The compact between the public and the NHS

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Part of The public and the NHS

As a society, we are proud of the NHS, and around three-quarters of the population feel we must do everything to maintain it. There is also widespread support for the founding principles of the NHS – namely, that it should be free at the point of use, funded primarily through taxation and provide a comprehensive service available to everyone. Even after a decade of austerity, public satisfaction with the NHS remains high, although there are increasing concerns about the future.

Alongside Brexit, the NHS is currently seen as the most important issue facing Britain today.

The 70th anniversary of the NHS, to be celebrated on 5 July 2018, is an opportunity to reflect on its enduring popularity and to revisit the implicit ‘compact’ – what people can expect from the service and what their obligations are in return – between the public and the NHS.

In place of fear

Nye Bevan spoke of the sense of serenity that occurs when people are freed from the fear of having to pay for medical care. With patient charges comprising a tiny proportion of NHS funding and international surveys showing that the UK performs better than other countries in the proportion of people who report that they were deterred from seeking medical advice by the costs of care, Bevan’s wish has been fulfilled, but new challenges have emerged.

Although the aim of the NHS is that care should be available on the basis of need and not ability to pay, inequities in access to care and health outcomes persist. The research of Julian Tudor Hart on the inverse care law and of Julian Le Grand, who showed that the middle classes receive a disproportionate share of NHS care, challenges a cornerstone of the founding compact. Similarly, the seminal work of Douglas Black, Donald Acheson and Michael Marmot on health inequalities demonstrates that removing financial barriers to care may be necessary but is insufficient if equity is the goal.

The quest for person-centred care

The implicit compact was based on the assumption that patients can expect to receive a standard response to their needs. Changing expectations and the rise of individualism have challenged this notion, and more attention has been given to treating each patient as a person with distinctive needs. Personal health budgets are one way of doing this and allowing patients to choose the time and place of their treatment has also become more important.

Shared decision-making, in which patients make decisions about treatment options in partnership with doctors and other clinicians is an example of what can be done. To cite just two examples, for men diagnosed with prostate cancer and for women diagnosed with breast cancer shared decision-making can be a powerful way of tailoring care to the needs of individuals. This helps patients to understand the risks as well as benefits of different options and helps to avoid the silent misdiagnosis that occurs when patient preferences are not understood.

The role of rights and responsibilities

The slow but steady decline of deference and the rise of consumerism across society has led to greater interest in patients’ rights, as reflected in the Patient’s Charter and the standards included in the NHS Constitution. There is a parallel narrative about our responsibilities as patients and citizens, encompassing what each of us does to maintain our health and wellbeing with support from others, and what this means for how we use services.

In his report on NHS funding, Derek Wanless argued that the public needed to be ‘fully engaged’ in taking responsibility for their health and wellbeing if the NHS was to be sustained as a universal, comprehensive and free at the point of use service. Growing concerns about risk factors such as being overweight or obese and the rising prevalence of diabetes and other long-term conditions suggest that much more needs to be done to achieve the level of engagement advocated by Wanless. The NHS must play its part in giving higher priority to prevention, and the government has a role through legislation, taxation and regulation.

Responsibilities extend to how patients use services. Anecdotal evidence of the inappropriate use of ambulance services and failure to attend appointments are often cited as examples of patients not always using services responsibly. The other side of the coin, of course, is patients having their appointments and operations cancelled at short notice because of pressure on overstretched services and having to wait longer than they would wish for diagnosis and treatment.

Who should pay for care?

The respective responsibility of individuals and the state in paying for care is an enduring issue of debate. Around two-thirds of people say they would be willing to contribute more in taxes to maintain the level of spending needed in the NHS. The political system currently seems incapable of responding to this preference, suggesting that the share of health care spending funded by the government may have reached a limit and that individuals may be required to contribute more out of their own pockets in future.

Looking beyond the NHS, increased life expectancy means that social care has become much more significant at times of need. Can a new health and social care settlement be reached to progressively align the funding and provision of social care with that of the NHS, as advocated by the Barker Commission? And can a cross-party consensus be developed to underpin the funding model needed in the future?

A new compact

Recent reviews of the history of the post-war welfare state (The Five Giants by Nicholas Timmins; Beveridge 75th anniversary lecture by Alan Milburn) are a timely reminder of how much has changed since Beveridge wrote his famous report in 1942. By comparison with other public services, remarkably little has changed in the NHS, with strong support for the founding principles and a limited appetite for radical changes in a service that forms part of the bedrock of our society. Many of us are grateful that the NHS is still there for us at times of need and adjust our expectations of the NHS in recognition of the pressures staff are under.

To make these points is not to be complacent, especially when the NHS and social care face an uncertain and challenging future. With this in mind, the Fund will be undertaking work in 2018 to revisit the implicit compact between the public and the NHS and to ask if it needs to be revised to take account of the way we live now. Our aim is to understand the expectations of the public and the NHS in relation to questions such as:

  • Where should the balance of responsibility for health and wellbeing lie between individuals, the NHS and the government?
  • What should patients expect when they use services and what are their responsibilities in doing so?
  • What should be the respective role of individuals and of the state in paying for the costs of the NHS and social care?

We will be carrying out deliberative work with the public and NHS staff, exploring the views of policy-makers, and reviewing the literature to clarify the meaning and role of compacts between the public and providers and funders of public services. We will be sharing the findings around the 70th anniversary as we play our part in recognising the achievements of the NHS and supporting its renewal now and for the future.


