This week saw the launch of a national consultation aimed at updating the NHS Constitution for England, which was implemented in 2009 under Gordon Brown’s Labour Government. The constitution itself sounds wonderful, apparently it
“establishes the principles and values of the NHS in England. It sets out patient and staff rights and responsibilities. It protects the NHS and helps ensure we receive high-quality healthcare that is free for everyone”
So far, so good. It sounds laudable. However, can a constitution really accomplish the things indicated in this quote? For example, at the height of the reform furore some commentators accused the government of reneging on their commitment to free healthcare for everyone. If the constitution were worth its salt then everyone from Unison, to the BMA to the Royal College of General Practitioners should have decried the reforms as unconstitutional. I am not aware of any of these critics invoking ‘a violation of the NHS constitution’ as a means of countering the juggernaut of reform. Far from establishing principles and protecting patients, the NHS constitution is better described as a straw man. It is being used to legitimise political reform that no members of the public either asked for or wanted.
The NHS constitution clearly has a role or function in terms of shaping (or even perhaps determining) how we think about our experiences and expectations of the NHS. The consultation document outlines 10 key areas that ‘need’ to be amended in the current constitution, ranging from patient involvement through to staff rights through to integrated care. The fact of the matter is that the review is necessary to bring the NHS constitution in line with the new (post-Health and Social Care Act) NHS. In effect, this consultation (with its list of NHS Future Forum proposed amendments) marks a further shift away from the principles of health as a public good and lurches towards further embedding the ideology of health as an individual right into the very fabric of the NHS.
The constitution is constructed around sets of 1) rights – across patients, public and staff, 2) pledges – which the NHS is committed to achieving, and 3) responsibilities – which public, patients and staff are obligated to honour, to “ensure the NHS operates fairly and effectively”. It is this conflation of rights and responsibilities that is most troublesome. David Harvey has talked about how processes of individual responsibility are a central part of the neoliberal state project; a process intended to ‘advance’ human wellbeing through the enhancement of private property rights, free markets and free trade. In terms of the issue of responsibility, within neoliberalism the dominant process is to guarantee personal and individual freedom, whereby
“each individual is held responsible and accountable for his or her own actions and well-being. This principle extends into the realms of welfare, education, health care, and even pensions … Individual successes or failures are interpreted in terms of entrepreneurial virtues or personal failings (such as not investing significantly enough in one’s own human capital through education) rather than being attributed to any systemic property”
It is responsibility that is the key issue. Who can be said to be truly wholly responsible for their health? We can be if, and only if, health is construed as an individual right. If health is regarded as an individual property, then health inequalities come to be construed as erroneous lifestyle choices (we choose not to exercise enough, to drink too much etc etc etc, i.e. we are irresponsible in our health choices). This approach functions to factor out the effects of poverty from our understanding of health inequalities. Petersen and Lupton wrote about this very dynamic in their excellent book on ‘the new public health’. Health is not a lifestyle choice. But the processes of responsibilisation inferred in the NHS constitution valorise this individual rights based, health behaviour model at the expense of a broader based approach that addresses inequalities in terms of wider systemic properties.
Health is a collective public good, and society (comprised of a compact between ourselves, e.g. the public, and the government and the health professions) is responsible for everybody’s health. The contract-uralisation and responsibilisation of this compact is an ideologically motivated strategy intended to weaken and diminish it, and ultimately to weaken and diminish the NHS as a collective public good.