOmbudsman’sreport,Care and Compassion,revealedanumberofexamplesofwherestaffhavenottreatedolderpeoplewithrespectandcompassion,andthatisclearlyunacceptable.

86. Astreatingallpatientswithcompassionshouldbehardwiredintoeveryorganisationandindividualmemberofstaff’sbehaviour,itisexceptionallydifficulttomakegeneralconclusionsabouthowtheNHSConstitutionhasalteredbehaviours.Itremainsimportant,however,thatallorganisationsandmembersofstaffstriveasfaraspossibleto“bridgethegapbetweentheprinciplesandrightssetoutintheConstitutionandtherealityofbeing…incare”,andtheGovernmentwillbeholdingtheNHStoaccounttoensurethisisdelivered.

16 Communitymentalhealthsurvey2011.Care Quality Commission.http://www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/community-mental-health-survey-2011(Accessed22June2012)


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87. TheNHSConstitutionalsocontainsapledgetosharewithpatientsanyletterssentbetweencliniciansabouttheircare.Thisisanareawherethereisclearscopeforimprovement,withonly59%ofinpatientssayingtheyreceivecopiesofsomeoralloftheletterssentbetweencliniciansaboutthem.17Whilethispercentageisslowlyincreasing,theGovernmentisexpectingtheNHStodomoretoimprovethisarea,andwillholdcommissionerstoaccountforhowtheyaremeetingtheirConstitutionalpledges.

Informed choice

88. ThisGovernment,likethepreviousGovernment,isclearthatgivingpatientsmorechoiceandcontrolwillmaketheNHSmoreresponsive,andwilldriveupquality.Asaresult,theNHSConstitutioncontainsrightsforpeopletomakechoicesabouttheirNHScareandtobegiveninformationtoenablethemtodothis.ItalsocontainsrightsforpatientstochoosetheirGPpractice,andtoexpressapreferenceforusingaspecificdoctorwithinthatpractice.Theserightsarerelatedtotherighttobeinvolvedindecisions,discussedinthefollowingsection.

89. Akeyelementoftherightforpatientstomakechoicesabouttheircareistheabilityforpatientstochoosetheirprovider,when

referredforafirstconsultant-ledoutpatientappointmentformostelectiveservices(whenthisisclinicallyappropriate).ThisiscloselylinkedtotherightsintheNHSConstitutionforpatientstobeinvolvedindecisionsabouttheircare.

90. WhileDHnolongercollectsinformationaboutwhetherpatientsareofferedachoiceofprovider,thereissomeevidencethatsuggeststhatthereisscopeforimprovement.Thelatestevidence,providedbytheKing’sFund,reportedthat75%ofpatientsfeltthatchoicewaseither“veryimportant”or“important”tothem.Thisshowedthat45%werealreadyawarethattheyhadarighttochooseaprovider.However,only49%ofpatientsrecalledbeingofferedachoiceofprovider.18ThisisconsistentwithdatacollectedbytheDepartmentofHealthforthesameperiod.

91. ThataroundhalfofpatientsdonotrecallbeingofferedachoiceofproviderinlinewiththeirrightsintheNHSConstitutionisunacceptable.TheDepartmentexpectstheNHStoimproveinthisarea,andwillbeholdingcommissionerstoaccounttoensurethatpatientsareofferedchoice,whereappropriate.TheGovernment’sdraftmandatetotheNHSCommissioningBoardcontainsobjectivesrelatingtochoice,intendedtoturnthiscommitmentintothenormacrosstheNHS.

17 Inpatientsurvey2011.Care Quality Commission.http://www.cqc.org.uk/public/reports-surveys-and-reviews/surveys/inpatient-survey-2011(Accessed22June2012)

18 PatientChoice:howpatientschooseandhowprovidersrespond(2010)TheKingsFund.http://www.kingsfund.org.uk/publications/patient_choice.html(Accessed22June2012)


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92. Whilewedonothavecomprehensiveevidenceontheimpactoftherighttomakechoicesforallpatientgroups,thereisevidencetosuggestthatsomepatientsstillfeltreluctanttoexercisetheirrightsaroundchoice,evenwhentheywereawareofthem.Forexample,theRaceEqualityFoundationfoundthatmanywomenfromblackorethniccommunitieswouldnotwishto“challenge”healthcareprofessionalsbyexpressingapreferencetobetreatedbyafemaleGPorconsultantevenwhenmadeawaretheConstitutiongivesthemtherighttodoso.19Thisisunacceptable,andreducingsuchinequalitieswillbeacentralpriorityfortheNHSCommissioningBoard.

93. TheNHSConstitutionalsoincludesarightforpatientstochoosetheirGPpractice.OfthosepatientswhodoexpressapreferencetherehasbeenasmalldeclineovertimeinthosewhoareabletoseetheirpreferredGPalways/almostalwaysoralotofthetime.

94. Inaverysmallminorityofcases(13),thehealthserviceombudsmanacceptedcomplaintsforinvestigationwherepatientshadbeenremovedfromGPlistsagainsttheirwisheswithoutthecorrectproceduresbeingfollowed.20All10ofthecaseswhichhadbeencompletedatthetimeofthereportwereupheld.

Involvement in your health and the NHS

“Despite widespread support for involving patients in decisions about their care, including a commitment in the NHS Constitution shared decision making is not yet the norm. National patient surveys suggest that at least half of those who experienced a hospital episode would have liked more involvement in decisions about their care and the trend shows no improvement over the last 10 years or so.”

the King’s fund, July 2011

95. PatientsandcarersshouldbeattheheartoftheNHS,throughshareddecisionmakingabouttheircare.Shareddecisionmakingneedstobecomethenormandnottheexception.ThenewdutiesoncommissionerstoinvolvepatientsandcarersindecisionsintheircaresetoutintheHealthandSocialCareAct2012willhelpmakearealityoftheprincipleof‘nodecisionaboutme,withoutme’.Patientdecisionaidsareexamplesoftoolswhichhavebeendevelopedtosupportshareddecisionmakingbetweenpatientsandclinicians.Inthecontextofacollaborativediscussionabouttreatmentoptions,theseevidence-basedtoolswill

19 Islam-BarrettFarah(2011)TheNHSConstitution:Perception,useandvalueinblackandminorityethniccommunities.Race Equality Foundation.http://www.raceequalityfoundation.org.uk/sites/default/files/publications/downloads/REF%20%20NHS%20Constitution%20Report%202011%20(2)%20(2).pdf(Accessed22June2012)

20 ListeningandLearning:theOmbudsman’sreviewofcomplainthandlingbytheNHSinEngland2010-11.Parliamentary and Health Service Ombudsman.http://www.ombudsman.org.uk/__data/assets/pdf_file/0019/12286/Listening-and-Learning-Screen.pdf(Accessed22June2012)

http://www.raceequalityfoundation.org.uk/sites/default/files/publications/downloads/REF%20%20NHS%20Constitution%20Report%202011%20(2)%20(2).pdf


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helpensurepatientstoparticipatefullyindecisionsabouttheircareandtohavetheinformationandsupporttheyneedtoenablethemtodoso.21

96. TheConstitutionenshrinespatients’rightstobeinvolvedindecisionsabouttheircareandtreatment,withfurtherrightsandpledgestoensurepatientshavetheinformationtheyneedtomakesuchdecisions.Therearealsorightsandpledgesthatensurepeoplehavetheopportunitytobeinvolved,directlyorthroughrepresentatives,intheplanningofcareservicestheyreceiveandthemethodbywhichsuchservicesareprovided.

