THE NHS CONSTITUTION State of Readiness Group...of change required to bring the NHS Constitution...

THE NHS CONSTITUTIONState of Readiness Group

Final Report November 2009

2 NHS Constitution State of Readiness Group - Final Report - November 2009

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Gateway Reference 13039

Title The NHS Constitution State of Readiness Group: final report

Author The State of Readiness Group

Publication Date November 2009

Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs, PCT Chairs, NHS Trust Board Chairs, Special HA CEs, Directors of HR, GPs

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Contact Details Anne Richardson, Deputy Director, Workforce Skipton House London Road London SE1 6LH 2079723740

www.dh.gov.uk/publications

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2 NHS Constitution State of Readiness Group - Final Report - November 2009 3 NHS Constitution State of Readiness Group - Final Report - November 2009

Contents

Foreword 4

Membership 6

1. Recommendations 8

2. Background to SORG 14

3. The Health Bill 16

4. NHS Constitution 17

5. Research and Findings 24

6. Strategic Health Authority State of Readiness 28

7. Aligning the Infrastructure 33

8. Stakeholder and SORG Feedback 38

9. Conclusion 42

10. Final Word 44


We are delighted to present the final report of the NHS Constitution State of Readiness Group (SORG) to the NHS Management Board. The report offers recommendations for all levels of the system to translate locally. Our hope is that it will help to mobilise renewed leadership around the NHS Constitution. For this reason, the SORG recommends to the NHS Management Board that it should also be shared with national stakeholders and Strategic Health Authorities.

The SORG was convened after the publication of the NHS Constitution. It was convened at the request of the NHS Management Board to understand and support development of a state of readiness in the health service to ‘have regard to’ the NHS Constitution. Subject to the passage of the current Health Bill through Parliament, all NHS organisations in England, as well as third sector and independent organisations providing NHS care, will be required to do this as a legal minimum. The SORG was also asked to make recommendations on how to embed fully the NHS Constitution - how to deliver the legal rights and responsibilities and the staff and patient pledges, which is a more significant task in terms of volume as well as time. The report which follows addresses both these aspects. It recognises that a number of steps are needed to embed the Constitution fully.

The SORG report covers work undertaken in six meetings between April and September 2009. It includes the background to the SORG; summaries of the Strategic Health Authority and stakeholder reports on readiness as well as research on Constitution awareness and information on system alignment.

It summarises discussion in SORG about readiness, and it includes SORG’s agreed recommendations on how to embed the NHS Constitution.

The SORG membership provides a wonderful example of co-production. The group has had representation from all levels of the system. The discussion and debates have been first class; we have received high calibre papers and the group showed tremendous passion and commitment.

The NHS Constitution signals a move away from the language of targets. This move is articulated in the Government’s new publication, Building Britain’s Future. In this initiative the Constitution is held up as a pioneering example of how public relationships are built around mutual responsibilities and rights rather than targets. It is also pleasing that in Building Britain’s Future there is a strong commitment to build upon the existing rights in the NHS Constitution.

Professor Steve Field said at our third meeting that the NHS Constitution offers the opportunity to bring the system closer together and promises to improve our working relationships for the benefit of patients, public and staff. To seize this opportunity, awareness needs to be raised throughout the system of the scale of change required to bring the NHS Constitution alive, and the benefits that this change will bring. Primary Care Trusts, as local leaders of the NHS, have a significant leadership role to play in this regard.

Foreword

‘The Constitution is seen as a pioneering example of how public relationships are built around mutual responsibilities and rights rather than targets.’


The NHS Constitution will endure beyond the present economic downturn, and, if used properly, will help our response to this challenge. SORG believes that the Quality, Innovation, Productivity and Prevention framework shows how this can be achieved. We can raise quality if we deliver the rights and pledges within the Constitution. We will inspire innovation if we work closer as a system and live the Constitution’s principles and values. We can support prevention, by responding to the right to vaccinations. And we will raise productivity if we truly work in partnership with our patients and staff.

‘The SORG membership provides a wonderful example of co-production and have shown tremendous passion and commitment.’

Clare Chapman Director General of WorkforceDepartment of Health

Keith S Pearson JP ChairmanNHS East of England

As joint chairs, we would like to thank everyone who gave valuable time and contributed so constructively to our meetings, the reference groups and to the research. We would also like to thank the officials from NHS East of England and the Department of Health for their administrative support.

Yours sincerely


Members of the NHS Constitution State of Readiness Group

CO CHAIRS

Clare Chapman Department of Health Director General of Workforce

Keith PearsonChair of NHS East of England

SYSTEM LEADERS

Patients and Public and Third Sector

Joan Saddler Department of Health National Director Patient and Public Affairs

Sally Brearley Chair of Health Link

Mark Platt Director of Policy and Public Affairs, National Voices

Clinical Leaders

David Fish UCL Hospitals Steve Field GP, Chairman of Council, Royal College of GPs Lesley Doherty Director of Nursing and Performance Management, The Royal Bolton NHS Foundation Trust

Partners

Karen Jennings Head of Health, Unison Anna Dixon Director of Policy, King’s Fund Steve Barnett Chief Executive of NHS Confederation Alastair Henderson Director of Operations/Deputy Director, NHS Employers Helen Bevan Director of Service Transformation,NHS Institute for Innovation and Improvement

Communications

Colin Douglas Department of Health Director of NHS Communications

Ed Garratt Head of Communications for NHS East of England

Anna Millar Senior Communications Officer, Department of Health

Providers and Commissioners

Miles Scott Chief Executive, Bradford Teaching Hospitals NHS Foundation Trust Rob Webster Chief Executive, NHS Calderdale Primary Care Trust

Regulators

Adrian Masters Director of Strategy at Monitor

Linda Hutchinson Director of Registration, Care Quality Commission to the Regulators


External Expert Policy

Will Hutton Executive Vice Chair of the Work Foundation

Una O’Brien Department of Health Director General of Policy and Strategy

NHS MANAGEMENT BOARD

People Matters Executive Group Stephen Welfare Director of Workforce, NHS East of England

Dean Royles Director of Workforce, NHS North West

Commissioning and System Management

Paul Streets Director of Patient and Public Experience, Department of Health

Strategic Health Authority Chief Executive

Jim Easton NHS National Director for Improvement and Efficiency

DEPARTMENT OF HEALTH CONSTITUTION TEAM

Policy Support Unit

Ian Dodge Director

Andrew Sanderson Deputy Director

Sarah Fisher-Mackey Policy and Strategy Section Head

Staff Experience Policy Team

Anne Richardson Branch Head

Becky Farren Head of Staff Engagement

GROUP PROJECT MANAGER

Tom Leach NHS East of England

SECRETARIAT

Sam Scott Department of Health


Recommendations1

1.1We propose recommendations, specifically for national and local stakeholders, Primary Care Trusts, Providers, Strategic Health Authorities, Department of Health and Department of Health Management Boards.

1.2In general terms, for all these bodies, it is important for their Boards to build understanding and conviction in their organisations; use reinforcements; develop skills and capability and to role model the NHS Constitution.

1.3 All Boards should consider carefully the ways they can understand, monitor and review the impact of the NHS Constitution for patients, public and staff. This will involve using data from, for example, staff and patient surveys, records of complaints, and feedback from patients and their representatives including Patient Advocacy and Liaison services, other advocacy services, and Local Involvement Networks. Boards should also consider any gaps they might have in understanding the impact of the NHS Constitution and find ways to close those gaps.

1.4As a bare minimum Boards should have regard to the NHS Constitution in their decision making and use the NHS Constitution in their communications and engagement activity (both internally and externally). Boards and Joint Consultative Committees should also ensure their terms of reference reflect the need to have regard to the NHS Constitution.

1.5Approaches to implementation should reflect the mutuality of the NHS Constitution. For example, this report provides a case study on Learning Disability services (6.16) where focus groups with service users and staff are not only being used to gain perspectives on the Constitution but also to improve partnerships between service users and staff. There is a double outcome here which is best practice for local implementation planning.

1.6National and local stakeholders

• Stakeholdershaveanimportantroletoplay in promoting the NHS Constitution, challenging the NHS to have regard to the NHS Constitution and using it to help deliver better care and support.

• Professionalbodiesshouldbeencouraged to incorporate the NHS Constitution in their education programmes and conferences - e.g. the Royal College of GPs have proposed a joint learning session between their College and The British Association of Medical Managers.

• Regulators,wherepossible/appropriate,should align the NHS Constitution to their registration and regulation processes, as in the example set by Monitor. (See 7.12).

• HealthOverviewandScrutinyCommittees and Local Involvement Networks could be empowered to consider whether proposed service changes and ongoing service delivery are in line with the Constitution. The forthcoming PR campaign to raise awareness of Local Involvement Networks, which will present the Constitution as a backdrop for local involvement, will be a helpful step.


• LocalAuthoritiescouldincorporatethe NHS Constitution when jointly commissioning services that people really want and need. They might also use the NHS Constitution to work more collaboratively with the NHS, especially on the health inequalities agenda.

• Patientgroupsandthethirdsectorcould help translate the NHS Constitution into the Service Level Agreements/contracts that Primary Care Trusts commission. Patient groups could also help to promote the NHS Constitution to the wider community, supporting members to exercise their rights. Patient groups could also help to promote the NHS Constitution to the wider community, supporting members (and in particular Black, Minority and Ethnic and seldom heard groups) to exercise their rights.