Ron Walker

PPG chairman & PNQ representative,
Comment date
29 January 2018

We are all aware of the issues of rising cost and stretched resources and clearly some new ideas need to be brought forward to make ends meet with the costs of new and expensive treatments. Cost cutting can reap benefits but there is only so much that can be done to save money. Patient responsibility needs to be enforced, everybody knows of the risk of smoking but people still choose to smoke. They need to be held responsible for their choice. We have a timed pathway for cancer treatment, those who chose to put themselves at risk cant expect the first class treatment that innocent parties should enjoy. Cause and effect should be stressed to those who smoke, the NHS offer forms of treatment to stop smoking, if these are not taken up by smokers, they can only expect second class treatment. If you abuse your body don't expect the NHS to fund the repairs.

Justin Jewitt

Hilton Nursing Partners
Comment date
10 January 2018

Future generations of millenials won’t want the same nhs as our parents have had. I support paying more taxes to create a different nhs , not a more costly version of our current model. Let’s use patient information on self help , better primary care services over the Internet ( Babylon-style Skype / FaceTime sessions from healthcare professionals across the world ), email communication with patients for real-time activity managing and tracking appointments , waits , DNA’s etc, E Patient records that are available wherever the patient turns up. Let’s pay to create the smart nhs and enjoy the health benefits for all.

David St Clair…

Community Engagement Group,
West Suffolk CCG
Comment date
05 January 2018

Greater public understanding of the costs of care is vital if attitudes are to be changed

Stephen Morgan

Westbourne Medical Centre, Bournemouth
Comment date
05 January 2018

The NHS is effectively a health insurance system with neither a small 'excess' that is not covered, nor a 'no claims discount'.
There are few examples of insurance systems anywhere in the world which operate well without one, or both of these elements. The NHS is a good example of what will usually happen if one tries. In particular minor 'claims' clog and drain resources from the system and there is a reduced incentive for the insured individual to reduce their risk of an 'incident'.
Modest co-payments at the primary points of access to the service could address this effectively. This is the situation in almost all other health care systems. The NHS already charges at these entry points i.e. General Practice and A&E, but does so with the different 'currency' of time (queuing and inconvenience) as well as the long established prescription charge which means perversely those who are seen and do actually need treatment are the only ones facing a financial cost!
Perhaps moving the prescription charge from after the consultation to a consultation charge before we are seen would both improve the system for the patients and be politically feasible in the often polarised dogmatic debate about these issues.
It at least seems worth a small trial so we all could get some real life information on which to base our decisions in the longer term.

Pearl Baker

Carer/independent Mental Health Advocate/DWP Appointee,
Comment date
05 January 2018

I would like to respond to the suggestion the elderly (middle classes) receive a disproportionate share of Health Care. It should be remembered Carers come from All classes, many are denied any financial support due to (means testing) , continue to Care into 'old age' and poor Health.

It should be remembered that elderly Carers are not entitled to a Carers allowance because this Government Discriminate against those who receive a State Pension (which we paid) for , based of the facts above.

Improvement in Health and Social Care via a Personal Budget/patient centred via a 'Needs Assessment' would help to alliviate a susceptibility to obesity and diabetes. It should be carried out by an Independent Agency with Carer/friend/relative support including an Independent Advocate.

I speak from experience and see too many Mentally I'll sitting in their accommodation for days and hours on end, with little purpose to their lives.

If improvements are to be made a completely different approach is required, many in the community would be willing to play their part, just by visiting and engaging in conversation or playing Board Games.

Consultation Propossals to purchase 'over the counter treatments' for self treatment will significantly save money (if this proposal) is moved to fruition.

I have seen the problems of LA Contracted Support Agency given a FREE reign to do as they please, resulting in poor care and support. I am not in favour of more Power to these organisation, unless they are legally accountable, currently accountable to those Agencies who have commissioned their Services.

I agree that the Public at large are concerned with the Governments spending,with no accountability; if the Public were allowed more involvement in how they spend our money I am sure sufficient money could be found for the NHS.

Eilleen Tipper

carer / volunteer,
Comment date
05 January 2018

We need to start helping people to take responsibility for their own health from as young an age as possible: within schools Personal,Health and Social Education (PHSE) offered in the curriculum provides and opportunity as does health plans for students with Long Term Conditions.
We also need to make politicians aware that austerity and welfare reforms causing increased levels of poverty compromise the immune systems of individuals increasing vulnerabilites to infection and causing people to be sicker when they succumb: social policy has as adverse an effect on NHS costs as the growing population of the elderly !

Jane Young

Disabled person/patient,
Comment date
02 January 2018

I don't agree that it isn't possible to increase tax take to contribute more to the NHS and social care. I suspect the reason it hasn't been politically possible to translate this public support into policy is that voters don't trust the Gov to spend general tax revenues as they would wish them to be spent. The answer to this is not to dismiss the idea of increasing the pooling of risk and resources in this way but to find a means of raising the money the public appear to be willing to spend.

Consideration should be given to a hypothecated tax or special fund for the NHS, to give confidence that the money raised is being used for health & social care. It would be well worth doing this because the NHS model has shown that pooling risk & resources is effective and popular; we just need more resources now because of demographic change & increased demand.

Mike Wedgeworth

Non- Exec Director,
East Lancashire Hospitals Trust
Comment date
01 January 2018

Looks a very important and relevant programme. It would be especially useful to follow the emergence of Accountable Care Organisations: how will the public understand them? Will the private sector be all over them to take contracts from the public sector? What will be the policies of an alternative government? Is the purchaser/ provider split really coming to an end...etc

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