97. TheevidencesuggeststhattheextenttowhichtheNHSmeetsthecommitmentssetoutinthissectionoftheConstitutionismixed.Whilethe2011NHSinpatientsurveyfoundthat52%ofrespondentsreplied“definitely”whenaskediftheyfeltinvolvedasmuchastheywantedtobeindecisionsabouttheirhealthcareandtreatment,37%feltinvolvedonlytosomeextentratherthanfully.22

98. However,researchbytheKingsFundalsosuggeststhat,evenwhenpatientsdofeelinvolvedindecisionsabouttheircare,atleasthalfofpatientsinvolvedinahospitalepisodewantedmoreinvolvement.23That

thetrendshowsnoimprovementoverthelast10yearsisespeciallytroubling.

99. ThissuggeststhatwhiletheNHSinvolvespatientstosomeextent,shareddecision-makingisnotyetthenorm.

100.Tomakegenuineinvolvementofpatientsintheircarearealityforall,theHealthandSocialCareAct2012includesnewdutiesontheNHSCommissioningBoard,andthedraftmandatecontainsanumberofobjectivestopromotetheinvolvementofpatientsandcarersindecisionsabouttheircare.TheGovernmentwillholdtheBoardtoaccountforimprovingpatientinvolvementindecisionsabouttheircare.

Complaints and redress

“There remains some way to go before a culture is created throughout the NHS that is open to complaints, sees these in the light of systemic weaknesses and supports staff.”

the Health Service ombudsman, october 2011

101.OneofthekeyaspirationsfortheNHSConstitutionwasthatitwouldbeameansforpatientstoknowandexercisetheirrights.Insomecases,thismayrequireformalchallengethroughthecomplaints

21 InformationaboutpatientdecisionaidsareavailablethroughNHSDirectandtheNationalPrescribingCentre:http://www.nhsdirect.nhs.uk/decisionaids;http://www.npc.nhs.uk/patient_decision_aids/pda.php).Accessed25June2012.


23 AngelaCoulterandAlfCollins(2011)MakingSharedDecisionMakingaReality:Nodecisionaboutme,withoutme.The Kings Fund.http://www.kingsfund.org.uk/publications/nhs_decisionmaking.html(Accessed22June2012)


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process.Asaresult,theConstitutioncontainsanumberofrightsandpledgestoensurethatcomplaints,oncereceived,areacteduponandresolved.

102.Theevidencesuggeststhatwhiletherehasbeenimprovementintheseareas,noteveryNHSorganisationfollowsbestpractice.24Acrossthecountry,thereareareaswherethenewcomplaintssystemisbeginningtodemonstrateitspotential,withtheOmbudsmanreportingthat“complaintsabouttheNHSnowreceivefasterconsiderationlocally,andarereferredtous[theOmbudsman]morequickly.”25Thisisclearlyapositivedirectionoftravel,aswithoutaneffectivecomplaintsprocess,theNHSwillnotbeabletomeettheaspirationslaidoutintheConstitution.

103.However,thereremainsignificantregionalvariations.Inherannualreport,theHealthServiceOmbudsmanalsosuggestedthat“atalocallevel,theNHSisstillnotadequatelydealingwiththemoststraightforwardmatters”,withexamplesofpoorhandlingofcomplaints,unnecessaryescalation,andfailurestoexplainoracknowledgemistakes.25ThisconcernwasalsoechoedbytheHealthSelectCommitteereportintocomplaints.Asaresult,anumberofcomplaintswere

unnecessarilyescalatedtotheOmbudsman,ratherthanbeingresolvedlocally.However,itremainsthecasethattheOmbudsmanrolegenerallyistostepinonlyaftertheNHShasbeenunabletoresolvetheissuelocally,andshecontinuestodealwithonlyaminorityofcomplaints.

104.Thereisclearlyscopeforimprovementinensuringthatpatientsareawareofhowtocomplainwhenthingsgowrong.TheNationalInpatientSurvey2011suggeststhatonly42%ofpatientssawleafletsorpostersexplaininghowtheycouldcomplain.Thisclearlyfallsshortofouraspirations,especiallyaslisteningtocomplaints,resolvingthem,andimprovingpracticeasaresultisavitalmeansfortheNHStoimprovetheserviceitoffersthepublic.26

105.ThereisalsoscopefortheNHStoimprovehowitacknowledgesitsmistakes,apologises,andlearnsthelessons.WhilstthereislimiteddataonhoweffectivetheNHSisatprovidingtheseoutcomeslocally,thetwomostcommonreasonscomplainantsgavetotheOmbudsmanfordissatisfactionwiththeprocesswere“poorexplanationsandnoacknowledgementofmistakes”.

24 HealthCommittee-SixthReport-ComplaintsandLitigation(2011)Recommendation1.http://www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/786/78602.htm(Accessed22June2012)

25 ListeningandLearning:theOmbudsman’sreviewofcomplainthandlingbytheNHSinEngland2010-11.ParliamentaryandHealthServiceOmbudsman.http://www.ombudsman.org.uk/__data/assets/pdf_file/0019/12286/Listening-and-Learning-Screen.pdf(Accessed22June2012)



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106.Insomeareas,theNHSisnotconsistentlymeetingtherightssetoutintheConstitution.Thisisclearlyacauseofconcern,andtheNHSwillbeexpectedtoworkoverthecomingyearstoimprove.InitsresponsetotheHealthSelectCommittee,theGovernmentacknowledgedthatmoreneedstobedoneinthisarea,andhascommittedthatengagementwithpatientsandthepublicwillbeoneofthecoreprocessesoftheNHSCommissioningBoard,puttingpatientvoicesattheheartoftheBoard’sworkfromanearlystage.27TheSecretaryofStatewillholdtheNHSCommissioningBoardtoaccountfordeliveringthis,andweexpecttheBoardtoensureotherNHSorganisationsalsodeliverontheircommitments.

107.WealsoanticipatethattheFrancisInquirywillraisefurtherlessonsfromthecareprovidedbytheMidStaffordshireNHSFoundationTrust.WewillconsiderthesefurtherwhentheInquirypublishesitsreport.

Staff rights and pledges

“The NHS Constitution contains important commitments about the rights and responsibilities of staff. As the NHS enters a new phase, with the prospect of increasingly diverse healthcare organisations delivering NHS services, it will be even more important that providers, patients, staff and commissioners are all clear about the shared values and standards that everybody expects from our NHS. Increased awareness of the Constitution can only help staff deliver effectively for patients and be assured of their rights in the workplace.”

