In terms of power the patient is always the weaker party in the healthcare equation. The nurse or doctor has a unique specialised professional knowledge and skill set to which the patient needs access. The patient may be feeling unwell, may be fearing the worst about their condition, and is being treated in an unfamiliar environment. The nurse or doctor is in their usual work environment, in control, has the specialist knowledge required, and may be the gatekeeper to future patient care and treatment. There is an imbalance in this relationship that needs to be carefully managed to prevent abuse.
There are many sources of advice for patients, nurses, doctors and the wider NHS on how to manage and balance professional relationships. Information sources include professional codes of ethics and publications from various regulatory bodies or stakeholders, academic commentary, legislation and judicial case law.
As I have commented before in previous columns, it is difficult for busy nurses and doctors to keep up to date with all the information coming out on patient safety from a wide range of national and international sources. The same applies to advice on the professional relationship between nurses, doctors, the wider NHS and patients. There is an urgent need for the NHS to develop a one-stop patient safety information hub that collects, collates and distributes key information across the NHS. At present, we have important publications, codes and practices emanating from a wide variety of sources. These can be hard to track down and can be easily missed. This hub should also include publications and advice on the professional relationship between nurses, doctors and patients, and the wider NHS.
NHS Constitution
The NHS Constitution for England (Department of Health, 2015) can be seen as an attempt to balance the healthcare equation. Rights and pledges for patients, the public and NHS staff are set out, as well as their responsibilities. The legal sources for both patient and staff rights are also stated.
The NHS Constitution articulates the principles of operation and purpose of the NHS along with its underpinning values. It is an important publication setting the tone of how the NHS and its staff function and relate to those whom it serves. It is the bedrock of NHS service delivery.
The Department of Health and Social Care (DHSC) has just published two important publications on the NHS Constitution. The updated Handbook to the NHS Constitution (DHSC, 2019a) includes a strengthening of the patient and public responsibilities section—making clearer the vital role that patients and the public play regarding NHS sustainability and in ensuring that resources are focused on those who need them most (Doyle-Price, 2019). Both this and the Third Report on the Effect of the NHS Constitution (DHSC, 2019b) also address the unequal power relationship.
The NHS Constitution handbook
The NHS Constitution handbook (DHSC, 2019a) is a large and complex document, running to 160 pages. The four parts discuss NHS values, principles that guide the NHS, patients and the public, and staff. Part 3, which covers patients and the public, discusses the following:
From a patient safety context, the rights set out in section 3a of the NHS Constitution are important:
‘You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organization that meets required levels of safety and quality.’
‘You have the right to be cared for in a clean, safe, secure and suitable environment.’
‘You have the right to expect NHS bodies to monitor, and make efforts to improve continuously, the quality of healthcare they commission or provide. This includes improvements to the safety, effectiveness and experience of services.’
These are all fundamental statements of rights and they should permeate through everything the NHS does.
Balancing the care equation
In the NHS Constitution, patients have several other rights, such as the right to an open and transparent relationship with the care-providing organisations. This includesbeing told about any safety incidents relating to their care that, in the opinion of a health professional, has caused or could still cause significant harm or death. Following on from this, to be given the facts, an apology and any reasonable support.
Part 4 covers staff rights, staff pledges, staff legal duties. There is also a section dealing with expectations, and how staff should play their part in ensuring the success of the NHS.
NHS Constitution review
The Health Act 2009 requires the Secretary of State for Health and Social Care to review and republish the NHS Constitution at least once every 10 years, and to review and republish the Handbook to the NHS Constitution every 3 years. The Secretary of State is also required to report to Parliament on the effect of the NHS Constitution every 3 years.
The third report to Parliament on the NHS Constitution (DHSC, 2019b) follows reports published in 2012 and 2015 (the NHS Constitution was first published on 21 January 2009, and last updated in 2015).
The findings
The findings are based on surveys carried out with NHS staff and the public between March and May 2018. In 2018, 1790 members of the public were surveyed through face-to-face interviews. The NHS staff surveyed were in specified staff groups in England.
The report goes into more detail on the methodology used, and the purpose of the research, which is that it:
‘Provides an indication of current levels of public and staff understanding, awareness, support, and use of the Constitution, their attitudes towards it, and how these have changed since its launch.’
Awareness of the NHS Constitution
The NHS Constitution is a key central repository of essential information that states how the NHS is governed, its principles of operation, its values and purpose. To be successful in its purpose of educating it must be accessible, widely known and understood. However well written and presented it may be, the NHS Constitution will not be effective if there is poor awareness of and understanding about it among the public and NHS staff. On this, the report paints a mixed picture. NHS staff are much more aware of it than the public. In 2018, 19% of members of the public surveyed said that they had heard of the NHS Constitution when prompted by a written description, but did not know its name. This is a fall of 5% from the 2015 figure of 24% and an overall fall of 3% since 2009 (DHSC, 2019b).
There has been a decline in the overall percentage of NHS staff saying that they have heard of the NHS Constitution since 2015 (from 69% to 61%). This is largely due to a steep fall among administrative staff (from 62% to 43%), with smaller reductions among practice nurses (working in GP surgeries) (from 59% to 46%). However, nurses, doctors, dentists and pharmacists all have higher levels of awareness of the NHS Constitution now than they did in 2009.
There has been a decrease in the overall percentage of staff who feel ‘very’ or ‘fairly’ well informed about the NHS Constitution since 2015 (from 23% to 18%), with the largest decreases again occurring among administrative staff. The proportion of staff who think it is important that the NHS has a Constitution remained high at 73%:
‘Better care for patients, improving safety and quality of care, and giving patients a voice continue to be the three reasons most mentioned by staff for the Constitution having a positive impact on patients.’
Where patients get information
The report's finding that the public are not very aware of the NHS Constitution is an important failing in the concept itself and it is important to explore the possible reasons for this. Few members of the public (ranging from 1% to 0%) mentioned the NHS Constitution as a source of information. The two most popular sources of information on topics such as keeping healthy, care services, patient responsibilities, and what patients can do if the NHS does not meet expectations are currently GPs/health professionals and the NHS website (www.nhs.uk). This is not surprising, particularly given the general popularity of the internet and online activity.
A makeover needed?
The NHS Constitution is an excellent concept, but in terms of how information about it currently reaches the public domain and how this is then perceived, it would seem that it may be too complex an idea for general consumption in its present form. The very name, ‘NHS Constitution’, conjures up images of parliament and government and legal terminology—presenting a very legalistic, even elite image. From the standpoint of members of the public you could equate the reading of the NHS Constitution with the reading of the small print on a contract or the terms and conditions for an online purchase.
‘The NHS Constitution articulates the principles of operation and purpose of the NHS along with its underpinning values’
The NHS Constitution needs a name makeover and a less academic writing style. Such changes would make it more accessible to the public generally and it would hopefully be read and understood more widely. That NHS staff are increasingly aware of its positive impact is at least a point in its favour.
Conclusion
The new publications on the NHS Constitution are to be welcomed. They clearly show that there are many good points resulting from the concept. The NHS Constitution Handbook contains information, ideas, concepts and values that underpin the operation of our NHS, and these can be seen to help balance the healthcare equation. In the NHS Constitution there are well-crafted ideals and these underpin our healthcare system.
The problem lies with the NHS Constitution's poor impact on the public, and this needs to improve, otherwise it will be seen by many as document that is relevant only to NHS staff.