• TheNHSConstitutionshouldbeincorporated into Social Partnership Forums. These forums have a crucial strategic role to ensure that the staff pledges and rights are honoured and translated into action locally. Regional Social Partnership Forums are better placed than the national forum to directly influence and support local NHS organisations in embedding the Constitution. For example regional forums can influence policy formulation for employers on how to incorporate the NHS Constitution.

• Allprovidersofprimarycare-notably GPs - have an important role to raise awareness of the NHS Constitution in local communities. Ideally they should work jointly with their commissioners on this important communications task. The Royal College of GPs are very supportive of this idea.

• TheCareQualityCommissionshouldsupport the proposal to ensure that patient rights and pledges are covered in the patient surveys that they run.

• TheNationalQualityBoardshouldhelp to ensure that the system is aligned on the NHS Constitution.

1.7Primary Care Trust Commissioning Boards

• PrimaryCareTrustChairsshouldcontinue as the local guardians of the NHS Constitution.

• PrimaryCareTrustsshouldsetanexample to their providers and partners in their leadership of and regard to the NHS Constitution.

• PrimaryCareTrustsshouldconsiderinviting patients and staff to share their stories at Board meetings.

• PrimaryCareTrustsshouldhaveclear narratives of how the NHS Constitution relates to their local visions - and record these in their Annual Reports.

• PrimaryCareTrustsshoulddevelopConstitution communications and engagement strategies for GPs and GP Practice staff.

• Theintroductionoftheroleof‘Constitution Champion’ should be considered by Primary Care Trusts. In line with the proposals in Building Britain’s Future this role should be determined locally and could include providing support for patients and their families and carers. Champions could liaise with LINks and patient advocacy groups at local level to promote awareness of rights and help patients obtain them.


•PrimaryCareTrustBoardsshouldbe able to report organisations failing to ‘have regard to’ the NHS Constitution to the relevant regulator, for example if a provider fails to deliver the right to ‘monitor, and make efforts to improve, the quality of healthcare they provide’.

•PrimaryCareTrustsshouldcontinueto support Strategic Health Authority work related to the NHS Constitution.

•PrimaryCareTrustDirectorsofWorkforce and Patient and Public Empowerment Leads should ensure that staff and patient and public engagement should be driven by the NHS Constitution.

•PrimaryCareTrustsshouldadoptprocesses for honouring and maturing the pledges as well as the rights in the NHS Constitution.

•Theapplicationoftheprinciplesfor Cooperation and Competition could be guided by the NHS Constitution.

•PrimaryCareTrustsshouldensurethat all contracts with providers and contractors reflect the Constitution, in particular the pledges. This includes the contractual and joint working arrangements with Social Care organisations.

•PrimaryCareTrustsshoulddebatewith their local population about what the NHS Constitution means for them, where possible, as part of their revised World Class Commissioning strategies.

• PrimaryCareTrustBoardsshouldbeencouraged to support those with most patient contact who have most opportunity and responsibility to make the NHS Constitution real.

•PrimaryCareTrustscouldinvolvepatients in the systems established to performance manage the services they commission. For example, they could create a customer insight pathway that clarifies the steps to take when the NHS is not living up to the NHS Constitution.

• PCTscouldmaketheConstitution’srights and pledges meaningful to local people (and especially Black, Minority and Ethnic and seldom-heard groups) by working with Local Involvement Networks, other community groups and third sector organisations to raise awareness and help people understand how to obtain their rights.

1.8Provider Boards

• ProviderChairsshouldbeencouragedto continue their leadership of the NHS Constitution.

• Boardsshouldbeencouragedtouse the NHS Constitution as an engagement tool for their members, staff, stakeholders and partners.

• Boardscouldconsiderinvitingpatientsand staff to share their stories at Board meetings.

• FoundationTrustBoardsshoulddescribe how they have had ‘regard to’ the NHS Constitution in their Annual Reports to governors.


• Boardscouldrefreshtheirlocalvalues and strategies in the context of the NHS Constitution.

• Boardsshouldbeencouragedtosupport those with most patient contact who have most opportunity and responsibility to ensure the care they provide is in line with the NHS Constitution rights and pledges. Boards should be encouraged to empower their customer services functions (including Patient Advice and Liaison Services and complaints teams) to help patients obtain their rights, and help those colleagues who provide care to understand how better to deliver them.

1.9Strategic Health Authority Boards

•StrategicHealthAuthorityChairs,as leaders and guardians of the NHS Constitution, should be encouraged to continue this role.

•StrategicHealthAuthorityBoardsshould set an example to their local NHS in their leadership of and regard to the NHS Constitution.

• StrategicHealthAuthorityChairsshould co-ordinate and support the ‘Constitution Champions’ in the local NHS.

• StrategicHealthAuthorityChairsshould build leadership of the NHS Constitution into the objectives of local NHS Chairs.

•StrategicHealthAuthoritiesshouldhave clear narratives of how the NHS Constitution relates to their regional visions - and record these in their Annual Reports.

•StrategicHealthAuthoritiesshouldcontinue to work in partnership with the Department of Health in leading the implementation of the NHS Constitution.

• StrategicHealthAuthoritiesshouldcontinue to support Primary Care Trusts in their work related to the NHS Constitution.

• StrategicHealthAuthoritiesshouldengage their Regional Social Partnership Forums in the NHS Constitution.

•StrategicHealthAuthorityDirectorsof Workforce and Patient and Public Empowerment Leads should ensure that staff and patient and public engagement are underpinned by the NHS Constitution. They should also ensure that a focus is given to the legal duty to involve disabled people, who, alongside older people, are the heaviest users of NHS services.

• StrategicHealthAuthoritiescoulduse the NHS Constitution to influence partnership working. For example, the NHS and Local Authorities or the voluntary sector working more closely together to address service needs.

• StrategicHealthAuthoritiescoulduse the NHS Constitution to mobilise ‘an army of agitators’, taking their local NHS to task about whether their rights are being met, and putting their results on NHS Choices.


• StrategicHealthAuthoritiesshouldengage their Deaneries and other education commissioners to incorporate the NHS Constitution in medical education (e.g. e-learning module for foundation level medical students).

• StrategicHealthAuthoritiesshouldhave processes for honouring and maturing the pledges as well as the rights in the NHS Constitution. This could include developing and running campaigns with Local Involvement Networks (e.g. on sharing patient correspondence or patient safety).

• StrategicHealthAuthorityDirectorsof Communications should develop, with the local NHS, Constitution Communications strategies for their regions. These strategies must be driven by the premise that the ‘NHS belongs to us all’ and therefore aim to be inclusive in its reach.

1.10Department of Health

•TheDirectorofCommunicationsshould write a narrative which describes the importance and central position of the NHS Constitution. The Director of Communications should also ensure that this narrative messaging is understood by all levels of society.

• DepartmentofHealthmediaand communications campaigns should reference the NHS Constitution more regularly than at present. For instance, the current pandemic creates an opportunity to incorporate NHS Constitution messages around personal responsibility and using services responsibly.

• TheDirectorofCommunicationsshould commission follow-up surveys on patient, public and staff awareness, at a regional as well as national level, of the NHS Constitution so we can track progress post Royal Assent of the legislation. This is important because, subject to Parliament, the Health Bill will require Department of Health to report on the effect of the Constitution at least once every three years.

• StrategicHealthAuthoritiesshouldbe asked by the Department of Health to compile a picture of progress within their areas, drawing on national and local survey data, developments in local systems to align with the Constitution, and feedback from patients and staff.

• DepartmentofHealthshouldensurethat standard contracts reflect the NHS Constitution.

•TheDirectorsofWorkforceandPublic and Patient Empowerment Leads should consider how staff and patient and public engagement might be driven by the NHS Constitution and ensure patient and staff surveys are aligned. This will include mapping existing gaps on tracking patient and staff rights and pledges, and supporting the NHS to fill those gaps.

• ThereisanopportunityfortheDirector of Workforce to make more explicit links between the staff pledges and the Boorman Review and to revitalise the Knowledge and Skills Framework.


•TheNHSConstitutionshouldreduce existing inequalities and promote equality. Engaging the new Equality and Diversity Council would support this ambition. Also, it would be helpful if the original Equality Impact Assessment be reviewed and updated with each triennial Department of Health report on the effect of the Constitution on patients, staff and the public. This will help to map progress on how equality, health inequalities and diversity issues are understood and being addressed as well as helping Department of Health identify where there are any gaps or shortfalls to be addressed.

• DepartmentofHealthPublicand Patient Empowerment and Equality and Inclusion colleagues should review with stakeholders the main policy findings and recommendations coming from the Community Investors review of the equality and diversity implications of the NHS Constitution. They should also ensure that the Constitution’s rights are aligned to the existing duties under equality and Human Rights legislation.

•TheDirectorofWorkforceshouldincorporate the NHS Constitution into leadership programmes.

• Allnationalpoliciesandpolicystreams should align to the NHS Constitution.

•TheDepartmentofHealthshouldensure that existing metrics, for example in World Class Commissioning, map across to the NHS Constitution. The SHA Assurance metrics show how this can be done effectively.

•TheDepartmentofHealthhasarole to ensure that best practice regarding the Constitution is being shared throughout the system, particularly regarding implementation. The Department of Health should support the NHS to persuade the Third Sector that the NHS Constitution will have an impact on experiences of health care.

1.11Department of Health Management Board

•TheDepartmentofHealthManagement Board should continue to show unified commitment to the NHS Constitution.