Unison, June 2012

108.ThededicationoftheworkforceoftheNHSinEnglandmakesitoneofthebesthealthcaresystemsintheworld.TheNHSConstitutionsetsoutavisionthatallstaffcommissioningandprovidingNHSservicesshouldhaverewardingjobs.Staffwillbeabletoprovidequalitycarebecausejobswillhavebeendesignedaroundpatientswiththeinputofstaff.TheinclusionintheNHSConstitutionofrightsandpledgestostaff,aswellasstaffresponsibilitiesandexpectationsastotheirbehaviour,reflectsthefactthatimprovingthe

27 GovernmentResponsetotheHouseofCommonsHealthSelectCommitteeSixthReportofSession2010-11:ComplaintsandLitigation.http://www.official-documents.gov.uk/document/cm81/8180/8180.pdf(Accessed22June2012)


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patientexperiencerequiresthecontinuedimprovementoftheworkinglivesofstaff.

109.Toachievethis,itisimportantthatNHSorganisationscontinuallymonitor,assessandactontheviewsofstafftohelpdriveimprovementsforbothstaffandconsequentlypatients.WherestaffinNHSorganisationshaveabetterexperienceatwork,arangeofoutcomesarebetterwithintheorganisation.Forexample,wherestaffengagement,health,andwell-beingarehigh,weseebetterqualityofcareforpatients,betteruseofresources,betterfinancialmanagementandlowerstandardisedmortalityrates.28

110.TheimportanceofmeasuringstaffexperiencehasbeenfurtheracknowledgedsincetheinceptionoftheNHSConstitutionthroughtheinclusionofspecificstaffrelatedmeasuresintheNHSOperatingFramework,inCQCqualityriskprofilesandinthePrimeMinister’sTransparencyCommitments.TheviewsofstaffarenowseenasanimportantbarometerofthequalityofcareNHSorganisationscandeliver.

111. AstheprimarysourceofinformationaboutstaffexperiencesintheNHS,theannualNHSstaffsurveyprovidesNHSorganisationswithinvaluableinformationtohelpthemreviewandimprovestaff

experiencesothat,inturn,staffcanprovidebetterpatientcare.TheresultsfromtheNHSstaffsurveyarealignedwithfourpledgesintheNHSConstitution,allowingNHSorganisationstoassesshowtheyareprogressing.

112.Aselectionofkeyfindingsfromthe2011NHSstaffsurveyareprovidedbelow,althoughthenationalresultsdohidevariation.Eachorganisationisencouragedtoreviewitsownresultsandtofocusimprovementstoaddresslocalconcerns.ThisreportdoesnottrytocoveralltheinformationintheNHSstaffsurveyfor2011buttoreflectonsomecoreelementsandexploretheextenttowhichtherehasbeenprogress.AfulleranalysisisprovidedinthebriefingnotetotheNHSstaffsurvey.29

113.TheNHSstaffsurveyfrom2011showsthatoverall,themajorityofNHSstafffindtheirjobssatisfyingwithmorethanthreequartersfeelingwell-supportedbytheircolleagues,demonstratingthecollegiatenatureoftheNHS.NHSstaffbelievethattheymakeadifferencewithnineintenstaffbelievingtheirjobmakesadifferencetopatientsand87%,satisfiedwiththequalityofcaretheyprovide.Giventhecurrentfinancialcontextandtheneedforpublicsectorreform,itisencouraging

28 AstonBusinessSchool(2011)NHSStaffManagementandHealthServiceQuality.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_129643(Accessed22June2012)

29 NHSStaffSurvey(2011).http://www.nhsstaffsurveys.com/cms/(Accessed22June2012)


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thatNHSstaffcontinuetoreportpositiveexperiencesoftheirorganisations,asseenyearonyearinresultsfromtheNHSstaffsurvey.However,thesurveyresultsalsoshowthatonly64%ofstaffwouldbehappyforafriendorrelativetobetreatedbytheirtrustand11%wouldnotbehappy.

114.TheNHSConstitutioncontainsacommitmenttoprovideallstaffwithpersonaldevelopment,accesstoappropriatetrainingfortheirjobsandlinemanagementsupporttosucceed.Appraisalsareanimportanttooltohelpstaffunderstandtheirrole,feelvaluedandcontinuallydevelop.Itisencouragingthatappraisalratescontinuetoincreasewith80%ofstaffreceivinganappraisalin2011.Thesurveyshowsthatstaffdovaluetheirappraisalsbutoftenfeelthatthequalityoftheirappraisalispoor.Participationintrainingalsoremainshighwith78%ofstaffreceivingjob-relevanttraining,learningordevelopmentinthelast12months.

115.ThesurveyshowsthatNHSorganisationsneedtomakestafffeelmorevaluedandtosupporttheminstrikingagoodwork-lifebalance–Only45%feltgoodworkwasrecognised,32%felttheirTrustvaluedtheirworkandjustoverhalfregularlyworkovertime.EmbeddingtheNHSConstitutionintotheorganisationalcultureandpractices,andinsomecasesappraisals,hasbeenshowntobenotonlyeffectiveinraisingawarenessamongstaffbutalsotoprovidestaffwithagreaterunderstanding

oftheimportanceandvalueoftheirworkandhowitrelatestotheprinciplesandvaluesoftheNHS(seeEastofEnglandcasestudyinChapter2).

116.TheNHSConstitutionmakesclearthatNHSstaffshouldbeprovidedwithsupportandopportunitiestomaintaintheirhealth,well-beingandsafety.TheNHSConstitutionstatesthatpatientshavearesponsibilitytotreatNHSstaffandotherpatientswithrespect.Thestaffsurveyshowsthat8%ofNHSstaffreportedexperiencingphysicalviolencefrompatients,theirrelativesandothermembersofthepublic.Inaseparatereportfor2010-11byNHSProtect,atotalof57,830reportedphysicalassaultsagainstNHSstaff,comparedwith56,718in2009-10.AlthoughthisrepresentsaminorityofthemillionsofpatientstreatedbytheNHS,itisconcerningtoseethisreportedlevelofviolencetowardsstaff.TheNHSstaffsurveyshowsthatofthe8%ofstaffwhoexperiencedviolencefrompatients,theirrelativesorothermembersofthepublic,aroundthreequarterssaythattheyhavereporteditandjustoverhalfsaidtheirorganisationwouldtakeaction.Staffshouldfeelthattheycanreporteveryincidentandexpecttheirorganisationtotakeaction.

117. Intermsofsupportinghealthandwellbeing,NHSorganisationshavesucceededinreducingyearlyaveragesicknessabsenceratesfrom4.48%to4.1%.Itisdisappointinghoweverthatonly63%ofstaffreportnothavinganydifficulties


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incompletingtheirworkbecauseofillhealthinthelastthreemonths.Therehasbeenaconcertedefforttosupportworkaroundprovidingstaffwithsupportandopportunitiestomaintaintheirhealth,well-beingandsafety.30

118.Thesurveyalsogivesdataonwitnessingandreportingpotentiallyharmfulerrors,nearmissesandincidents:thisisavitalcomponentinmakingsurestaffaresafeatwork.Itisencouragingtoseethatstaffreportingoferrors,nearmissesandincidentsishighwith96%oftheseerrorsreportedeitherbythepersonmakingtheerrororacolleague.Themajorityofstaff(83%)surveyedfeltencouragedtodosobytheirorganisation.However,itisconcerningthat12%wereconcernedthatreportingwouldleadtopunishmentorblame.In2012,followingpublicconsultation,theNHSConstitutionwasstrengthenedtoincludeanexpectationthatstaffshouldraiseconcernsattheearliestopportunity;apledgethatNHSorganisationsshouldsupportstaffwhenraisingconcerns;andclarityaroundtheexistinglegalrightforstafftoraiseconcernsaboutsafety,malpracticeorotherwrongdoingwithoutsufferinganydetriment.

