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A fractured NHS constitutes a lottery

27 March 2009

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How have you been doing with the lottery? Are your numbers working out well? I don’t mean the Wednesday and Friday tombolas – I mean the postcode lottery, whereby treatment on the NHS varies from area to area. But then, whereas we originally had one draw in the National Lottery, there seem to be countless games being added. And the similarities continue: we now have the European dimension to add to both the National Lottery (Euromillions) and the NHS (guidance on entitlement via E111).

It is all very complex. When we prepare AMSPAR’s national assessments, we have to look at the broad picture. Inevitably, we are required to have “country advisers”, who review papers to ensure that questions are applicable across the board and that marking schemes take into account different policies and titles across the four nations.

Yet not only do policies vary, but also procedures can differ throughout the different health authorities in England. Different demands can be placed on the system dependent on the demographics of the community, and it is important that flexibility can be built into structures in order that we can respond most effectively to needs.

However, it is when anomalies arise that concern is expressed. We have all heard the high-profile debates about the differences in prescription costs and car-park charging. These are easy pickings for the tabloid newspapers to focus on and something the general public can easily grasp. It is slightly more complex when it comes to drugs and treatments.

Bamboozled over alcohol
The Scottish government, which led the way in the UK over the public smoking restrictions, is now turning its attention to alcohol. Among the mooted measures for discussion are stopping cut-price “booze” deals, a minimum price per unit and, although the government has backed down from increasing the age across Scotland for off-sales to 21, it still proposes to create powers for that measure to be imposed on a local basis.

The Scottish government claims that alcohol abuse costs Scotland £2.25bn every year in lost work days and costs to the health service.(1) Health Secretary Nicola Sturgeon said: “Plummeting prices and aggressive promotion have led to a surge in consumption, causing and adding to health problems ranging from liver and heart diseases to diabetes, obesity, dementia and cancers … we remain determined to press ahead with tough policies to tackle alcohol misuse.”(2)

Few would disagree that Scotland, and the UK as a whole, has to tackle alcohol abuse, but one would be looking for a cohesive approach across the spectrum, which is sustainable. It is all very well quoting the cost to the country but this should be paralleled with the revenue earned through the sales. The Scottish whisky industry, for example, is one of the UK’s top five export earners and contributes £800m to the Scottish economy annually.(3)

To set up a minimum charge on a unit of alcohol in Scotland will simply see warehouses being set up in Carlisle and Berwick-upon-Tweed for cross-border trips. We only have to look at Newry at Christmas time, when shoppers from the Republic of Ireland swarmed across the border to cash in on the exchange rate. One supermarket had to close after 90 minutes in order to restock empty shelves.

All rights reserved
Essentially, we are looking for a level playing field. And is that what the new NHS Constitution is offering the health sector? The short answer is “no” – since it only applies in England.

This document was signed by the prime minister, Health Secretary Alan Johnson and the chief executive of the NHS, David Nicholson, in late January.(4) Of course, it still requires approval by parliament to ensure that organisations have a statutory duty of regard to the constitution. Note: this means to take heed of it – not a legal obligation to follow it.

Responding to criticism, Mr Nicholson said that the document struck the right balance between being a “lawyer’s charter” and having teeth.(5)

As you may be aware, the draft of the constitution went out for consultation in July 2008.(6) It is an interesting exercise to compare the first draft with the signed-off version. It would appear that many comments have actually been taken onboard!

The introduction itself has seen the addition of phrases such as “wellbeing” and “communities”, making it more embracive. A key change is in the description of the constitution itself. From: “It sets out commitments to patients, public and staff in the form of rights to which they are entitled and pledges which the NHS will strive to deliver …” to: “It sets out rights to which patients, public and staff are entitled and pledges which the NHS is committed to achieve …”

The dropping of the term “strive” is significant, and it has generally been removed from the document to be replaced with “commitment”. Nowhere is this more evident than in Section 3, which deals with the NHS pledges to the staff and their rights.

Managerial matters
Practices should bear in mind that this constitution covers them, as it does private and third sector providers supplying the NHS. If you don’t already have a copy, you can download it (and the 145-page Handbook to it) from the Department of Health website ( Pay particular attention to Section 3: this commits you to providing, and receiving, more from your “rewarding job”. Another commitment is “to provide all staff with personal development, access to appropriate training for their jobs and line management to succeed”.(4) Is there an echo of Agenda for Change here? And where have we got to with the individual learning plans?

On the other hand, you also have duties and aims spelled out – although acting in accordance with the “implied terms of your contract” may not be all that clear …(4)

It is the section on staff that has caused most concern to NHS Employers. Deputy Director Alistair Henderson said he sincerely hoped it would not lead to staff taking their organisations to court.(5) Should you be concerned? One wouldn’t have thought so – as long as you can demonstrate that you have taken regard to the constitution, even if you are not fulfilling it.

If you are concerned, you can always relocate to one of the other home nations and continue working for the NHS.

1. The Scottish Government. Moving Scotland Forward: The Government’s Programme for Scotland 2008-09. Edinburgh: Scottish Government; 2008. Available from:
2. The Scottish Government. Media Briefing – 2 March 2009. Available from:
3. DTZ Pieda Consulting. The Economic Impact of the Production of Scotch Whisky, Gin and Vodka in Scotland. Scotland: Scotch Whisky Association; 2003.
4. Department of Health. The NHS Constitution for England. London: DH; 2009. Available from:…
5. Santry C. NHS constitution sets managers a challenge. Health Service Journal. 22 January 2009. Available from:…
6. Department of Health. The National Health Service Constitution. London: DH; 2008. Available from:…