•TheManagementBoardshouldaimto lead by example and could show, for instance, how decisions taken at the Management Board have regard to the NHS Constitution; include references to the NHS Constitution in public speeches; and ensure that the Constitution’s values are role modelled.

•ItisvitalthattheNHSManagementBoard communicate the scale of the task that still remains to embed the NHS Constitution, and that Strategic Health Authorities understand that effort is required in their regions to engage patients and the public as well as staff.


2.1In the sixtieth anniversary year of the foundation of the NHS, the Prime Minister asked Lord Darzi to consider the case for an NHS Constitution. His report High Quality Care For All concluded that the time was right to introduce a Constitution, and a draft was published for consultation in June 2008.

2.2The consultation on the draft NHS Constitution was overseen by the Strategic Health Authority Chairs and was led locally by Chairs and Non-Executives. In many areas of the country there was widespread, even ground-breaking, consultation, which revealed significant support for the NHS Constitution. Strong leadership from Chairs and Non-Executives in relation to the NHS Constitution, as well as partners, such as the British Medical Association and Royal Colleges, continues to be vital to ensure that the NHS Constitution is embedded locally.

2.3The NHS Constitution was launched by the Prime Minister at Downing Street on 21 January 2009. The media coverage was very positive; in particular, the Guardian and all of the tabloids referred to the NHS Constitution as ‘historic’.

2.4The SORG was convened in April 2009 at the request of the NHS Management Board to understand and support readiness in the health service to have regard for the NHS Constitution, and to understand the steps needed to embed the Constitution fully.

2.5The SORG was given a head start by the work of the Constitutional Advisory Forum (CAF), which had overseen the NHS Constitution consultation. The report published by the CAF in December 2008 made it very clear that the NHS Constitution should not be seen as a central initiative to be driven by the Department of Health. It said we would only realise the Constitution’s potential when everyone, from clinicians to commissioners, shared its ambitions and shaped daily practice in light of its principles, values, rights and responsibilities.

Background to the State of Readiness Group (SORG)

2

‘The SORG has worked from the premise that the Constitution should be locally driven and part of the ‘water we swim in’.’


2.6Prior to the creation of the SORG, the Department of Health launched the first phase of strategic communications around the NHS Constitution, focusing on engaging staff. This was designed to help ensure that staff were well positioned to have appropriate conversations with patients about the content of the Constitution; and to ensure that patient experience would be consistent. A toolkit to support local staff engagement with the Constitution was developed. It was distributed to all NHS communications, workforce and Patient and Public Empowerment leads, communications leads in independent sector organisations providing NHS care, the Social Partnership Forum and other national stakeholder communications leads.

2.7The second phase of the communications strategy is being designed to engage patients, public, third sector and patient stakeholder representatives, to coincide with Royal Assent of the Bill. This will ensure that the NHS is fully prepared to meet patients’ expectations of it once the duty to have regard to the Constitution comes into force.

2.8The SORG was established in April 2009 as a `task and finish group’ for six months to give assurance to the NHS Management Board that the NHS would be ready to have regard to the Constitution, and to help the Board and the Service ensure the Constitution would be embedded. Its work covered:

•Whatbuildingastateofreadinessto embed the Constitution means in terms of: public and patient engagement, staff engagement, communications and legislation and what enabling activity should be commissioned.

•Theimplicationsforsystemincentives, regulation and levers to ensure system alignment in priority areas to reinforce the outcomes and behaviours that the Constitution seeks.

•TheroleoftheNHSManagementBoard in embedding the Constitution, in line with the NHS Change Principles of system alignment, clinical leadership,

co-production and subsidiarity.


3.1Subject to Parliamentary approval, all NHS bodies and private and third-sector providers supplying NHS services will be required by law to ‘have regard to’1 or (as the Handbook to the Constitution expresses it) ‘take account of’2 the NHS Constitution in their decisions and actions. Organisations will have to be able to show that they have had regard to the Constitution, and be able to give good reasons for any departures from it.

3.2Ways in which the duty to have regard to the NHS Constitution could be fulfilled might include assessing existing policies and activities (for example annual reports, staff or patient surveys) to make sure they are in line with the NHS Constitution, and checking against the NHS Constitution before publishing new policies or documents.

3.3The ‘duty to have regard’ applies to the NHS Constitution as a whole. Of course, the Constitution’s rights and staff duties are already legally binding. They are directly enforceable in law quite apart from the fact that they are set out in the NHS Constitution. The pledges all represent existing policy so, if they are operating well, organisations should have systems in place to meet them, although those systems may not always be adequate. The duty to have regard to the Constitution should therefore not place significant new requirements on the NHS - even though the fact that rights and pledges are highlighted in the Constitution gives them renewed emphasis.

The Health Bill3

3.4The legislation underpinning the NHS Constitution is part of the Health Bill, introduced into the House of Lords in January 2009. The first seven clauses of the Bill propose that:

• Variousbodiesandprovidersofservicesareunderadutyto ‘have regard’ to the Constitution when performing their NHS functions. These bodies include:

- Strategic Health Authorities - Primary Care Trusts - NHS Trusts (including Mental Health Trusts) - Special Health Authorities - Foundation Trusts - Monitor - Care Quality Commission - Local Authorities and Carers - Any provider contracted to provide NHS services, including the independent and third sectors, GPs, dentists etc.

•TheDepartmentofHealthmustreviewandrepublishthe Constitution at least once every 10 years, consulting patients, staff, members of the public, the bodies listed above and others. The Constitution may be revised more frequently, with appropriate consultation. In either case, the Constitution’s principles may only be changed with the agreement of Parliament, through regulations.

•TheDepartmentofHealthmustreviewandrepublishtheHandbook at least once every 3 years.

•TheDepartmentofHealthmustpublishareportevery3years on how the Constitution has affected patients, staff and members of the public.

3.5Subject to its passage through Parliament, the Health Bill 3 is expected to receive Royal Assent in the autumn of 2009 and to come into force in Spring 2010. The prominence of the NHS Constitution is likely to grow in light of the proposals in Building Britain’s Future which proposes new rights relating to waiting times and health checks for 40-74 year olds. These new proposals will be subject to consultation.

1As expressed in the legislation 2As expressed in the handbook to the NHS Constitution 3 http://www.dh.gov.uk/en/Publicationsandstatistics/Legislation/Actsandbills/DH_093280


4.1The NHS Constitution is a historic document. It brings together existing and long cherished values, principles, legal rights, responsibilities and staff duties. It creates a new deal between patients, the public and staff that will inspire people to take responsibility for their local health service. It challenges the way that we build ownership, empower communities, and demonstrate commitment to the development of staff as well as their health and well-being. As Will Hutton, Chief Executive of the Work Foundation, said: ‘No other British organisation analogous to the NHS has gone this far.’

4.2There are three new rights in theNHS Constitution (rights relating to choice, vaccinations and the right to expect local decisions on funding of other drugs and treatments to be made rationally) and a number of new pledges and commitments. However, most of the content is familiar to people close to the NHS. The NHS Constitution provides a renewed focus on some important areas where performance across the health system is variable, such as work to promote equalities.

4.3The NHS Constitution is radical less in its letter than in its spirit, and, as Adrian Masters of Monitor said at SORG1, it is imperative to strike a balance between the two. Organisations should be encouraged to find this balance, which should be reflected in the approach taken to monitoring how well organisations are fulfilling their duty ‘to have regard’.

4.4Until the duty ‘to have regard’ to the NHS Constitution comes into force, the attention of the NHS is on compliance with the existing legal rights and ensuring that the duty to have regard to the Constitution is understood by Boards. Keith Pearson has argued that, after this milestone is achieved, attention should be given to delivering the pledges and commitments so that, if appropriate, they are ready to become rights. The process of maturing targets into pledges and potentially into rights would meet the ambition of politicians and NHS leaders, the expectations of patients and the approval of the public and staff. The pledges, which express an ambition for the NHS to improve the quality of the service over time, will be delivered if the values and the principles in the NHS Constitution are made real through leadership.

4.5The radicalism of the NHS Constitution derives from the concept of ‘mutuality’ that it expresses. The Constitution presents the existing legal and cultural elements of the NHS, and is organised around patients, public and staff. The energy and enthusiasm for the Constitution in the Constitutional Advisory Forum and SORG has always been at its highest when exploring the term ‘mutuality’ and the way to move away from patients, the public and staff having ‘rival’ interests to being mutually responsible for improving service quality. To achieve this, the NHS Constitution sets out what people can expect and importantly what the service expects in return.

NHS Constitution4

‘The radicalism of the NHS Constitution is drawn from the ‘mutuality’ of the document.’

19 NHS Constitution State of Readiness Group - Final Report - November 200918 NHS Constitution State of Readiness Group - Final Report - November 2009

4.6The NHS Constitution encourages the notion that we engage staff to create high quality workplaces and improve patients’ experience, safety and clinical outcomes. Under the NHS Constitution, high performing NHS organisations are characterised by staff that are committed, trained and honoured, working in a relationship with their organisations and patients where they can take real ownership for quality. This moves us closer to the vision of the NHS that puts patient care at the centre. It is also a vision that is dependent on the skills of employees and how they live the NHS Values.

4.7Clare Chapman explained in SORG1 how the NHS Constitution gives voice to the thousands of members of the public, patients and staff. Based on this empowering vision, the public, patients and staff are encouraged to behave with greater independence and responsibility: ‘There are things that we can all do for ourselves and for one another to help it [the NHS] work effectively, and to ensure resources are used responsibly’, and ‘All staff should have rewarding and worthwhile jobs, with the freedom and confidence to act in the interest of patients. To do this they must be trusted and actively listened to.’

