“...The greatest challenge has in my view always been to win the whole-hearted cooperation of doctors. We have needed to avoid taking too much time away from the frontline care of patients and to ensure that enough doctors turn out to be able, willing and keen to take on the new proposed responsibilities.

With the benefit of hindsight, the greatest mistake has probably been not consulting doctors and their professional bodies more fully prior to publishing the original White Paper. The Government’s proposals are largely based on a belief that doctors and professionals in the NHS know best. At the same time some doctors feel that the Government is not fully respecting their views. This apparent inconsistency damages morale and has implications for working in a spirit of cooperation. A bottom-up decision-making process imposed unilaterally from the top has great potential for teething problems. It is a possible recipe for disaster. The top priority of Andrew Lansley should be to make every effort to get doctors firmly back on side without compromising on the important strategies underlying the proposals...

...More work is needed to determine what tasks doctors are willing and able to carry out and with what assistance. The Government must be seen to be on the same side as NHS professionals. In an undertaking as large and complex as the NHS wise principles and strategies are to no avail without skilled and careful management implementation. If the changes are to be made to a tight timetable, even more attention to detail is vital because there is little time to correct any mistakes.” – Barbara Arzymanow, 2020Health, 20 January 2011

“...Doctors and nurses are asking what our plans will mean for them. We hear that – and we want to work with you, not against you. Now that the Health and Social Care Bill has passed through committee stage in the House of Commons, we’ve got a natural break before this legislation reaches its final stages in Parliament. We’re taking this time to pause, listen, reflect on and improve our NHS modernisation plans. Let me be clear: this is a genuine chance to make a difference. Where there are good suggestions to improve the legislation, those changes will be made.” – David Cameron 6 April 2011


Prevention is better than cure (2020health blog) – January 2013

Proposal: Awareness of healthy diet and lifestyles should be increased by education.

Response: Increased attention is being paid to certain causes of ill health e.g., excessive sugar


Department of Health Consultation on NHS Constitution (Consultation response) – January 2013

Proposal: The main points in the new draft constitution deserve strong support.

Response: The new constitution was one of Jeremy Hint’s first moves as Health Secretary and was well received.

//consultations.dh.gov.uk/nhs-constitution-team/nhs-constitution/


Liberating the NHS: Commissioning for Patients (Consultation response) – October 2010

Proposal: GP consortia should have the services (not necessarily full- time) of a financial expert and a compliance officer, who would check that all rules and procedures were being followed (page 5).

Response: The Bill published in December 2010 requires the appointment (not necessarily full-time) of an "accountable officer", who will essentially cover regulatory aspects of both roles.


Liberating the NHS: Transparency in outcomes- a framework for the NHS (Consultation response) – October 2010

Proposal:Promising research in industry should be rewarded, whether or not it turns out to be successful (pages 2, 3 & 5).

Response:The Treasury's proposals over R&D tax credits partly meet this objective but much more needs to be done if the UK is to regain its former attractions as one of the best bases for R&D. Richard Sykes has highlighted some of the issues.

Proposal:Drug prices should be negotiated over a company’s total product portfolio rather than over individual products.

Response:Richard Sykes has highlighted the attractions of the old PPRS drug pricing system. The challenging aspects of measuring the value of drugs are recognised even by NICE.


NHS Reforms: Health and Social Care Bill 2011 (2020health blog) – January 2011

Proposal: The top priority of Andrew Lansley should be to make every effort to get doctors firmly back on side.

Response: The blog by Barbara was published on 20th January 2011. Eight days later (28th) DAVID CAMERON wrote to doctors.

Proposal: The wording in the Bill of the statutory duty to pursue equality should be changed.

Response: Proposals to amend the wording were considered in Committee. However, my concern was eventually overcome by extending the duty in respect of research to commissioning consortia.

Proposal: More than two doctors should be required to run a GP Consortium.

Response: The inclusion of hospital doctors and nurses along with other safeguards covers this point Click here.