119.TheNHSConstitutionstaffpledgesreflectthefactthatimprovingthepatientexperiencerequiresthecontinuedimprovementoftheworkinglivesofstaff,

includingengagingthemindecisionsandinmakingimprovements.Itisencouragingthatjustovertwothirdsofstafffeltabletosuggestimprovementstotheirteamordepartmentandasimilarproportionhadfrequentopportunitiestoshowinitiative.However,moststafffeelthatseniormanagersdonotinvolvethemindecisionsoractonstafffeedback–only26%ofstafffeltanyinvolvementindecisionmakingand30%thoughtseniormanagersactedonfeedback.Thenationalpicturedoeshidelocalvariation.NHSorganisationsthatbringtheConstitutiontotheforefrontofeverythingtheydohaveagreatopportunitytoaligntheirstaffpoliciesandfeedbacktotheNHSConstitutionasawayofdrivingimprovements.

Patient and staff responsibilities

120.AsthepreambletotheConstitutiondeclares,theNHSbelongstothepeople.Asaresult,patients,staffandthepublicowecertainresponsibilitiestooneanothertoensuretheNHSoperatesfairlyandeffectively.Bymakingsignificantcontributionstotheirownandtheirfamily’sgoodhealthandwell-being,usingNHSservicesappropriately,andtreatingNHSstaffandotherpatientswithrespect,patientsandthepubliccanmakesignificantcontributionstotheeffectiveandsafeoperationoftheNHS.

30 NHSEmployers(2012)Healthandwell-beingfivehighimpactchanges.http://www.nhsemployers.org/HealthyWorkplaces/ReducingSicknessAbsence/Pages/FiveHighImpactChanges.aspx(Accessed22June2012)


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examples of how patients and the public are meeting their responsibilities

• Thepublicareparticipatinginimportantpublichealthprogrammessuchasvaccination.Themostrecentinformationshowsthatnotsince1995,whenUKdatawerefirstreported,hasthecoverageofallprimaryimmunisationsmetorexceededtheWorldHealthOrganizationtargetof95%–thattargethasnowbeenachieved;

• Withthepublicofferedvariouswaystosignuptotheorgandonationregister,itisencouragingtoseethatdonorrateshaveincreasedbyaround35%since2007/08;

• PatientsarealsohelpingtoimprovetheNHSbytakingpartinprogrammessuchasPatientReportedOutcomeMeasures–providingaccurateinformationabouttheirhealthtoenabletheNHStoimproveoutcomesanduseresourcesmoreeffectively.

121.Whilethereissomeevidencethatpatientsandthepublicaremeeting

,bywlsoisisasarate

onshipspeople

theirresponsibilities,theevidenceisitsnature,mixedandlimited,andfegeneralisationscanbedrawn.ItisaimpossibletodeterminewhethertharesultoftheNHSConstitution,sepfromthecomplexsetofsocialrelatithatexistbetweentheNHSandtheitserves.

122.TherearealsoanumberofwaysinwhichtheNHSishelpingthepublicandpatientstoliveuptotheirresponsibilities.Forexample,whenpatientsandthepublicmakeappointments,theyhavearesponsibilitytokeepthatappointmentorcancelitwithinareasonabletime.Whilstpatientshavetheirparttoplayinkeepingtheirappointmentsthereare

31 http://www.drfosterhealth.co.uk/features/outpatient-appointment-no-shows.aspx

32 MartinSJ,BassiS,andDunbar-ReesR(2012)Commitments,normsandcustardcreams–asocialinfluenceapproachtoreducingdidnotattends(DNAs).JRSocMed.105(3):101-4.http://jrsm.rsmjournals.com/content/105/3/101.full.pdf+html(Accessed22June2012)

toolsthattheNHSisusing(forexampleChooseandBook)31aswellasinnovativesocialinfluencingapproachestobookingprocedures32thathelppatientsmeettheirresponsibilities,whichinturnsignificantlyreducesmissedappointmentsandallowstheNHStoploughthemoneyintobetterpatientcare.

123.ThedepthoffeelingandpassionthatpeoplehavefortheNHScontinuestobearemarkableandenduringsourceofstrengthandsupportfortheNHSasanorganisation.However,tomaximisetheeffectivenessoftheNHS,workneedstocontinuetofocusandchannelthatcommitmentintoalsosupportingthepracticalworkoftheNHS,andfullyupholdingtheresponsibilitiesofthepublicsetoutintheNHSConstitution.


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4 effect of the NHS Constitution

124.ThedeliverybytheNHSoftherightsandpledgescontainedintheConstitutionprovidesimportantcontextforunderstandingtheeffecttheConstitutionhashadtodate.Butitisnotthekeytestofthedifferenceithasmadetopatients,staff,carersandthepublic.

125.Codifyingtheenduringprinciples,values,rightsandpledgesinasingledeclaratorydocumentwasneverintendedtohaveadirectcausaleffectonNHSperformance.Instead,theeffectoftheConstitutionwasmeanttobelongerterm.ItmeanttohelpsafeguardtheNHSasanequitableandefficienthealthservice,andtoempowerpatients,thepublicandstaffwithintheNHSsotheyareequippedtochallengeandencourageimprovementsinNHSservices.

126.ThreeyearsaftertheConstitutionwaslaunched,itispossibletoofferinitialconclusionsaboutitseffect.Butdefinitiveconclusionsarenotpossibleatthisearlystage.TherequirementontheSecretaryofStateforHealthtoreportontheeffectoftheConstitutioneverythreeyearsisanimportantone.ItmeansthattheeffectoftheConstitutionwillbekeptunderreviewandthat,overtime,thiswillhelptoestablishaclearerunderstandingofhowithasmadeadifference.

127. ThischapterexaminestheextenttowhichtheNHSConstitutionismeetingtheobjectivesitwasintendedtoachieve.

Protecting the principles and values of the NHS

128.BycodifyingtheprinciplesandvaluesoftheNHS,theConstitutionissupposedtohelpreinforceandsafeguardtheNHSforthefuture.AstheoriginalimpactassessmenttotheConstitutionmadeclear,thefoundationsoftheNHSasacomprehensive,tax-payerfundedserviceforall,basedonclinicalneedandregardlessofthepatient’sabilitytopay,continuetohavethestrongsupportofthepublic.

129.ApotentialthreattothefutureoftheNHSidentifiedintheimpactassessmentwastheemergenceofatwo-tierhealthservice,inwhichpeoplewhousetheNHSreceiveworsecarethanthosewhocouldaffordtopayfortheirtreatment.SuchathreatwouldleadtowideninginequalitiesandtothepossibilityoftheNHSbeingdowngradedtoa“safetynetservice”.33Atthesametime,theimpactassessmentmadeclearthattheNHSwouldneedtochangetomeet21stCenturychallenges–risingpatientexpectations,changesinthewayservicesaredelivered,improvedtechnology,andcontinuouslyimprovingmedicalpractice.