‘The Constitution challenges the way that we build ownership, empower communities, and demonstrate commitment to the development of staff as well as their health and well-being.’

4.8Work to promote the NHS values in the Constitution, to inform relationships and decisions across organisational boundaries, sits alongside work that is going on locally to develop values within Trusts. The best of these are based on deep conversations around the spirit and purpose of the local organisation. The Royal Bolton Hospital NHS Foundation Trust has taken a lead in aligning the NHS Constitution to their local values.

4.9The NHS Constitution represents a new kind of ‘compact’ or understanding between clinicians in primary and secondary care, managers and patients. The importance of engaging clinicians in this has never been more urgent, given the combined challenges posed by the global economic downturn and the drive to lift quality. Where the NHS has struggled is not in ‘what’ we have to do but ‘how’ we achieve engagement. The NHS Constitution provides a centrally important tool to support this ambition.

4.10Communications and Engagement

Effective delivery of the NHS Constitution depends centrally upon effective communication and engagement - a point raised in all of the work undertaken by the SORG, and by most of those individuals and organisations consulted. The aim should be to create a culture of ‘this is how we do things here’ - rather than to see communications and engagement around the Constitution as a one off project.


4.11The NHS Constitution can be presented as an integrated whole, which brings coherence and stability, enhances the values and principles of the NHS and presents a new compact.

4.12At the same time, we fall down if we over-generalise. The NHS Constitution is made up of a complex set of legal rights and pledges - ranging from a right to vaccinations to rights around pay. To avoid platitude, we must also consider how we can use the discrete elements of the Constitution to appeal to the numerous audiences in the health system. For example, a paper received by the SORG3 identified the areas that might particularly appeal to GPs. It argued that GPs would find the Constitution supportive because it:

•Bringsbenefitstopatients,particularly in terms of dignity and respect, informed choice and involvement in healthcare.

•ReinforcesthecentralroleoftheGPand the Government’s commitment to the central list.

•Promotesfundamentalpatientresponsibilities and health improvement.

•Givesaframeworkofstaffdevelopment.

•Helpsstaffinprimarycare,andGPsin particular, to feel more fully part of the NHS.

4.13GPs (and GP practice staff) are an important audience to target. They are normally the first point of contact within the healthcare system and how they engage with patients is key to overall patient experience and outcomes. GPs are keen to work collaboratively to support communications activity on the NHS Constitution. However, the challenge is greater than communications - it is also about effective engagement.

4.14As Joan Saddler has pointed out, the NHS Constitution is central to the engagement narrative of the NHS as a whole. This prompts at least three thoughts. Firstly, the importance of using the Constitution to bind conversations with Local Involvement Networks, Overview and Scrutiny Committees and other key stakeholders, as well as public, patients and staff. Secondly, the importance of using patient, public and staff stories to illustrate the impact of the NHS Constitution, as well as patients and staff survey data.If Boards are responsible for having regard to the NHS Constitution then they could invite local people to speak at their meetings on what the Constitution means to them. Thirdly, in a related point, that the mutuality of the NHS Constitution should be used to generate information in order to improve the service. The following two case studies show how two Primary Care Trusts are bringing the NHS Constitution alive through engaging their local communities.

‘If the NHS shows proper legal regard and respect for the Constitution it will in parallel inspire people to use it creatively.’


4.15Case Study:NHS Eastern and Coastal Kent Citizen’s Panel An intensive three day session with 19 local residents provided NHS Eastern and Coastal Kent with a robust mechanism to deliver its part of the NHS Constitution. The Citizen’s Panel involved members of the public and patients from all walks of life in order to help the Primary Care Trust review and refresh its strategic commissioning plan, promoting local people’s rights to be involved in the planning of healthcare services. A real cross-section of the community was selected including people who had not engaged with the Primary Care Trust in the past. The Panel concluded that prevention and healthy lifestyle were the priorities when it came to buying new healthcare services, recognising that this would require disinvesting in other areas.

‘The Constitution is central to the engagement narrative of the NHS.’

Citizen’s Panel member Janet Vickery said: ‘I really enjoyed taking part in this. Although at times it has been hard work it has given me the chance to use my experience to help influence the future direction for healthcare in this area.’ Following on from this very in-depth process NHS Eastern and Coastal Kent will be using its on-line virtual panel of just under 1,000 people to test further the findings of the Citizen’s Panel. Lorraine Denoris, NHS Eastern and Coastal Kent’s Director of Citizen Engagement and Communications said: ‘By starting off with a small group of people we could test our Primary Care Trust’s commissioning intentions and really understand the needs of our area. We will then be able to test these outcomes with our larger group of participants.’


4.16Case Study:Embedding the NHS Constitution in the Newham Commissioning Cycle The Newham Commissioning Cycle is the over-arching framework for engaging communities and clinicians. NHS Newham are using the NHS Constitution to make the NHS values of access for all, partnership, accountability and best value into living principles, owned equally by the NHS and the communities they serve, and capable of delivering tangible health benefits for local communities. NHS Newham’s Community Ownership approach has shown that the principles enshrined in the NHS Constitution can be animated and used to drive measurable lifestyle change and greater community ownership of NHS services, giving local people a new and powerful voice in transforming health services, together with a new range of choices in taking action for health within their families and communities. For example, NHS Newham used a powerful blend of social marketing techniques and direct engagement with its ‘Communities of Health’ network of community groups to create a multi-stranded ‘Newham Health Debate’, engaging more than 5000 residents in a wide range of local languages.

‘At the core of the NHS Constitution sits human decency, compassion and good manners, which ultimately is the firmest base for any positive, large-scale change.’

The Newham Health Debate 2008 was used as a resident facing communication mechanism to engage with the local audience of diverse and Black, Minority and Ethnic (BME) communities, who might not be comfortable interacting with a typical NHS brand. Phase One embedded the Newham Health Debate brand as the umbrella for a range of activities including a borough wide survey, two interactive workshops and a question and answer event. Over 1000 residents took up the challenge of being involved in further activity. Phase Two of the Newham Health Debate started with a consultation on the NHS Constitution principles and responsibilities, comparing the responses of a Local Involvement Network-sponsored BME focus group with a randomised ‘e-blast’ to 1500 local residents. The BME Focus Group’s contrasting answers were used to brief Commissioners tailoring services to the needs and preferences of Newham’s diverse communities. Results were then incorporated into commissioning strategies, procurement processes and service specifications to deliver further targeted impacts grounded in the rights and responsibilities of the NHS Constitution.


4.17Turning rhetoric into reality

Once individuals and organisations have more information about and understand what the NHS Constitution says, it is essential to translate the rhetoric into reality. For example, the NHS Constitution says that patients and the public should ‘ensure that those closest to you are aware of your wishes about organ donors’. This responsibility has been turned into action by Cambridge University Hospital NHS Foundation Trust where Transplant Coordinators ensure that the issue is dealt with sensitively in a partnership between staff, patients and the public - showing how to draw upon a specific area of the Constitution and bring the spirit of the document to life. Another example, being taken forward in a practical way in the West Midlands, is the pledge ‘to share with you any letters sent between clinicians about your care’. At Brighton and Sussex University Hospital they have produced a film which shows how the NHS Constitution’s values underpins patient safety.

4.18A conversation held at SORG5 centred on the issue of redress. SORG agreed that if the NHS is to apply NHS values to redress, then we should more actively welcome, encourage and act upon staff and patient feedback and complaints. The information generated would provide useful insight but also help the NHS to improve the quality of its service. The Constitution can also be a helpful framework through which trusts can support their customer services functions (including Patient Advice and Liaison Services and complaints teams) to help patients achieve their rights, but also to embed the principles of good customer service throughout their organisations. Given that a high percentage of complaints centre upon end of life care (54% in acute hospitals - ‘Spotlight on Complaints’, Health Care Commission, 2007), it would be worthwhile aligning the NHS Constitution to the End of Life Care strategy.

4.19This example shows how the NHS Constitution can support Quality, Innovation, Productivity and Prevention. Providing end of life care closer to home improves patient experience and can be delivered at lower cost. Another example is Long Term Conditions. In SORG3 Steve Field made the point that the involvement, choice and dignity elements of the Constitution supports the self care and personalisation agenda in Long Term Conditions and encourages patient leadership. NHS East of England has calculated up to £200m savings in their region - as well as improving quality, prevention and innovation.


4.20Quality, Innovation, Productivity and Prevention of course does not replace the High Quality Care for All visions created across the ten Strategic Health Authority regions. Instead, it describes how the context is changing within which these visions will be delivered. Therefore, the original statement in High Quality Care for All in 2008 regarding the NHS Constitution has never been more vital: ‘To provide high quality care for all, the NHS must continue to change. But the fundamental purpose, principles and values of the NHS can and must remain constant. Setting this out clearly, along with the rights and responsibilities of patients, the public and staff, will give us all greater confidence to meet the challenges of the future on the basis of a shared understanding and common purpose’.

4.21The NHS Constitution is an important part of the large-scale change process already underway within the NHS and intrinsic to its day to day business because the heart of the NHS ‘must remain constant’. The challenge is making people see this. Although the NHS Constitution underpins High Quality Care for All and Quality, Innovation, Productivity and Prevention - and all NHS Boards will soon begin to make decisions with regard to the NHS Constitution - it must become more prominent in the narrative and thinking of the NHS. Clare Chapman in SORG5 made the point that to achieve large scale change around the NHS Constitution we need to use it to build trust within all the relationships within the system. As she says, at the core of the NHS Constitution sits human decency, compassion and good manners.