NHS Reforms – What the UK Government Policy changes Really Mean (2020health blog) – June 2011

Proposal: Competition must not be stifled but should be carefully organised so as to promote the best healthcare at the lowest cost.

Response: Debate on this subject was intense during the passage of the Health and Social Care Bill. Unfortunately, some commentators seemed to have difficulty in being objective because of ideological misconceptions. The thrust of the Government's reforms has remained intact.


Equity & Excellence: Liberating the NHS (Full Submission to Department of Health; brief summary on 2020health blog) – September 2010

Proposal: The main aims in NHS reform should be to provide excellent healthcare, control total costs (net of incoming revenues) and encourage R&D and exports (page 5).

Response: The Conservative Party has a well-established track record of recognising the importance of excellent healthcare, controlling costs and aiming to encourage R&D and exports. Lansley emphasised his commitment to health research on 20 January 2011. The subsequent news over the closure of the Pfizer site in Kent is giving new impetus to the drive to strengthen the environment for R&D.

Proposal: NHS to make more money from industry e.g. by sharing facilities & more cooperation over clinical trials (pages 11-12).

Response: December 2010 Lansley said that the Academy of Medical Sciences had been asked to recommend ways of simplifying medical research regulation and governance to cut the time it takes for the NHS to set up clinical trials. 

Proposal: No major changes should be made to patent/drug exclusivity or medical approval systems (page 5).

Response: None have been proposed by Government during the process of formulating policy over the NHS.

Proposal: For the NHS to generate more revenue from the provision of non-medical and add-on services (pages 10-11).

Response: The required legal authority is provided under the headings 13R and 14S by sections 19 and 22 of the Bill introduced in late December 2010.

Proposal: Drug pricing systems that involve agreeing prices of individual drugs before launch should be avoided so as not to delay the availability of valuable new medicines to patients (page 6).  

Response: This problem can potentially be overcome by the Government’s proposal put forward in December 2010 to allow launch at a contingent price that will be adjusted later.

Proposal: NICE’s role in drug rationing should end.

Response: Lansley decided in November 2010 to end NICE’s role in drug rationing (additional commentary here). However, Lansley later partly back-tracked but NICE's terms of reference and powers are being adapted.


Misleading, Biased Reporting on the Health and Social Care Bill in the Media (2020health blog) – January 2012

Proposal: Journalists should take special care to ensure that their reporting on the Health and Social Care Bill is fair and accurate.

Response: The dire claims of many uninformed journalists in 2012 can be seen in 2014 to have been false.


The Health and Social Care Bill: Final Stages in Parliament (2020health blog) – February 2012

Proposal: When the Bill becomes law, the NHS will suffer if medical professionals and others fail to co-operate.

Response: Fortunately, by 2014 co-operation between the professionals and others involved appears to have improved.


The NHS needs outstanding management as well as a legal framework, for example, to unlock the potential of the property portfolio (2020health blog) – April 2012

Proposal: The vast potential of the NHS property portfolio is great enough to justify having some of the very best managers or advisers on the case.

Response: The NHS is increasingly seeking ways of being more commercial whilst still putting patients first.


Management Priorities in the NHS under the Health and Social Care Act (2020health blog) – June 2012

Proposal: Medical professionals, politicians and patients must work together to take tough decisions.

Response: The misleading criticisms of the Health and Social Care Act are by 2014 fading into history.


Do private patients in the UK help or harm the NHS? (2020health blog) – September 2012

Proposal: Most decisions should be taken on their merits with a minimum of political preconceptions.

Response: No serious proposals have been put foreword to limit the freedom of patients to choose private treatment if insured or able to pay.


The NHS Constitution - the turning point? (2020health blog) – November 2012

Proposal: Real hope exists that public support for the Government’s handling of the NHS has turned the corner. 

Response: Looking back in 2014 Jeremy Hunt appears to have understood the public mood on a number of key issues e.g. dementia.


