It appears that the founding principles and aspirations of the NHS remain largely intact, but they are under great and increasing strain. This relates in part – but only in part – to increasing demands and costs brought about by demographic change, high expectations and new therapeutic opportunities offered by technological advance.
But these factors are not the sole cause, nor in the views of patients, public and staff are they the most important.
As the Francis Inquiry – the latest of several into shameful events – has so painfully shown, unless certain conditions are met, patients cannot be sure of humane, dignified care.
The evidence revealed – or rather confirmed, because many had been reported and known for years – that dark factors in the culture of the NHS have allowed and tolerated attitudes and behaviours that are wholly unacceptable. They betray values that should be accepted or assumed without question by all.
There must be a unified effort to ensure that resources are used well, and useless interventions and unjustified variations in practice should cease
At another level it is clear that the resources available to the NHS, which necessarily are limited, are not used as productively or efficiently as they should be.
In a service where investment in trained staff is the major cost, this can mean that the numbers and levels of competence of staff are not sufficient everywhere for safe, high-quality care, and at worst, blunt compassion.
What do health and political leaders need to do? They are not a cadre apart; the qualities we look for in leadership are necessary at every point of service and level of organisation. But senior leaders set the tone, the example, and enable the conditions necessary for health organisations to flourish and their staff serve patients well.
We recall that the NHS Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities which they owe one to another to ensure that the NHS operates fairly and effectively.
The staff pledges of the NHS Constitution require organisations to engage staff in decisions that affect them and the services they provide, to deliver better and safer services. Senior leaders are motivators and catalysts of engagement. But unless the values they claim to espouse are reflected in day-to-day behaviours, they will fail.
The extent of the failure of the system shown by Francis showed the need for a fundamental change – not of organisation but of culture. It will restore a culture in which the proper concerns of patients and their families, and staff at all levels, are expressed fearlessly, heeded willingly and acted on.
All are necessary but they are not sufficient. There must be a unified effort to ensure that resources are used well, and useless interventions and unjustified variations in practice should cease.
Education and training, and continuing professional development, should be designed to ensure that staff are ready to meet changing patient and population needs and working conditions.
For political and societal reasons, and the powerful hold of the NHS on people in the UK, I believe that it will remain largely free at the point of use. However, even if possible cost savings are realised and productivity increased, should the national economy be unable to keep pace with need and opportunity, it seems likely that some form of co-payment will arise.
My single message reflects the findings of many reports and inquiries which long ago should have been sufficient to bring about the changes needed: the value and quality of the NHS is measured through the views and experience of patients, which must be heard, heeded and acted upon.
This is an extract from Professor Dame Carol Black DBE’s contribution to the Nuffield Trust publication: The wisdom of the crowd: 65 views of the NHS at 65. The collection of essays was published on Thursday 4 July 2013.
Black C (2013) ‘NHS @ 65: views of patients must be heard’. Nuffield Trust comment, 3 July 2013. https://www.nuffieldtrust.org.uk/news-item/nhs-at-65-views-of-patients-must-be-heard