Research and Findings5

5.1Overview

The SORG commissioned analyses into the awareness of and support for the NHS Constitution amongst patients, NHS and Department of Health policy staff. This work was carried out by:

• GfKNOP-abaselineassessmentto establish levels of awareness and support for the Constitution amongst the general public. Fieldwork was conducted by telephone.

• SHM-ananalysisbasedonin-depth interviews with NHS staff and conversations with a cross section of 68 staff in three NHS organisations.

• InhealthAssociates-ananalysisof the patient rights and pledges, through a series of telephone calls with representatives from six NHS organisations and six organisations representing patients.

• CommunityInvestorsDevelopmentAgency (CIDA) - an analysis of 24 of the patient pledges, the 14 patient rights and 4 staff pledges, based on evidence provided by Department of Health policy leads.

The results of this work is summarised below. However, it is important to note that, whilst there was an encouraging degree of consistency between the findings, sample sizes were relatively small.

‘The research shows that there is strong but not widespread support for the NHS Constitution amongst patients, public and staff and that people feel that it will make a positive impact.’

5.2Key Themes

5.2.1Awareness of the Constitution

The research shows that in the small sample of people surveyed awareness of the NHS Constitution is relatively low. This is a very important issue. Staff need to understand the NHS Constitution so that they are able to answer any questions that patients might have about their rights, responsibilities, and the pledges that the NHS Constitution commits NHS organisations to deliver. The GfK NOP research shows that:

Almost half of staff surveyed (47%) were aware of the NHS Constitution compared to one in five (22%) of the general public. Staff awareness is higher than public awareness, but this is to be expected, given that the Department of Health Communications strategy has been focused on raising only staff awareness prior to Royal Assent of the Health Bill (subject to its passage through Parliament) and the subsequent coming into force of the duty to ‘have regard’. The SHM research stated that ‘members of staff in general are not aware of the Constitution and either have no knowledge of it at all or believe that things have ‘gone quiet’ despite the fact that people working in Strategic Health Authorities believe that there is a great deal of activity going on.’ This raises the issue of the diffusion of the message.


To date, work on the NHS Constitution (including the communications effort) has been led at the centre and intermediate tiers, but not the front line. The recommendation of the Constitutional Advisory Forum (December 2008) Report was for a bottom up approach, which has yet to take hold. The research also emphasised the need for clarity over the purpose of the NHS Constitution. Inhealth describe a ‘vision gap’. Some respondents see the Constitution as an ‘implementation’ document or a public-facing accountability document. Others see it as a values document. The patient representatives interviewed argued that it could lack ‘teeth’ - and the NHS queried how it would be performance managed. The Inhealth research concluded that:‘Without a vision for the change required or about purpose (i.e. whether it is values, implementation or accountability document), it will suffer from a profusion of purposes, lack of focus for change and de-coupled from NHS priorities. It will fade from people’s hearts and minds.’The solution is to find a way to harness the profusion of purposes offered by the Constitution and to encourage debate as a way of increasing both awareness and understanding of the document.

‘The research shows that awareness of the NHS Constitution is relatively low.’

5.2.2Support for the Constitution

The research showed strong support for the NHS Constitution amongst patients, public and staff. Most people felt it would make a positive impact. All respondents were in sympathy with the rights and pledges, understood them, and felt that they reflected the right kinds of commitment. The GfK NOP research showed that in February 2009:

• Overhalf(56%)ofstaffthoughtthat the Constitution would have a positive impact on patients experience.

• 41%ofstaffthoughttheConstitution would have a positive impact for staff.

• SupportfortheConstitutionwasslightly higher amongst the general public (67%) than members of staff (63%).

The results also showed the strength of positive support to be higher amongst the public than staff and the Inhealth research gives a clue as to why this might be. It showed a common attitude amongst NHS managers that ‘we are doing it already’ because the NHS Constitution contains existing rights and familiar principles and values. By contrast, the public have a different view. They see the spirit of the NHS Constitution, as illustrated by the themes of inclusion, rights, support and empowerment as new. A key challenge is therefore to move the NHS away from seeing the NHS Constitution as a box that has already been ticked, to something that is vital and fresh.


Interestingly, the closest areas of agreement between staff and the public concern the concept of mutuality. Several commented on the importance of finding an appropriate balance between the patients and public rights and responsibilities and of using the document as a ‘moral compass’ to guide relationships. However, the document is also seen as ‘middle-class’. In other words, there is a lack of conviction that the mutuality of the NHS Constitution extends across all aspects of society. The concern is that it might widen health inequalities rather than narrow them, and this is an important issue for the NHS to consider further.

5.2.3Reactions to readiness for the NHS Constitution

The SHM research found that staff responsible for implementing the NHS Constitution believed their organisations had measures in place to ensure that they were ‘ready’ with regard to legal rights and pledges. When members of staff not directly responsible for the Constitution were asked about the rights and pledges they recognised precisely the same measures and instruments that organisational leaders cited. They spontaneously linked them to the pledges and rights. This is positive news - this research supports our conclusion that the NHS will be legally compliant to discharge its duty to have regard to the NHS Constitution.

The research also revealed concerns relating to how the NHS Constitution was being translated into practice. Staff not directly concerned with the Constitution or its implementation did not think that their experience of the measures being put in place adequately or consistently matched up to the promise. The SHM report said `bringing the rights and pledges to the attention of ordinary members of staff seems to ‘touch a nerve’ that leads them to question the degree to which pledges and rights are fulfilled in reality.’ And `there is evidence that a great deal of discretion is left to individual managers and that some ‘opt out’ of implementing the relevant measures.’

Dean Royles commented at SORG4 on the aspirational nature of the NHS Constitution pledges - an important message to get across to organisations and their staff and a view reinforced by SORG members’ comments. SORG thought that whilst pledges should be taken very seriously, there are still gaps for some NHS organisations in meeting their legal obligations to deliver rights. The research shows, for example, that patients have concerns about a lack of consistency in relation to rights on equality and diversity.

They commented that initiatives were not mainstreamed across the NHS as a whole; a concern that was also reflected in the March 2009 Care Quality Commission report ‘Tackling the Challenge’ on race equality in the NHS.


For staff, there were also concerns about some significant inconsistencies in relation to the delivery of the pledges. For example, occupational health services are patchy; the 2008 Staff Survey shows that bullying and harassment still occur (health and wellbeing pledge). There were concerns about access to training. The Staff Survey also reveals that fewer than 40% of staff report that they are working in well-structured teams and appraisals are not undertaken consistently.

5.2.4Mapping and Monitoring the Rights and Pledges

There are two key messages from the CIDA research. Firstly, it is critical that there are metrics to track progress on implementing the NHS Constitution’s rights and pledges and that these metrics align with levers and incentives.

Secondly, whilst there is no exact fit between the NHS Constitution and existing measurement metrics and system levers related to performance management, there are a number of areas of overlap. Regarding system levers, CIDA’s analysis indicates that of the 38 patient facing rights and pledges, 12 could be measured or performance managed using existing Vital Signs indicators, whilst 9 could be managed against corresponding World Class Commissioning competencies. Eleven rights and pledges could, in part, be measured by patient experience questions in the National Inpatient Survey.

Likewise seven rights and pledges could be measured by the National Outpatient Survey and several by the GP patient access and/or primary care survey. It is clearly important that the Department of Health works with the Care Quality Commission to ensure better coverage of the NHS Constitution in patient surveys, just as Clare Chapman has done with the Staff Survey.

CIDA recommended strongly that the NHS would benefit from a set of metrics that would establish a baseline for NHS Constitution implementation and ensure consistent measurement. The most obvious approach would be to ‘Constitution proof’ the World Class Commissioning metrics so that Strategic Health Authorities and Primary Care Trusts would be able to monitor implementation of the Constitution, without establishing a separate system. It is also important that regulators, such as the Care Quality Commission, align to the NHS Constitution. The issue of system health is a very important one for the NHS at a time when the opportunity of Quality, Innovation, Productivity and Prevention dictates that the system needs to work more closely together. Setting up a new performance regime for the NHS Constitution could be damaging to Strategic Health Authority / Primary Care Trust relationships, and this should be kept in sight when considering how to monitor the NHS Constitution.

‘At present there is no exact fit between the NHS Constitution and existing measurement metrics and system levers related to performance management.’


6.1All ten Strategic Health Authorities have confirmed that the NHS in their regions will be ready to have regard to the NHS Constitution.

6.2In all regions there has been a significant amount of effort in embedding the NHS Constitution, but there is still a long way to go. The main focus of communication and engagement activity has been directed at the NHS workforce, but comparatively little systematic attention has been given to patient and service user engagement or the wider challenge of public promotion.

6.3All Strategic Health Authorities have taken steps to ensure that specific leads for the NHS Constitution have been identified both at a regional and Primary Care Trust level, and there is evidence of growing Board ownership across health systems and increasing determination to reinforce this with Chairs’ appraisals and, in a few cases, Strategic Health Authority/Primary Care Trust Board-to-Board meetings.

6.4Readiness to ‘have regard’ to the NHS Constitution

The reports show variance in the leadership of the NHS Constitution, with NHS East of England, North West, East Midlands and West Midlands leading the field.