130.BycreatingasettlementontheenduringprinciplesandvaluesoftheNHS,theConstitutionwasintendedtohelpprotectthefundamentalsoftheNHSduringperiodsofchangeandtoensurethatthe

33 ImpactassessmenttotheNHSConstitution,30June2008,p.4http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085852.pdf(Accessed22June2012)


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threatofatwo-tierservicedidnotcometopass.Theimpactassessmentstated:

“TheConstitutionaimstoequiptheservicewiththecapabilityitneedstoworkwithallthesechangesandpreserveitsuniquenature,safeguardingefficiencyandequity.TheConstitutionaimstosecurethefoundationsoftheNHSandtoensurethattheenduringprinciplesandvaluesoftheNHSwillnotbeundermined,preventingthreatsofaninequitablehealthsystemwithintheNHSmaterialising.”34

131.Theseaimswerenotshortterm;theywereaboutprotectingthefundamentalsoftheNHSasanequitableandefficienthealthcaresystemforbothcurrentandfuturegenerations.AkeytestoftheConstitutionis,therefore,itslongevity–howithelpstomaintainandembedthecoreprinciplesandvaluesthatmaketheNHSuniqueandspecial.Thiscanonlybemeasuredmeaningfullyoverthelongterm.

132.Whatisapparent,however,isthatthreeyearsonfromthelaunchoftheConstitution,theNHSremainstruetoitsfundamentalprinciplesandvaluesasexpressedintheConstitution.ThoseprinciplesandvaluesareasrelevanttodayastheywerewhentheNHSwasfounded,andcontinuetoenjoystrongsupportfromthepublic.TheConstitutionremainsafocal

pointtowhatthehealthserviceisallaboutandcontinuestoremindusofwhattheNHSisstrivingtoachieveeveryday.

133.TheNHScontinuestobeauniversal,comprehensiveservice,basedonclinicalneedratherthanonanindividual’sabilitytopay.ThemodernisationoftheNHSisgroundedintheseprinciples:

• ThecontinuingcomprehensivenatureoftheNHSisenshrinedintheHealthandSocialCareAct2012.TheActmakesclearthattheSecretaryofStateforHealthretainshisdutytopromoteacomprehensivehealthservice.35HisaccountabilitytoParliamentforthehealthserviceinEnglandismadeexplicitintheAct.TheActsetstheframeworkforempoweringfrontlinecliniciansandencouraginglocalinnovationwithinthecontextofaclearnationaloffertopatientsandstaff,andmakesclearthattheNHSremainsaconsistentnationalhealthservice.Itdoessoinaframeworkofencouraginglocaldecision-makingandenablinggreaterscopefordeterminingprioritieslocally.

• InlinewiththewordingoftheConstitution,theHealthandSocialCareAct2012makesclearthatNHSservicesmustremainfreeofchargeexceptincertaincircumstancesexplicitlysanctionedbyParliament.33

34 ImpactAssessmentoftheNHSConstitution,21January2009.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093416.pdf(Accessed22June2012)

35 Section1oftheHealthandSocialCareAct2012


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empowering patients and staff

134.TheNHSConstitutionwasalsomeanttoempowerpatientsandstaffbyhelpingthemtounderstandwhattheycouldexpectfromtheNHSandbyhelpingtoeffectachangeinbehaviour.AstheimpactassessmenttotheConstitutionmadeclear:

“Greaterpatient,publicandstaffunderstandingofwhattheycanexpectwouldbeasteptowardsgreaterempowerment;itcouldprovokechallengeandmutualrespectforNHSservices,andforceupstandards[…]Bybringingtogetheralltherightsandpledgesinoneplace,morepeoplewillunderstandwhattoexpectfromtheNHS,andwillbeprovidedwithafirmerbasistochallengewhentheNHSdealswiththeminwayswhicharenotinaccordancewiththeirrightsandtheNHSpledgesmadetothem.”

135.TheeffectoftheNHSConstitutioninensuringthisdepends,inpart,ontheextenttowhichpatientsandstafffindtheConstitutiontobeaclearandaccessiblearticulationofwhattheycanexpectfromtheNHS,andwhetherpatientsandstaffchallengewheretheirrightsandpledgestothemarenotdelivered.

136.ThearticulationofrightsandpledgesintheNHSConstitutionremainstheclearestandmostconcisestatementofwhatcharacterisestheNHSandwhatweallcanexpectfromit.Duringthedevelopmentof

theConstitution,theindependentforumadvisingtheDepartmentnotedthat:

“Thereactionofpatients,thepublic,staffandmajorstakeholderstotheConstitutionwasoverwhelminglypositive[…]EvenwheretherewerepartsoftheConstitutionthatpeoplewishedtochange,theyagreedwiththeneedforitandsupportedthebasicshapeandbalanceofit.TheDepartmentshouldkeepinmindthebroadconsensusinfavouroftheConstitutioninaddressingtheissuesraisedintheconsultation[…]Alargemajorityofrespondents[totheconsultation]thoughtthearticulationofthepurpose,principlesandvaluesoftheNHSwasbroadlyright.”

137. SubsequentawarenesssurveysconductedbytheDepartmenthavenotsoughttotesttheextenttowhichthepublicandstaffremaincontentwiththewayinwhichthevalues,principles,rightsandpledgesareexpressedintheConstitution.Informalengagementwithstakeholders,however,suggeststhat,onbalance,mostpeoplecontinuetofindtheConstitutionaneffectivearticulationoftheseprinciples,values,rightsandpledges.WhilesomehavecommentedthattheConstitutioncouldbeshorter,andhavecautionedagainstitbecominganeverexpandingdocumentwitheachrevision,mostpeopleappeartowelcomethefactthatitbringstheseessentialstogetherinoneplace.


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138.AwarenessoftheConstitution,however,isgenerallylow(assetoutinChapter2)andthissignificantlycompromisestheabilityoftheConstitutiontohavearealandmeaningfuleffect.TheawarenessresearchstronglyindicatesthatpeoplearenotturningtotheConstitutionasawayoffindingoutinformationabouttheNHS,whattheycanexpectfromit,orwhattodoiftheirexpectationsarenotmet.

139.Wherepatientsfindthattheirrights,andthepledgesmadetothem,arenotbeingdelivered,theConstitutionwasintendedtoempowerthemtochallengetheNHS,andpromptimprovementsinNHSperformance.

140.Thefactthatpatients,ingeneral,donotusetheConstitutionasabenchmarkagainstwhichtocomplainsuggeststhattheNHSConstitutionisnotyethavingtheeffectoriginallyintended.Putsimply,peoplearenotusingtheConstitutionasawayofupholdingtheirexpectationsoftheNHS.Thecomplaintssystem,whileshowingsomesignsofimprovement,hasnotleadtoachangeofcultureinwhichcomplaintsareencouragedasameansofdrivingimprovementsinthequalityofcare.Atthesametime,whilemanagersonthewholearemostawareoftheConstitution,itisimportantthatstaffatalllevelsthroughouttheNHSarewellinformedabouttheConstitutionandthattheyknowhowtouseit,bothtoimproveservicesforpatientsandtoempowerthemtoensure

theirownrights,andthepledgesmadetothem,aredeliveredbytheiremployers.


