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The compact between 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.