Steve Field: the NHS constitution is a 'precious gift'

The independent public inquiry report from Robert Francis QC provided a powerful insight into a care system “which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety” – and into the culture that allowed this to happen.

His challenge has been resolutely clear that “if there is one lesson to be learnt, it is that people must always come before numbers”. He wrote: “It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented.”

The significance of the magnitude of care failings at Mid Staffordshire Foundation Trust, and others since, makes the warning last year from Robert Francis that a “tsunami of anger was heading our way” even more profound when he reminds us that “the NHS is a vision and an aspiration, and it’s a value, intrinsic in our society”.

‘It’s wonderful, you know, we respond with humanity and kindness to each person, in pain and in distress, anxiety or need’

Brand values

If we accept that the NHS is a brand then we have to tackle variation in the quality and standards of care provided across the NHS. In Mr Francis’ words, “a culture that is satisfied with 95 per cent of care being right is the wrong way round because the brand can be destroyed by the 5 per cent that’s going wrong”.

Providing consistently high-quality, safe, compassionate care across all of the NHS is not insurmountable, and for Professor Steve Field, the deputy national medical director of NHS England (the newly renamed NHS Commissioning Board), embedding the values and principles of the NHS constitution is an important first step. The NHS constitution is “a precious gift to those who understand its value”, he says

Mr Francis’ endorsement of the NHS constitution as a core reference point and a model framework upon which fundamental standards of behaviour can be built in the NHS was a welcome message to Professor Field. He “couldn’t understand why such a basic document about human beliefs and values” was not taken seriously in the past.

“The constitution goes beyond the fundamental standards, it crosses party politics and professional groups”, says Professor Field. “It should be embedded within the codes of behaviour, used for appraisal and it should be absolutely core to everything we do.

Everyone counts

To address the cultural barriers that get in the way of providing compassionate care, board members must live and evidence the values and behaviours of the NHS constitution. 

‘Organisations need to recruit from a wide range of backgrounds to all levels in NHS trusts, and then “everyone counts” will emanate’

For Professor Field “the single most important thing board members need to read and understand is the first paragraph of the NHS constitution, that is that the ‘NHS belongs to the people’”.

He is also convinced that boards committed to reducing health inequalities and promoting equality can achieve this by aligning their strategy with the principles and values of the NHS constitution. He says that if board members truly believe that in England “everyone counts”, boards would want to promote equality and do everything possible to address health inequalities.

In this way, “it is the values of the NHS constitution which endure and that should pervade everything that the board and NHS trusts, GP surgeries, dental, practices, and mental health organisation should do”.

“Boards need to structure their meetings so that at each one, NHS values are demonstrated clearly in board papers and in how the meetings are conducted,” the former Royal College of GPs chair says.

He adds that boards must lead by example to create an environment in which “everyone counts”, because “happy, inspired, motivated staff are more likely to look after patients with care, compassion and dignity, whether they are a porter, a professor of medicine or a nurse on the ward”.

Everyone Counts is a challenge, says Professor Field. Especially when “a number of really inspiring, motivated staff, particularly from black and minority ethnic communities”, feel they have been held back by not “being encouraged or supported to apply for higher-level jobs”.

Lost compassion

However, he believes that “organisations need to recruit from a wide range of backgrounds to all levels in NHS trusts, and then ‘everyone counts’ will emanate from all staff by treating each other, their patients and their relatives with respect and dignity, and responding to each other with humanity and kindness”.

Professor Field pauses briefly to reflect on the wording under the compassion section in the constitution.

‘All the regulators, commissioners and providers must look at their codes of practice as a matter of top priority’

“It’s wonderful, you know, we respond with humanity and kindness to each person, in pain and in distress, anxiety or need. We search for the things that we can do, however small, and that includes how we look after patients but also more importantly at a time when we are looking at Stafford, we seem to have lost the ‘compassion’ element both for how people look after staff and patients”.

To aspire to an “NHS that belongs to the people, the NHS Constitution needs to be a living, breathing document that is aligned to and connects with, all the key stakeholders in the health and social care system, including commissioners, providers and regulators.”

Restoring confidence

He agrees 100 per cent with Robert Francis that “if the other countries in the UK have different ways of looking at things it’s because their health systems are now different and diverging, but the values of the constitution should pervade everything we do”.

“All the regulators, commissioners and providers must look at their codes of practice as a matter of top priority and look at how their work can reflect more strongly the constitution because we don’t want one code for one profession and another code for another − we need those underpinning values, which is the constitution.”

He remains absolute that: “Every member of the board should live the values of the constitution, in the staff they employ and the patients they serve. They should be beacons for those values and selected for board positions as people who can demonstrate they live the values in everything they do.

“They should be held to account for those values, because values such as dignity and respect, care and compassion are what matters most to patients, families and to staff. We must find every way, however simple, to put patients first, support staff and restore public confidence.”

Robina Shah is lead, NHS constitution, at Manchester Medical School and director of the patient safety ambassadors programme at the Advancing Quality Alliance