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5 Conclusions and next steps

141.TheNHSConstitutionisaremarkableandimportantdocument.ItbringstogetherinoneplacetheessenceofwhatmakestheNHSuniqueandspecial.Notonlydoesitgiveafocalpointtowhatthehealthserviceisallabout,itremindseveryonewhattheNHSisstrivingtoachieveeachandeveryday.

142.Threeyearsonfromitslaunch,theNHSConstitutioncontinuestohavethepowertoinspireandenthuse.AsthefirstreportontheeffectoftheConstitution,thisreportcanofferaninterimassessmentofwheretheConstitutionstandstoday.ButtherealtestoftheConstitutionliesinitslongevity–thewayinwhichitrepresentsanarticulationoftheprinciplesandvaluesoftheNHS.

Awareness and use of the NHS Constitution

143.PeoplewhoknowabouttheNHSConstitutionsupportandvalueit.Overwhelmingly,patientsandstaffthinkaConstitutionfortheNHSisagreatidea.ItisparticularlystrikingthatthosewhoknowabouttheConstitutionaremorelikelytosupportandvalueit,andthatthemoretheyknowaboutitthegreatertheirsupport.Itisclearthatpeopleremainenthusiasticfor,andsupportiveof,theNHSConstitution.ThiscanbebuiltonintheyearsaheadbytheDepartmentofHealth,theNHSCommissioningBoard,clinical

commissioninggroups,regulatorsandallprovidersofNHSservices.

144.Itisalsoclear,however,thatawarenessoftheConstitutionisgenerallylow.GreaterawarenessoftheConstitutionisanessentialstartingpointforhelpingpatientsandstaffunderstandwhattheycanexpectfromtheNHSand,inturn,theresponsibilitiestheyowetothehealthserviceandeachother.Butawarenessaloneisnotsufficienttoempowerpeople–neitherpatientsnorstaff.AwarenesssimplymeansknowingtheConstitutionexists.Realempowermentmeansmorethanthis.ItmeansunderstandingwhatisintheConstitutionand,crucially,howtousetheConstitutiontoensurepatientsandstaffreceivewhattheyareentitledtoexpect.PeopleneedtoknowwhattheycanexpectfromtheNHS.Theyalsoneedtoknowwhattodo,andwhototurnto,whentheydonotgetwhattheycanexpect.

145.EveryoneinvolvedinthehealthserviceateverylevelhasaroletoplayinbothraisingawarenessoftheConstitutionandinhelpingpatientsandstafftounderstandhowtouseit.TheroleoftheNHSCommissioningBoardinpromotingtheConstitutioninthenewsystemwillbeparticularlyimportant.

146.TheHealthandSocialCareAct2012placescleardutiesontheNHSCommissioningBoard,andonclinicalcommissioninggroups,topromotetheNHSConstitution.


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ThismeanspromotingawarenessoftheConstitutionamongpatients,staffandthepublic.ItalsomeansthattheBoardmustexerciseitsownfunctionsinawaythatpromotestheNHSConstitution.Rightly,itwillbefortheNHSCommissioningBoardtodeterminepreciselyhowitwillfulfiltheselegalduties.

147. TheDepartmentofHealthwillholdtheNHSCommissioningBoardtoaccountformeetingitslegaldutytopromotetheNHSConstitution.ItwillalsoholdtheBoardtoaccountfordeliveringontherightsandpledgescontainedwithinit.

148.Thiswillbeachievedthroughthedraftmandate,whichsetsouttheGovernment’sobjectivesfortheBoard,andwhichwillbethemainaccountabilitymechanismforthis.Thedraftmandate,onwhichapublicconsultationhasnowbeenlaunched,setsanobjectivefortheBoardtodemonstratethattherightsandpledgesintheNHSConstitutionarebeingmet.

149.Inlinewiththedutiesinthe2012Act,theDepartmentexpectstheNHSCommissioningBoardtomakeclearinitsbusinessplanhowitwillachievetheobjectivesinthedraftmandate,includinginrelationtotheNHSConstitution.Likewise,itexpectstheBoardtomakeclearinitsannualreporthowithasfulfilledthoseobjectives.Atthesametime,theDepartmentwilllooktotheNHSCommissioningBoardtoholdclinical

commissioninggroupstoaccountforfulfillingtheirlegaldutiestopromotetheNHSConstitution.

Subsequent reports on the effect of the NHS Constitution

150.TheHealthAct2009requirestheSecretaryofStatetoreportontheeffectoftheNHSConstitutioneverythreeyears.Thisisthefirstsuchreport.ThenextreportmustbelaidbeforeParliamentby5July2015.

151.ThepurposeofthesereportsistoexploretheeffectoftheNHSConstitutiononpatients,staff,carersandthepublic.ThisisaboutexaminingtheextenttowhichtheConstitutionhasmadeadifference–inparticular,whethercodifyingtheprinciples,values,rightsandpledgesinoneplacehasmadeadifferenceinempoweringpatientsandstaff.TheyarenotreportsongeneralNHSperformance.ThetruetestoftheConstitutionisnotwhetherrightsandpledgesarebeingdeliveredinfull,butwhethercodifyingthemhashelpedempowerpatientsandstaff.Nevertheless,performanceisrelevantcontextforunderstandingtheeffectoftheConstitution.

152.Thechapteronrightsandpledgeshighlightedthechallengesinvolvedinmeasuringtheextenttowhichthesearebeingdelivered.Itnotedthattheperformancedatacollecteddoesnotnecessarilymapeasilyagainsttherights


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andpledgesintheConstitution.Evidenceisoftenlimitedinscope,onlypartiallyaddressestheeffectoftheConstitution,orsimplyalludestotheeffectsoftheConstitution.

153.FuturereportsontheeffectoftheNHSConstitutionwouldbenefitfromrichersourcesofevidencethataddressmoredirectlytheextenttowhichrightsandpledgesarebeingdeliveredinpractice.TheDepartmentwilllooktotheBoardtoidentifythebestwaytocollecttheinformationrequiredtodemonstratethatitisdeliveringontheobjectiveinrelationtotheConstitution,assetoutinthedraftmandate.

Next steps

154.TheworkoftheNHSFutureForumhasbeenimportantininformingthisfirstreportontheeffectoftheNHSConstitution.Itsfindingsabouttheneedtoraiseawareness,topromoterealunderstandingabout,anduseof,theConstitutionunderpintheconclusionsofthisreport.

155.TheGovernmenthasaskedtheNHSFutureForum,inthesecondphaseofitsworkontheConstitution,toconsiderhowtheConstitutioncanbestrengthenedandreinforcedforthefuture–intermsofbothcontentandawareness.TheSecretaryofStatewillwritetotheNHSFutureForumshortlysettingoutspecificareasonwhich

hewouldbeparticularlygratefulfortheForum’sadvice.

