NHS Constitution is “patchy, low key, and inconsistent,” says review

BMJ 2012; 345 doi: (Published 06 November 2012) Cite this as: BMJ 2012;345:e7494
  1. Zosia Kmietowicz
  1. 1London

The government must do more to publicise the NHS Constitution among the public as well as NHS staff and give the document “more teeth” by defining more clearly what people in England can do when they do not get their rights, says an independent group of experts.

In a letter to the health secretary dated 31 October, Steve Field, head of the NHS Future Forum, said that the forum working group’s consultation with many NHS organisations, patients, staff groups, and charities led it to conclude that there was “a striking degree of consensus” on the constitution and its objectives.1

But he added, “Despite the importance and potential of the NHS Constitution, its effect so far has been patchy, low key, and inconsistent. It has failed to have the impact required to influence the quality of the service, the level of patient experience, and give appropriate support to hardworking staff.”

The Future Forum was asked in March this year to advise the government on how the document could be strengthened.2 The constitution, which was launched in January 2009, sets out the principles and values of the NHS in England for patients and staff. The government plans to relaunch the constitution in April 2013 and is running a consultation on what changes need to be made until 28 January.

The government has accepted all of the forum’s six recommendations for strengthening the text of the constitution. These include adding a new principle to reflect the fact that the NHS welcomes feedback. There is also a new pledge that NHS staff must be open and honest if things go wrong. The government has said that this “duty of candour” will become a condition in the NHS Standard Contract from April 2013. It also pledges that patients will not have to sleep in mixed sex wards.

The consultation also says that patients, their families, and carers should be involved in decisions about patients’ care and treatment, including at the end of life.3

Field said that the East of England strategic health authority had tried to embed the constitution into its culture by having champions, by including it in appraisals, and by publicising it among staff and patients. He added, “This needs to happen everywhere. All organisations commissioning and delivering NHS services must be able to demonstrate clearly how they have taken account of the constitution and be held publicly accountable for doing so in a meaningful way.”

In his letter Field said that he would not support an expensive advertising campaign to publicise the constitution but that carefully targeted resources were needed to make sure that “this time, the message gets through to staff, patients, and the public.”

The new legal duties of the NHS Commissioning Board, clinical commissioning groups, and Health Education England presented opportunities to embed the principles more fully, said Field.

The consultation also found that many NHS staff felt poorly supported when they raised concerns about services and that patients and carers did not know where to turn when their expectations of the NHS were unmet.

“When people just want help sorting out an immediate problem they find themselves pushed down a regulated and imperfect complaints system,” leading to loss of credibility of the constitution, said Field. “One organisation we spoke to gave a striking account of how initial enthusiasm for the constitution among its members gave way to disillusionment when they could not get a clear answer about how they could use it where they didn’t get their rights.”

No extra legal powers were needed for the constitution, but the health department should do more work to explore how the constitution could be given greater traction, he recommended.

In the consultation document the Department of Health said, “Early next year, we will develop and consult on proposals, following the publication of the Francis inquiry report into the events at Mid Staffordshire NHS Foundation Trust, on how to give the Constitution greater traction.”


Cite this as: BMJ 2012;345:e7494