6.5The approach to achieving readiness for compliance ranged from those led from the centre to those who devolve leadership to local organisations. The majority of Strategic Health Authorities have assessed readiness through regional Primary Care Trust meetings; Board-to-Board meetings or via a combination of channels (via directors of workforce/HR, communications, Patient and Public Involvement leads, Strategic Partnership Forums). One Strategic Health Authority has issued an assessment toolkit to NHS organisations.

Strategic Health Authority State of Readiness

6

‘By October the NHS will be ready to have regard to the NHS Constitution but there is still a long way to go in embedding it, especially with patients and the public.’


6.6Case Study:East of England Approach to System Compliance

The NHS East of England approach has been to ask their Primary Care Trusts to ensure that by 1 October 2009:

•TheirBoardhasdiscussedthe legal rights in the NHS Constitution; identified any risks to compliance; fed those risks into their risk register and developed a mitigation strategy.

•Acommunicationsplanisdeveloped to ensure that staff and stakeholders are briefed on the content of the Constitution and that best practice is encouraged and shared.

•ANHSConstitutionchampionis nominated, who is empowered by the Primary Care Trust Board to embed the Constitution locally.

They have also asked Primary Care Trust Boards to ensure that by 1 October 2009 all providers (both public and independent sector) of NHS services commissioned by the Primary Care Trust are aware of their duty to have regard to the NHS Constitution and have an implementation plan in place.

6.7Several Strategic Health Authorities emphasised the importance of integrating and embedding the NHS Constitution in existing initiatives and were cautious about defining measures of readiness which were separate from those set for regional strategies. All Strategic Health Authorities described a range of measures that could be used to monitor the NHS Constitution, and public polling and patient and staff surveys were mentioned by most. Several included a range of proxy measures (e.g. performance management indicators, complaints audits, induction and training records, workforce metrics, use of bullying and whistle-blowing policies). A number of reports stressed the need to include assessment of the Constitution as part of mainstream performance management and assurance e.g. World Class Commissioning competences (3a & c, 7c, 8,10), or as part of existing regional initiatives around informed choice, workforce planning, and reducing health inequalities.


6.8Embedding the NHS Constitution

The reports showed a considerable amount of activity being invested in embedding the NHS Constitution. This has been driven in many examples by NHS East of England, who have co-produced a communications toolkit with the Department of Health; and developed a poster campaign on single sex accommodation and the NHS Constitution which has been adopted in the North West and South West. In addition, they have developed the first NHS Constitution website (www.eoe.nhs.uk/nhs_constitution), which the majority of Strategic Health Authorities are adapting with their own branding and message. Their Annual Report illustrates how the NHS Constitution ties in with the eleven pledges in their Darzi vision.

6.9In other regions there are initiatives involving strategic and policy reviews; staff awareness raising through briefings, inductions, posters, online and other communications methods; and specific efforts to engage stakeholders, including LINks and Social Partnership Forums. A greater part of the work to date has been focused on staff engagement both at a regional and local level, building on efforts made during the process of consultation.

6.10NHS East Midlands, for example, has created a ‘Constitution Countdown’ campaign to build staff support for the pledges, which will have patient and public elements at a later stage. NHS West Midlands has promoted the Constitution through the Strategic Health Authority Health Insight Group which includes 2,500 patients and members of the public across the region. In NHS North West, five ‘key promise themes’, reflecting main themes of the Constitution, have been developed through public consultation. NHS East of England has funded a programme of local staff engagement projects. In such ways Strategic Health Authorities are broadening their promotion of the Constitution to staff, patients and members of the public alike.


‘The energy of SORG has always been at its highest when exploring the term ‘mutuality’ and the way to move away from patients, the public and staff having ‘rival’ interests to being mutually responsible for improving service quality.’

6.11All the Strategic Health Authorities made helpful suggestions for how their work on the NHS Constitution could be supported. For example, several argued that nationally produced case studies could help bring the Constitution to life.

6.12Many Strategic Health Authorities thought that national support for a staff and public information campaign to help capture hearts and minds would be helpful. Others wanted guidance for commissioners (addressing the contractual and legally enforceable aspects of the Constitution), or central support for third sector engagement. Some thought that the centre should allow time to build local ownership and impetus and many commented on the importance of developing systems to measure the impact of the Constitution. One or two wanted to bring forward national staff survey results to January 2010; resources to support patient and public engagement; further alignment of national policies; clarity about the vision; clarification on wider relationships for example with housing/employment. This last point picks up on whether the NHS Constitution should say more about the responsibilities of the local NHS to deliver health and well-being through other mainstreamed services, such as Local Strategic Partnerships, that are critical to reducing health inequalities.

6.13 Case Study: North West Consultation

with Third Sector Partners

Through its health equality stakeholder engagement model, NHS North West asked their regional equality stakeholder partners to provide feedback on the aspects of the NHS Constitution which had the most obvious relevance to their own agendas. Specifically, partners were asked to identify any areas which might be detrimental to, or which opened up opportunities to promote equality of outcomes. Partners included a range of third sector organisations relating to disability, gender, sexual orientation, religion and belief.

6.14In addition, the Strategic Health Authority reports helpfully reveal a number of gaps which could be filled. Firstly, SORG thought that clear guidance for all NHS organisations on implementation and risk planning around the NHS Constitution would be welcomed. Secondly, it would be helpful to consider how we could track progress on implementing the NHS Constitution’s rights and pledges. Thirdly, whilst progress is being made with the raising of staff awareness in Strategic Health Authorities and local organisations, it is not yet clear how at either level organisations intend to mobilise higher levels of patient and public awareness and engagement. This is a significant communications and leadership challenge.


6.15Case Study:People-powered health in West Midlands

NHS West Midlands has commissioned a local digital healthcare service that will improve the lives and health of people across the West Midlands by providing easy access to local news, information, tools and services that individuals need to manage their own health effectively. It will support frontline staff in delivering high quality, innovative healthcare services. It will focus on local people, local resources, local services and support local networks. Providing easy access to relevant news, information, tools, support and services for healthcare workers and local citizens is fundamental to meeting the challenges of Quality, Innovation, Productivity and Prevention and to delivering the pledges and rights contained in the NHS Constitution. NHS West Midlands’ local digital healthcare service will connect staff and citizens to the best available online resources and enable staff, patients, service users and the wider public to link directly with each other. This strategic approach to harnessing the power of information sharing to support the delivery of better services will simplify the finding of information and other on-line resources. It will help to signpost people through disparate and confusing information sources across the NHS, and put them in touch with trusted organisations and each other.

6.16Case Study: Staff and service user perspectives from Learning Disability Services Learning Disabilities provides a vibrant model of service user engagement, a governance structure which can gather valuable feedback from a wide range of people, and long standing experience of involving service users in development planning. NHS East of England, with support from the Department of Health, are engaging Learning Disabilities service users, carers and staff to find out how they perceive different aspects of the NHS Constitution.

This work is being done through focus groups, which identify what the Constitution rights, pledges and responsibilities mean to service users, carers and professional staff who work with them, what helps to bring it alive for them, and what practical difference it can make in their lives and day to day relationships.

The outcomes from this project will be a statement of key behaviours related to the elements of the Constitution; a view on how the Constitution can be brought to life for particular groups; and a set of expectations arising from the mixed group interaction about how service users and staff can work more effectively in partnership.


Aligning the Infrastructure7

7.1 To help us to understand the challenge of system alignment around the Constitution, SORG approached key players in the NHS system to gather their views. This was undertaken in much the same way that SORG consulted with Strategic Health Authorities concerning their state of readiness to have regard to the Constitution and the action needed to embed the Constitution fully. However, before setting out some of the findings from this work, it is important to highlight some general principles of system alignment highlighted during discussions at SORG.

7.2Levers and drivers for change

SORG emphasised the importance of taking a broad approach to understanding the levers for change and the importance of work at national, regional and local level. Figure one (right) illustrates this with a few examples, at each level, of the steps that are currently being taken.

7.3SORG also emphasised the importance of prioritising the agreed action. For example, members agreed that it was currently more important, given the relatively low levels of knowledge in the NHS about the Constitution, to win hearts and minds; to disseminate information and promote engagement with the Constitution. SORG also considered that there might be ways to incentivise appropriate behaviour, and to measure change in levels of knowledge over time about the NHS Constitution and manage performance, especially where it is poor, in the medium and longer term.

Figure 1: Action at different levels to align the NHS system

• Systemalignment:DHpolicy,actionbyregulatorsandinspectors

• SORGadvicetotheNHSMBonstepstoembedtheConstitutionfully.

• AlignNHSstaffsurveytomeasuretheConstitution

• SupportStrategicHealthAuthoritiestomobilisetheirapproachtohaveregardtotheConstitutionandembeditfully

• Providegoodpracticeexamplesandcasestudies

• Fosterthedevelopmentofcapacityandcapability

• ProvideguidanceontheappointmentofPrimaryCareTrustConstitutionChampions

• SecureprofileforConstitutioninPrimaryCareTrustassuranceframework

• Supportthirdsectorto‘agitate’topromoteawarenessoftheConstitutionatlocallevel

• DevelopcommunicationsinpartnershipwithRCGPforprimarycare-thefirstpointofcontact

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7.4Knowledge and information

The vision embodied in the NHS Constitution is of services provided close to the patient, with power residing as closely to patients as possible. This is a central theme of High Quality Care for All. Yet in SORG’s view - based on the evidence - embedding the vision depends, firstly, upon knowledge and information and it appears that levels of awareness about the detail of the Constitution are still too low.