156.TheNHSFutureForumwillpresentitsadvicetotheGovernmentintheautumn.Followingthis,theGovernmentplanstolaunchapublicconsultationonanychangestostrenghtentheConstitutionsothatpatients,staffandthepublichavethechancetohavetheirsay.Theconsultationwillbelaunchedlaterthisyear.


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Annex 1: Advice from the NHS future forum

Letter to the Secretary of State for Health from the NHS future forum working group on the NHS Constitution

26June2012

HavingbeeninvolvedinthedevelopmentoftheNHSConstitutionfouryearsago,itwasaprivilegetobeaskedtoadviseyouontheeffectithashadonpatients,staffandthepublic.Overrecentmonths,theNHSFutureForumhasconsideredtheextenttowhichpeopleareawareabouttheConstitutionanditseffecttodate.Thislettersetsourconclusions,whichIhopeinformsthereportyoumustlaybeforeParliament.

TheNHSConstitutionisreallyimportant.Itexpressestheprinciplesandvaluesthatunderpintheuniquecharacterofourhealthservice.Itspowerfulopeningwordsresonatewithpatients,staffandthepublic.WhenItalkabouttheConstitutiontopatientsandthepublic,theirsupportfortheConstitutionisimmediatelyapparent.AmongNHSstaff,while54%areawareoftheConstitution,72%believeitisimportanttheNHShasaConstitution,andthemoretheyknowaboutitthegreatertheirsupport–90%ofstaffwhofeelwellinformedabouttheConstitutionthinksuchadocumentisvaluable.

Inatimeofreorganisationandfinancialpressure,theNHSConstitutionhasassumedgreaterimportance,perhapsmorethanitsfoundersrealised.ItisastatementoftheenduringprinciplesandvaluesthattheNHSstandsforandwhatitismeanttodeliver,regardlessofstructureandorganisation.ItsetsoutanationalofferthatpatientsandstaffacrossEnglandcanexpect,nomatterwheretheylive.

TheNHSConstitutionisanexpressionofenduringprinciplesandvaluesoftheNHSaroundwhichpeoplecanuniteregardlessoftheirviewsoncurrentchangesinthehealthservice.ItofferstheSecretaryofStateapowerfulwayofholdingthenewpartsofthesystemtoaccountfordeliveringnotonlytherightsandpledges,butalsothevalues,principlesandbehaviourstowhichweallwanttheNHStoadhere.

WewelcomethefactthatyourecognisethisandthatyoulistenedtotheNHSFutureForumbyencouragingParliamenttostrengthenthedutiesrelatingtotheNHSConstitutionintheHealthandSocialCareAct2012.TheGovernment’smandatetotheNHSCommissioning


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BoardprovidesanopportunitytoholdtheBoardtoaccountforensuringthatpatients’rightsandpledgessetoutintheConstitutionaredelivered.

ItisnotsurprisingbutneitherisitsatisfactorythattheConstitutionissolittleknown–andrarelyused–bystaffandevenlesssobypatientsandthepublic.Just3%ofNHSstaffsaytheyhaveencounteredapatientusingtheConstitutioninthisway.PlanstoraiseawarenessoftheConstitutionamongNHSstaffwerenotconsistentlycarriedout,andplanstoraiseawarenessamongthegeneralpublicwerenotimplementedasintended.Thereisabigtaskaheadnotonlytoraiseawareness,butalsotohelppeopleunderstandhowtousetheConstitution.Farfrombeingthe‘lawyer’scharter’thatsomefeared,theConstitutionsofarseemstohavebeenverylittleusedasameansofsecuringparticularrightsandpledgesforpeopleorofchallengingpoorservice.

TheNHSConstitutionisforeveryone.WerecognisethatthereportyoumustlaybeforeParliamentisabouttheeffectoftheConstitutionsinceitslaunchin2009,ratherthanareportonthestateoftheNHSitself.Wehavefeltfrustrationthattheevidencehasbeensopatchy.WherethereisevidenceoftheeffectoftheConstitutionthisindicatesthatevenwhererightsandpledgestopatientsandstaffaredeliveredwell,theyarenotconsistentlydeliveredforeveryone.Thisisparticularlythecaseforthosewhoaremostmarginalisedandmostoutofsight.Thismustchange.InequalitiesneedtobetackledandtheConstitutionhasaroletoplayinthis.BoththewaythatNHSservicesaredelivered,andthewaywemeasurehowtheNHSdeliversagainsttherightsandpledgesintheConstitutionmustimprove.

WetakeheartfromthefactthatstaffwhoaremostinformedabouttheNHSConstitutionarealsothemostlikelytovalueandchampionit;andfromtheextenttowhichpeopleintheEastofEnglandhavebecomeawareoftheConstitution,showingtheeffectivenessofeffortsmadethere.Itisalsoclearthat,whensharedwithdifferentgroups,theConstitutionhasthepowertoenthuseandgalvanisepeople.Forexample,childrenarenotwellinformedabouttheConstitutionbutwhenchildrenreadittogether,theysawitcouldmakeadifferencetotheirlives.

TheNHSConstitutionmustnotsimplybereferredtowhenthingsgowrongbutsomethingwhichbecomessoembeddedinthemindsandlivesofeveryoneconnectedwiththeprovisionofNHSservices–patients,staffandthepublic–thatitinfusesandunderpinseveryactionandinteractionthattakeplace.


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InoursecondphasewewilltakesoundingsandadviseyouonhowtheConstitutioncanbestrengthenedandreinforced,buildingontheenduringvaluesandprinciplesoftheNHSitalreadyexpresses.Withoutdoubt,thiswillincludepromptingabiggerroleforpatientsinmanagingtheirowncareandsharingindecisionsabouttheircare.Itshouldalsoincludetheneedforpatientcaretobemoreintegrated.ThisworktakesplaceinacontextverydifferentfromthatinwhichtheConstitutionwasoriginallydeveloped.WehavealreadybeguntodiscussmanyideasandproposalsforupdatingandextendingtheConstitution.Wewillconsiderthesewithanopenmind,butseektoavoidbecomingtangledinanariddraftingexercise.

ThepoweroftheConstitutionliesatleastinpartinbeingshortandsimple.Ifanything,itcouldbesimplerstill.Fundamentally,thismeansbeingclearaboutrights,responsibilitiesandredress.Patientsneedtoknow:whatdoIhavearighttoexpect;whataremyresponsibilities;andwhatistheredressifIdonotgetsomethingtowhichIamentitled?

Morethananyotherviewexpressed,ithasbeenputtousforciblythattheConstitutionamountsto“finewordsbutnoteeth”.Itneedstobealivingdocument,aguidinglightforstaffintheNHSandapointofreferenceandreassuranceforpatientsandcitizens.Wheretherightsitcontainsarenotlivedupto,theremustbeanunderstandable,accessibleandeffectivemeansofchallengeandredress.WewillthereforebelookingespeciallyhardathowtheConstitutioncanbestrengthenednotonlyinitscontentbutalsoinitsapplication.

Finally,thepoweroftheNHSConstitutionliesinthefactthatitenjoyswidespreadsupportfrompatients,staffandthepublic,andthatittranscendspartypolitics.Thecrosspartysupportitreceivedatitslaunchwas,Ibelieve,crucialtoitssupport,andIwouldhopethatpoliticiansofallpartiesbuildonthisasawayofstrengtheningtheroleoftheConstitutionaswegoforward.