Health and Social Care Act 2012: Response to Attacks on the Act (here) – November 2012

Proposal: The Act creates an opportunity for greater alignment of the interests of patients, doctors, managers, taxpayers and other interested parties.

Response: Viewed from 2014 relationships appear to have improved.


The following is a summary of the submission made to Department of Health on the NHS constitution (January 2013). Background notes published by the Department of Health are here. Further comment on the NHS Constitution is here 

1 What is your name?

Barbara Arzymanow 

2 What is your email address? 

barbara@trueresearch.co.uk 

3 What is your organisation? 

True Research Limited 

4 Patient involvement: What are your views on the proposed changes to strengthen patient involvement in the NHS Constitution? 

I support them strongly. A good healthcare system should try to align the interests of patients, medical professionals and Government. Patients have been underrepresented in the past because the Government pays and a doctor or other professional usually selects the treatment. The changes will help to redress the balance.

5 Feedback: What do you think about our proposal to set out in the NHS Constitution the importance of patient and staff feedback towards improving NHS services?

This proposal can only help. Too many good ideas are wasted because the originators of the ideas do not know who to tell or do not wish to be seen as interfering.

6 Duty of candour: Do you agree with, or have any concerns about, amending this pledge to make it more specific as suggested? 

I am concerned about patients being given negative information (e.g. that they are terminally ill) or having their morale depressed during treatment (e.g., ahead of surgery). However, I recognise the benefits of being told the truth at all times. Maybe patients should be allowed to express their wishes e.g. (1) being told everything promptly and truthfully (2) being told the full position but with a delay if agreed between the doctor and a nominated relative or friend (3) never being told if certain specific things happen. A patient is not necessarily getting what he wants just because he is told everything candidly. 

7 Making every contact count: What are your views on including in the NHS Constitution a new responsibility for staff to make ‘every contact count’ with the aim of improving health and wellbeing of patients? 

This proposal is a good idea and will particularly help preventative medicine. 

8 Integrated care: Do the proposed changes to the NHS Constitution make it sufficiently clear to patients, their families and carers how the NHS supports them through care that is coordinated and tailored around their needs and preferences? 

This proposal can only help. Too many good ideas are wasted because the originators of the ideas do not know who to tell or do not wish to be seen as interfering. 

9 Complaints: Do you think it is helpful for the NHS Constitution to set out these additional rights on making a complaint and seeking redress? 

Absolutely. To a patient an effective, impartial complaints procedure is the main reason to believe that the Government really intends the Constitution to be enforced. 

10 Complaints: Do the additional new rights make the complaints process easier to understand and make clear to patients what they should expect when they make a complaint? 

Yes- but a separate complaints form/leaflet with practical, anonymous (or fictional) examples would help. It would be helpful to give guidance on what information should be provided to back up a complaint, whether more detail might be requested later, and what sort of redress or action might follow. 

11 Patient data: Do the proposed changes to the NHS Constitution make clear how the NHS will safeguard and use 

Yes. The greatest concern is that the rules might be inadvertently broken or that illegal hackers might obtain data. I am not qualified to comment on how possible this might be, particularly in the light of changing IT objectives in the NHS. However, the NHS should adopt the highest reasonable level of security. 

12 Staff rights, responsibilities and commitments: Do you agree with the proposed changes to the wording of the staff duties and the aims surrounding the rights and responsibilities of staff? What do you think about the changes to make clear to staff around what they can expect from the NHS to ensure a positive working environment? 

I agree with the proposed changes in wording and those relating to a positive working environment. 

13 Parity of esteem between mental and physical health: Do you agree with the wording used to emphasise the parity of mental and physical health? Are there any further changes that you think should be made that are feasible to include in the NHS Constitution? 

The wording emphasises parity sufficiently and I have no further changes to suggest. 

14 Dignity, respect and compassion: What are your views on the wording used to highlight the importance of ensuring that the tenets of dignity, respect and compassion are sufficiently represented in the NHS Constitution? 

