Views And Reviews Acute Perspective

David Oliver: Time for an honest patient’s charter?

BMJ 2016; 355 doi: (Published 30 November 2016) Cite this as: BMJ 2016;355:i6388
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

The parliamentary act that led to the NHS’s creation set out what the public could expect—a universal service based on need, free at the point of delivery.1 Since then, the government has repeatedly set out standards that the public should expect.

We had John Major’s “patient’s charter,”2 then NHS standards for four hours in emergency departments or two weeks for investigation of suspected cancer.3 The NHS constitution strengthened the founding principles.4 The government response to the Francis inquiry guaranteed fundamental standards of care.5 The Care Quality Commission explicitly inspects services for “responsiveness.” The current government has promised the same quality of care across all seven days.6

Such promises are a kind of government contract with the people: “Elect us, pay your taxes, and in return this is what you can expect the NHS to provide.” I welcome them, when they have a realistic chance of delivery.

I also welcome continued high levels of public pride in the NHS and decent levels of user satisfaction.7 8 I welcome the consistent rating of the NHS as one of the most equitable, fee-free, and efficient health services in the world. And it’s miraculous that we continue to deliver so well on national waiting time targets, such as those for emergency departments.

Some of the unhappiness stems from expectations we can’t reliably meet and should perhaps stop promising

But there’s no denying that plenty of patients and families are unhappy—even if many don’t formally complain—and no shortage of journalists, phone-in callers, or web commentators describing unhappy personal or family experiences of the system.

NHS key performance indicators are worsening in the face of funding shortfalls, workforce gaps, and unprecedented demand, as the King’s Fund’s latest quarterly monitoring report shows.9 Some of the unhappiness stems from expectations we can’t reliably meet and should perhaps stop promising.

More people are waiting longer in seriously overcrowded emergency departments.9 10 More are stranded in acute beds, waiting for social or community health services.11 Many feel rushed out from scarce acute beds, with wider system pressures perforce taking priority over individual needs.12 More planned procedures are being cancelled or delayed: waiting lists have reached nearly four million this year.13

Nurses on very short staffed wards may struggle to find time to care, and morale suffers.14 Therapist hours aren’t always enough for anything beyond basic rehabilitation.15

Maybe it’s time for a new, realistic patient’s charter, honest about current constraints. Instead, we have grand, government driven promises to maintain performance and expand access—promises it will struggle to keep.16 17

In a contract, you’re meant to get what you pay for. As NHS England’s chief executive, Simon Stevens, recently admitted, we’re no longer paying enough.18



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