ProfessorSteveFieldCBE,FRCP,FFPH,FRCGP


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Annex 2: Review of the Handbook to the NHS Constitution

1. ThisreviewoftheHandbooktotheNHSConstitution(theHandbook)fulfilsSecretaryofState’sdutyunderSection5oftheHealthAct2009toatleastinanyperiodofthreeyearscarryoutareviewoftheHandbooktotheNHSConstitutionandthatthisfirstreviewmustbecompletednotlaterthan5July2012.

2. TheHandbookisdesignedtoprovidestaffandpatientswithalltheinformationtheyneedabouttheNHSConstitutionforEngland.ItprovidesaguidetotherightsandresponsibilitiesofpatientsandNHSstaffaswellassettingtheprinciplesandvaluesoftheNHS.

3. ThefirstpartoftheHandbookisaguidetothepatients’rightsandpledgescontainedintheConstitution,andcanbeusedforreferencetoexplainwhattheConstitutionmeansforpatients.ItalsosetsouttheresponsibilitiesofpatientsandthepublicinworkingwithNHSstaff.

4. ThesecondpartoftheHandbookisforstaffinvolvedinprovidingNHSservicesandcoversthepledgestheNHShasmadetostafftohelpthemdeliverbetterqualitycareandtomaketheNHSabetterplacetowork.ItisclearabouttheexpectationstheNHShasofitsstaffandtheirrightsasemployees.

5. TheHandbookalsocontainsanappendixoutliningthelegalsourcesofboththepatientandstaffrightsintheNHSConstitution.

6. TwoversionsoftheHandbookarepublishedonline.OneversionisasinglePDFoftheHandbookpublishedontheDepartmentofHealthwebsite.AninteractivePDFversionoftheHandbookispublishedontheNHSChoiceswebsite.TheinteractiveversioncontainsthesuiteofNHSConstitutiondocuments(TheNHSConstitutionforEngland,theHandbookandtheStatementofNHSAccountability)andallowsuserstomovebetweentherightsandpledgesintheNHSConstitutionandtheexplanationofthoserightsandpledgesintheHandbook.

7. Sinceitspublicationin2009,theHandbookhasbeenrevisedtwice,oncein2010andoncein2012.Inaccordancewithsection5oftheHealthAct2009,theHandbookwasrepublishedaftereachrevision.

8. In2010,theNHSConstitutionwasupdatedtoinclude:

• anewrightforpatientstostartanynon-emergencytreatmentwithinamaximumof18weeksofaGPreferralandfortheNHStotakeallreasonablestepstoofferarangeofalternativesifthisisnotpossible;and

• anewrighttobeseenbyaspecialistwithinamaximumoftwoweeksfromGPreferralforurgentreferralswherecancerissuspected.


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9. In2012,theNHSConstitutionwasupdatedtoinclude:

• anexpectationthatstaffshouldraiseconcernsattheearliestopportunity;

• apledgethatNHSorganisationsshouldsupportstaffwhenraisingconcerns;and

• clarityaroundtheexistinglegalrightforstafftoraiseconcernsaboutsafety,malpracticeorotherwrongdoingwithoutsufferinganydetriment.

10. InApril2013,theHandbookwillrequirerevision.TheHealthandSocialCareAct2012introduceschangestotheorganisationsthatwillcommissionandprovideNHSservicesandthemajorityoftheseorganisationswilltakeontheirfunctionsinApril2013.

11. TheHandbookwillneedtoremovereferencestoPrimaryCareTrusts(PCTs)andStrategicHealthAuthorities(SHAs)andinsteadrefertotheorganisationsthatwillcommissionandprovideNHSservices.TheStatementofNHSAccountability,whichdescribesthesystemofresponsibilityandaccountabilityfortakingdecisionsintheNHS,willalsorequirerevisionbyApril2013.

12. TheHandbookwillalsoneedtoexplainhowtheexistingrightsintheNHSConstitution,andtheirlegalforce,willcontinuewhentheneworganisationstakeontheirfunctionsinApril2013.Tothatend,theappendixoutliningthelegalsourcesofboththepatientandstaffrights

intheNHSConstitutionwillneedtobeupdatedasnecessary.

13. TheNHSFutureForumwillbeconsideringpotentialchangestostrengthenandreinforcetheNHSConstitutionandwilladvisetheSecretaryofStateintheautumnof2012.Aspartoftheengagementprocess,theNHSFutureForumwillalsoconsidertheaccessibilityoftheHandbookandeaseofuseforpatients,staffandmembersofthepublicandwhetherthesedifferentgroupsareawarethattheHandbookexists.Apublicconsultationwillbeheldonanyproposedchanges,includinghowtoraiseawarenessoftheHandbookaswellastheNHSConstitution.Followingthepublicconsultation,ifchangesaremadetotheNHSConstitution,theHandbookwillneedtobeupdatedtoreflectanychanges.


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Annex 3: Glossary

TheNHSConstitutionforEnglandisa‘declaratorydocument’,articulatingexistingrightsandresponsibilitiesinoneplace.TheNHSConstitutionismadeupoffivemainelements:

• Principles–describedas“enduringhighlevel‘rules’thatgovernthewaythattheNHSoperates,anddefinehowitseekstoachieveitspurpose”.

• Values–whichunderpintheprinciplesandareintendedto“providethecommongroundforco-operationtoachievesharedaspirations”.

• Rights–an“entitlementprotectedbylaw”.TheseincluderightsconferredexplicitlybylawandrightsderivedfromlegalobligationsimposedonNHSbodiesandhealthcareproviders.TheConstitutionbringstogetheralloftheserightsinoneplacebutdoesnotcreateorreplacethem.

• Pledges–aimsthattheNHSiscommittedtoachieve.Pledgesarenotlegallybindingandexpressanambitiontoimprovegoingbeyondlegalrights.Pledges,though,aremorethanaspirations;thereisanexpectationthatpledgeswillbedeliveredwhetherthroughperformancemanagement,regulation,choiceoraccountabilityframeworks.

• Responsibilities–“expectationsofhowpatients,thepublicandstaffcanhelptheNHSworkeffectivelyandensurethatfiniteresourcesareusedfairly.”

TheConstitutionisalsosupportedbytwoadditionaldocumentsthatprovidefurtherinformation,includinginformationthatwouldbesubjecttofrequentchanges,allowingtheNHSConstitutionitselftobeamorehigh-levelandenduringdocument:

• the Handbook to the NHS Constitution–whichprovidesadditional,detailedinformationontherights,pledgesandresponsibilitiessetoutintheConstitution,aswellasexplainingwhatunderpinsthem.

• the Statement of NHS Accountability–adescriptionofthesystemofresponsibilityandaccountabilityfortakingdecisionsintheNHS.TheConstitutioncommitstheGovernmenttoprovidingaclearandup-to-dateStatementofNHSAccountability.

4 July 2012

Documents

Report on the effect of the NHS Constitution · the NHS Constitution. I also believe they will help the NHS better to meet them. In times of change, the Constitution provides continuity,