I fully accept that violent patients may need to be denied access to the NHS and police involvement may be appropriate or essential. However, to my mind verbal abuse is in a different category where there is no threat of violence, no threat to property and no disruption of the hospital's treatment of other patients. Tempers can get very frayed after hours of waiting in A&E departments or where seriously ill patients cannot receive immediate attention or in many other circumstances within hospitals. Whilst I cannot condone any aggressive or rude behaviour, I think that withdrawing NHS facilities from a person for verbal abuse without any clear avenue of appeal is too harsh. We should try to encourage all medical staff to be proud of their work and prouder still if they can successfully brush aside, unreasonable, verbal abuse. Of course, the safety of staff and patients comes first and every case must be assessed on its own merits.  

15 Dignity, respect and compassion: Do you agree with the suggestion of including a new pledge for same sex accommodation? 

Yes. 

16 Local authorities role: Do the proposed changes to the NHS Constitution make it clear what patients, staff and the public can expect from local authorities and that local authorities must take account of the Constitution in their decisions and actions? 

Yes. 

17 Raising awareness and embedding the Constitution: Have you seen further examples of good practice in raising awareness and embedding the NHS Constitution that should be taken into account in these plans? 

See question 18. 

18 Raising awareness and embedding the Constitution: Do you have further recommendations for re-launching, rolling out and embedding the Constitution from next spring? 

Brief one-page summaries of the Constitution could be available in waiting rooms and handed out on discharge from hospital. They could be displayed on notice boards and made available to take away in GPs’ surgeries, hospitals, dentists, opticians, retail pharmacies, citizen’s advice bureaux, old people’s homes, public libraries and the places of work of other healthcare professionals. A major campaign could be mounted to encourage journalists to write about the Constitution. Messages could be played instead of music or silence to people waiting on the telephone. More detailed leaflets on the complaints procedure should also be made available. 

19 Giving the Constitution greater traction: To  help shape our future consultation, do you have views on how the NHS Constitution can be given greater traction to help people know what they should do when their expectations of the NHS are not met? 

If the Constitution succeeds in the way that looks possible, it will be highly worthwhile to improve and update it in the future. The emphasis should be on ever stronger enforcement of and accountability.

20 Equalities: How can we ensure the NHS Constitution is accessible and useable to individuals of different backgrounds and to different sections of society? 

See Question 18. Apart from the obvious (e.g. advertising in publications with the right readership profile; translating leaflets into foreign languages and displaying them in suitable outlets such as food shops or clubs of the appropriate nationality) there are few ways of accessing people with specific minority backgrounds. An idea worth trying might be to compare entries in the electoral roll with lists of people not registered with NHS doctors but this would require the development of special computer software and possibly legislation to permit use of the data. 

21 Equalities: Are there any ways in which the proposed changes set out in this consultation could have an adverse impact, directly or indirectly, on groups with protected characteristics? If so, how? 

Successful research tends to increase inequality because opinion leaders normally employ the new treatments before being ready to train others. This fact results in new procedures often being taken up first in top teaching hospitals. The difference is amplified because leading consultants carrying out research like to work in a hospital with others. They can then compare expertise and share facilities. There is no way of avoiding the fact that areas served by a large teaching hospital will often offer superior medical care. 

22 General: Do you have any further comments about our proposals for strengthening the NHS Constitution?

The Health and Social Care Act 2012 was opposed by a disappointing number of healthcare professionals, patients and journalists. The Government failed to win the hearts and minds of the electorate. The media must accept some blame for having misrepresented the true aims of the Act. 

The proposed NHS Constitution represents evidence that the tide may be turning. The document sets out in a readable form the principles of the NHS; the rights and responsibilities of patients, the public and staff; and the pledges that the NHS is committed to achieve. The reception has been encouraging. If the tide is turning, the proposed Constitution will prove to be unusually important.