7.5Feedback from national bodies consulted by SORG reinforces this view. The Office of the Parliamentary and Health Service Ombudsman, for example, recently held a series of regional conferences on the new NHS complaints system to highlight changes that took effect from 1 April 2009. In total, around 200 NHS complaints handlers from across England attended. Their attention was drawn to the NHS Constitution and those rights and pledges that relate to complaints and redress such as the pledge, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. Based on feedback from these conferences, it was clear that complaints managers currently have only limited awareness of the NHS Constitution and its supporting documents. They could not, as yet, apply the Constitution effectively and confidently in their work and the Parliamentary and Health Service Ombudsman drew attention to the importance of preparing staff well and communicating clearly.

7.6It is encouraging, then, that several national organisations are gearing up to strengthen their communications to staff about the NHS Constitution. For example, the Foundation Trust Governors Association are preparing to put material on their website. In addition the Appointments Commission, who carry out inductions for around a thousand non executive appointments each year, of which 450 are new to the NHS and 40 are new chairs, are planning to put a copy of the Constitution at the front of the induction pack and supply information at their induction events. Discussions are also currently in train to explore the scope for including material about the Constitution in training.

7.7The National Leadership Council is updating the ‘Governing the NHS Guide’, setting out the rules and responsibilities of board members and this will include information on the Constitution. The NHS Litigation Authority is currently considering ways in which the Constitution is reflected in their standards. The Department of Health is working with Professor Steve Field, chair of the Royal College of General Practitioners, to develop appropriate communications with primary care. The National Social Partnership Forum have begun to draft a staff passport with strong references to the pledges and the information in the NHS Constitution handbook.

‘The National Leadership Council is updating the ‘Governing the NHS Guide’, setting out the rules and responsibilities of board members and scope to include information on the Constitution.’


7.8Case Study:NHS Blood and Transplant The NHS Blood and Transplant is now two years into atransformational change programme. Part of that transformation has been to bring together two previously culturally disparate organisations, the National Blood Service and UK Transplant, under the banner of NHS Blood and Transplant and begin making the changes necessary to realise our ambition. This change is being supported by the NHS Constitution. To date NHS Blood and Transplant have: • Broughttheirstaffsurvey

into line with the wider NHS timetable, using consistent question sets including those relating to the essence of the Constitution.

• Inlinewiththestaffpledges,re-launched their appraisal system that helps identify learning and development needs of staff so that they can deliver excellent donor care and value for money for the public.

• IntheBloodDonationDirectorate the Head of Nursing has embedded a culture where safe, effective, compassionate care is given to all donors, and staff are given regular feedback to help progress their careers.

• Investedinimprovinginternalcommunication in the organisation so that everyone knows the values they cherish and is clear about how their hard work helps contribute to realising their ambition to deliver on the core purpose to save and improve lives.

In the year ahead they will continue to embed the NHS Constitution in what they do.Work already underway includes: • Consultingonarecognition

scheme for staff that rewards and acknowledges staff who work above and beyond the call of duty and that brings to life the values of the organisation.

• Implementinganorganisation-

wide leadership development programme that will bring life to our values and translate

those into leadership behaviours that will inspire staff to do so themselves.


7.9Building on partnerships

During discussions at SORG - backed by the views of external groups consulted during the process of gathering evidence - it became clear that knowledge and awareness, whilst essential and necessary, may not be sufficient to achieve the level of change demanded by High Quality Care for All and the NHS Constitution. In addition, it will be important to support behaviour change and to mobilise activity - perhaps even mobilise agitation - at local level with NHS partners such as third sector charitable and voluntary groups.

7.11Regulation and inspection

Key players in the NHS system of care concerned with inspection and regulation have already taken significant steps to ensure that they themselves are making a start to have regard to the Constitution and to embed its principles at the heart of their activities.

7.12Case Study:Monitor Aligning the NHS Constitution

For example, Monitor, the independent regulator of Foundation Trusts, is intending to consult later in the year as part of their annual process on their Compliance Framework proposals to:

• Includetherequirement‘tohaveregard to’ the NHS Constitution in the Terms of Authorisation of Foundation Trusts;

• Requireselfcertificationbyboards on this requirement in the Compliance Framework; and

• IncludeinFoundationTrusts’Annual Reports a reference to how the Constitution has affected patients, staff and members of the public at their trust.

From April 2010, all providers of health and adult social care will need to be registered with Care Quality Commission to show that they are meeting registration requirements - new essential common standards of safety and quality across the care sector.

7.10Case Study:National Directors for Learning Disabilities

One excellent example of mobilising activity is provided by the national directors for learning disability. Local networks are linked to regional and national policy groups, and there is a clear system of governance to ensure quality and connections to people with learning disabilities, their families and carers. This network offers an opportunity to connect with a large number of organisations to drive change at local level, using existing networks like Local Involvement Networks, Patient Advice and Liaison Services and local Partnership Boards. Support for these organisations is being provided by SORG through development of key messages about the benefits of the Constitution that can be adapted for local use.

‘Key players in the NHS system of care concerned with inspection and regulation have already taken significant steps that they are making a start to have regard to the Constitution and to embed its principles at the heart of its activities.’


7.15At the same time, it will be important to understanding in a more formal way how NHS staff and the general public perceive progress to embed the NHS Constitution. National staff survey questionnaire data, currently being strengthened to reflect the NHS Constitution, will be essential to helping the Department and, more importantly, local NHS organisations to understand progress.

7.16As the CIDA report showed, many of the rights and pledges are already tracked through one or more of the national patient surveys, and the baseline assessment will be repeated in January 2010. Further work is underway in the context of system alignment and embedding of the Constitution to explore how significant gaps on the measurement of patient rights and pledges could be filled, and to influence the modification of existing measures to make them more Constitution-specific where possible. Work is also underway to ensure the NHS staff survey covers the staff-facing rights and pledges.

7.17To complement intelligence compiled centrally, Strategic Health Authorities should be asked by the Department of Health to compile a picture of progress within their areas, drawing on national and local survey data, developments in local systems to align with the Constitution, and feedback from patients and staff.

7.13Case Study:The Care Quality Commission

The Care Quality Commission is currently developing guidance on what providers must do to be compliant with registration requirements, which have enhanced legal status compared to previous standards as they are legally enforceable. This guidance will cover rights included in the NHS Constitution and provide a means for checking on compliance with many of the patient and public rights including access to health services; quality of care and environment; respect, consent and involvement; and complaints and redress. In addition, it will include coverage of the staff rights such as having a good working environment.

7.14Measurement

Subject to Parliament, the Health Bill will require the Department of Health to report to Parliament on how the Constitution has affected patients, staff, carers and members of the public every three years. Although the details of this have yet to be agreed, the SORG believes a relatively light touch to measurement by the centre will be important, consistent with the subsidiarity principle, and the principle of partnership working. It will be important to build on what already exists rather than develop new approaches to measurement and/or performance management.


Stakeholder and SORG Feedback 8

8.1Patients, public and third sector

In parallel to the process of consultation with Strategic Health Authorities on their state of readiness, other key stakeholders were approached for their views. For example, a Reference Group was established with representation from patient groups and third sector organisations. The aim was to understand:

•FitnessintheNHStodelivertheNHS Constitution from a patient, public and third sector perspective.

•HowtheNHSConstitutioncanbeembedded into the fabric of the NHS for patients and the public.

•HowpositivelyengagedistheNHSto deliver the NHS Constitution for patients and the public.

• Howthethirdsectorcansupportimplementation and embedding.

8.2Three main themes arose in discussion during meetings held during June and July. First, the point was made strongly that if the aspirations of the Constitution are to be realised, then real-life examples are important to help people understand. A good service needs to be modelled; aspirations must be translated into action; and buy-in must be real.

8.3The third sector can have a potentially very valuable role to play in developing themes around the Constitution; helping to embed it, and in supporting patients and the public to understand their rights. However, in order to do this, Department of Health needs to work in closer partnership to help convince the sector that the NHS Constitution will have an impact on experiences of health care. This requires not only leadership messages from Department of Health but also from NHS Trusts.

8.4Second, a clear theme relating to equality and diversity emerged. There are potentially a number of ways that the Constitution can reinforce the important messages and action on health inequalities, and could potentially be used in the new Equality and Diversity Council. However, for this to translate into real behaviour change, staff, service users, patients and carers with a range of needs and backgrounds need to be aware of their rights and their responsibilities. The Constitution could be a powerful even revelatory document for those who have not previous been aware of their rights. Consideration must also be given to aligning messages from the NHS Constitution to current and proposed legislation in this policy area (such as the Equality Bill / Single Equality Act).

‘The Constitution could be a powerful even revelatory document.’


8.5The third theme concerned the importance of `bespoke’ communications which should be planned using methods and channels that are appropriate as well as appealing to patients and the public. It might be valuable to have ‘frequently asked questions’ and case studies to help people understand and use the Constitution. The three big themes in this feedback might simply be put as communications, engagement and alignment.

8.6National stakeholders

An invitation to comment was sent to a wide range of national stakeholders who were asked three questions:

• Actionstobetakenatalocallevelto embed the Constitution.

•Mainobstaclestoembedding.

•MainactionsforDepartmentofHealth to ensure readiness.

8.7The primary themes, in terms of actions to be taken at a local level, centred on generating awareness of the NHS Constitution; aligning local values, policies and strategies to the Constitution; staff engagement and Board ownership; using these to gain feedback and information from staff and the public. Similarly, the actions to be taken at the Department of Health level also focused on awareness-raising and alignment of policies and regulatory frameworks to the Constitution; coordination of communications and an emphasis on values and responsibilities; sharing best practice; and role modelling.

8.8The three themes of communications, engagement and alignment all require authoritative and concerted leadership. In SORG5, Helen Bevan helpfully presented an influence model within which these themes could be organised. She argued that, in order to embed the NHS Constitution, we need to create:

• UnderstandingandConviction.

• Reinforcementmechanisms.

• SkillsandCapabilities.

• RoleModelling.


8.9SORG considered these four frames in terms of System Alignment, Patients and the Public and Staff. The following analysis summarises the comments made at SORG5.

•UnderstandingandConviction: a common narrative is required

on the NHS Constitution, which describes how people sit at the heart of the Constitution. The narrative should explain the fit with existing policies and agendas (e.g. the personalisation of care). The narrative could be used to build understanding and could be taken forward by ‘Constitution Champions’, when they are recruited. These might be patients, public or staff, but they should be an integral part of the system of care rather than outside it. Learning about the Constitution should also be built into education commissioning via Deaneries and other education commissioners, and included in staff induction and continuing professional development plans.

•Reinforcements: there are existing levers within the system which can be used to reinforce the messages in the Constitution. They include Quality, Innovation, Productivity and Prevention, Human Resources practice (recruitment and selection, objective setting and appraisal); Multi Professional Education and Training spending; staff survey; Strategic Health Authority Assurance; values-based education and training; codes of practice, Care Quality Commission registration and regulation, contracts (commissioning and employment), clinical excellence awards; the Boorman review

of health and wellbeing; Social Partnership Forums; National Leadership Council. The NHS Constitution should also encourage the use of technology to increase patient access to information and staff and patient feedback.

•SkillsandCapabilities: SORG agreed that leaders at all levels of the system of care need to be helped to understand the letter (the detail) as well as the spirit (the mutuality) of the NHS Constitution. In this way, they can help to make the narrative real. Leadership includes both staff and patients. At Department of Health and in NHS Boards, it is important the Constitution is promoted by all Directors, so there is coherence in the messages about the Constitution. It is equally important that PALS and Complaints teams are fully engaged.

•RoleModelling:this is seen as the most important frame. To role model the NHS Constitution it is important to show commitment to patients, public and staff. This could be achieved by inviting patient stories at Board meetings; by leaders spending time at the front line of care; by staff living the NHS values. Leaders should be given examples of where the Constitution has ‘worked’ for patients and staff and should be encouraged to make connections between the Constitution and the clinical or managerial challenges they face. Boards should set the Constitution as the tapestry behind their discussions and leaders should recognise and empower staff and patients who role model the Constitution’s values.

‘The three big themes in this feedback might simply be put as communications, engagement and alignment. All three of these themes require authoritative and concerted leadership.’


8.10There was a striking similarity between the feedback of stakeholders and the views of SORG members about the actions needed to embed the NHS Constitution. There was also coherence in the risks and gaps identified - the main one being the challenge to win hearts and minds. SORG thought that the current lack of understanding about the NHS Constitution could lead to apathy and scepticism from staff, patients and the public, and affect the credibility of the Constitution.

8.11It is felt strongly by SORG that insufficient ambition about, or awareness of the scale of change required is also a major risk. The successful implementation of the NHS Constitution will be derailed if we do not overcome this challenge, and implementation is not helped by the timing of the NHS Constitution legislation, coinciding as it does with the flu pandemic and an economic downturn. There is a risk that staff and leaders will fail to make time to attend to the NHS Constitution, if it is not communicated as a priority. There may be a tendency to ‘retro-fit’ the Constitution into existing initiatives, rather than use it creatively to develop new ones. There is a risk of over complication; a need to change a defensive mindset around feedback and complaints; and a lack of the take up of the Knowledge and Skills Framework. These are all examples of the discrepancy between aspiration and reality.


Conclusion9

9.1The SORG has had the benefit of a considerable amount of information on the state of readiness of the system to have regard to the NHS Constitution. In addition, materials (brief summaries of the legal requirement to have regard to the Constitution, examples of good practice drawn from the East of England, and emerging themes from the SORG consultation and preliminary discussions) have been sent to Strategic Health Authorities. As a minimum, by the time the duty to have regard comes into effect SORG believes that Boards will need to have satisfied themselves that they have:

•Builtawarenessamongststaffofthe legal duties (action to have regard to the Constitution and observing patient and staff rights and pledges) in the Constitution.

•Managedrisksandtakenactiontoidentify and close gaps consistent with the different levels of proof likely to be required for rights as compared to pledges.

•Engagedwithstaffonhowthelocal regional vision aligns with the aspirations for the NHS as embodied in the Constitution, and how the cultural and service transformations that are currently underway are linked.

•Madeastarttounderstandtheaction needed to embed the Constitution fully.

9.2Based on feedback from the Strategic Health Authorities, SORG has drawn the following conclusions:

•ThereisstrongsupportfortheNHSConstitution amongst patients, public and staff and people feel that it will make a positive impact.

•AllStrategic Health Authority regions have given assurance that their NHS organisations will be ready to have regard to the NHS Constitution.

•Thereis,however,variationbetween Strategic Health Authority regions in terms of the quality and scale of work being done both to have regard to the NHS Constitution and to embed it fully over time.

•Organisationswhohaveshownrealownership of the NHS Constitution are invariably those who have Chair and Non-Executive Director leadership of the agenda who have also invested in communications activity.

• Thepassionandenthusiasmforthe NHS Constitution at the centre and intermediate tiers needs to be more strongly felt at the front line - this is both a leadership and a communications issue.


•Itisessentialthatorganisationsare strongly encouraged to look at management practice and the degree to which unofficial ‘opt outs’ from the Constitution rights and pledges for staff as well as patients appear to exist. It is important that the messages of the Constitution are applied consistently.

•ThechallengeofembeddingtheConstitution would be greatly helped by closer alignment of the framework for regulation and inspection. Although a number of very helpful preliminary steps have been taken (for example, Monitor has written to the Boards of Foundation Trusts; the Strategic Health Authority Assurance process has been aligned) there is more that could be done. For example, closer alignment between the NHS Constitution and World Class Commissioning would be helpful.

•Moreemphasisneedstobegivento patient and public engagement in the NHS Constitution. Although this is important across the system as a whole, one route would be to drive this through the primary care system (e.g. GPs and GP practice staff, who are normally the first point of contact within the healthcare system). However PCTs and trusts need to engage patients and communities in how to make the Constitution rights and pledges meaningful to patients, families and carers.

•Weneedtoincreaselevelsofawareness of the NHS Constitution and ensure that the Constitution is positioned properly within narratives around High Quality Care for All and Quality, Innovation, Productivity and Prevention.

•ThereisadangerthattheNHSConstitution may be seen as a ‘middle-class document’ and therefore more engagement is needed to reach wider communities, working in partnership with the third sector. There is a disparity of views from patients and NHS staff on how much attention is being given to equality and diversity.

•Thecentreshouldrecognisethatit will take time to build local ownership and impetus in relation to the NHS Constitution. Building commitment is not a quick fix and support needs to be given to organisations dealing with difficult challenges.


10.1The NHS Constitution sits at a crossroads. It has received unified support from politicians, national stakeholders, trade unions, front line staff and service users and patients. It has been consulted on and launched. Subject to the Health Bill’s passage through Parliament, the duty to ‘have regard’ to the Constitution is expected to come into force in Spring 2010 and the NHS is making ready to meet this obligation. The NHS Constitution is acknowledged as a pioneering example of how public relationships are built around mutual responsibilities and rights rather than targets.

10.2At the same time, there is considerable work still required to raise awareness of the Constitution so that it forms a central component of conversations between patients, public and staff. The recommendations around system alignment, communications and engagement offer potential solutions. However, none of this will happen without authoritative and passionate leadership from all levels in the system. It is every member of staff’s job to actively role model the values of the NHS Constitution - and to use the Constitution to bring the NHS system closer together for the benefit of patients.

10.3For the NHS Constitution to take hold, Board ownership is crucial and the introduction of the role of ‘Constitution champions’ will help. However, we need leadership on an ambitious scale and we need to challenge our leaders to develop their own narratives that resonate locally.

We need to ensure that the ideas, language and energy around the NHS Constitution are supported centrally but created locally. We need to keep in mind the mutuality of the NHS Constitution, and that staff engagement alone will not be sufficient to embed it. The opportunity to do this is here and now, especially given the publication of Building Britain’s Future, but it will fade if we do not continue the momentum generated by SORG.

10.4The NHS Constitution offers an opportunity to build trust between staff and patients at all points in the NHS system of care. This can be achieved if we use the mutuality of the NHS Constitution to surface information and ideas that are acknowledged, and acted upon, and lead to service improvement. But trust will ultimately be created if the consistency, decency and coherence in the NHS Constitution are made real by NHS leaders, and if they truly put their patients and their staff at the heart of everything they do.

10.5The NHS Constitution is the first of its kind in the world. It has been created through thousands of conversations with patients and NHS staff and is a shared commitment to enshrine the principles and values of the NHS in England. The hard work that is currently being invested to bring it to life will be rewarded through a higher quality service, higher performing staff and healthier organisations. We urge you to engage with this report and to consider your role in taking forward its recommendations.

Final Word10

THE NHS CONSTITUTION State of Readiness Group...of change required to bring the NHS Constitution...

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