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Can or should the NHS expect more from patients and communities?

Jacob Lant

The idea of a social contract between the NHS and the public will only work if it is based on a new ongoing, two-way relationship. This must be supported by an acceptance that the knowledge needed to fix our country’s challenges lies in communities.

  • Lived experience
  • Communication and administration
  • Health inequalities

There’s been much commentary in recent weeks about how to put the NHS on a more sustainable footing. And whatever your political view, it’s clear we need to talk about this. If you think things look bad right now, cast your eyes to the likely demand pressures in the 2040s when many people reading this article are likely to be heavier users of the NHS.  

We have a growing aging population, more people living with complex and multiple conditions, and the cost of delivering care is increasingly expensive as we look to deliver more advanced treatments. None of these pressures are reducing, and we are already spending about 12% of GDP on health.

Some have suggested the answer lies in introducing more charges to access services, yet if we look at NHS dentistry, we can see how charges have been an abject failure and have significantly increased inequality.

Others have called for a shift to an insurance model (private or social). These are a nonstarter, public polling and qualitative feedback consistently shows people don’t want a new model for the NHS, they want the model we’ve got to work. Taxpayer funded and free at the point of use are here to stay.

More sensible commentators like Matthew Taylor and Professor Sir Chris Ham (via the NHS Assembly) have ventured that the time might be right for a new social contract or compact between the NHS and the public. This should be jointly developed with people and communities to set out rights to care and the corresponding responsibilities on each of us to maintain our health.

I have a lot of time for this approach, particularly the idea of the NHS and people working together to set their relationship for the coming decades. But there are challenges.

Firstly, the problem with contracts is that once you strip back the legalese, they fundamentally rely on trust. And right now, public trust in the NHS to deliver against its promises is not high.

People don’t expect the NHS to be able to turnaround performance overnight, especially with the current workforce and financial pressures. But as a system we could be doing a lot more to show the trajectory of improvement and start building back the trust needed for people to enter into a new kind of relationship. As National Voices found in our recent work to support the NHS 75th Anniversary, this needs to start by the NHS consistently getting more of the basics right, like its communications and administrative processes that cause so many frustrations for people, especially those already facing health inequalities.

Secondly, a contract that sits on the shelf and is barely known about beyond the NHS itself (like the NHS Constitution that is already in place) is unlikely to shift the dial.

Thirdly, for a contract to work, people need to have the capacity to comply with its terms and conditions. And yet we know from the public side not everyone comes from the same starting point.

Let’s look at the NHS Constitution here for a moment. That already sets out a list of basic responsibilities (I have picked out three below) but complying with these is not straight forward:

  1. Register with a GP. Seems simple enough, but even though primary care guidance is crystal clear, evidence continues to show GP surgeries asking for proof of ID and address upon registration. This means many of the most vulnerable groups in society will fall at this first hurdle. 
  2. Treat NHS staff with respect. This is a given and I would never condone any abusive behaviour towards staff. However, NHS processes don’t always show respect to patients, particular when it comes to their time. For example, calling out-patients to clinics all at the same time and then leaving people waiting for hours is a huge problem for those on zero-hour contracts.
  3. Give feedback, positive and negative. We know that the NHS collects millions of bits of feedback in various forms every year, and yet trying to understand what it does with all this is pretty opaque. And we know there is still fear out there, due to the perceived power imbalance between medics and patients, that if people do speak up or complain then it will worsen their care.  

Rather than talking in terms of a new social contract, we should talk about how to create an active relationship between the NHS and patients. This must be one where the NHS continually engages with communities to identify what it’s getting right, asking people for their suggestions for improvement, and then working with them to implement these together.

I do believe the NHS can expect more of the public but not in a way that chastises people to exercise more, eat better or use services less. Indeed, it’s important to remember that due to the cost-of-living crisis many in society cannot afford to make healthy choices.

The NHS should instead have higher expectations that communities have the answer to how they can live healthier lives and should work with them to unlock these solutions.

This will require more investment in developing engagement mechanisms, which will need greater financial and time resource to ensure we get out into communities and create the space for genuine two-way conversations and co-production of solutions.

But by unlocking the power of communities, this investment will see significant return by helping us put the NHS on a sustainable footing for the future.

This blog was first published on The NHS Confederation’s website.


Jacob joined in May 2023 as Chief Executive of National Voices. He is a committed advocate for working with people accessing health and care services and the wider public to help improve the accessibility and quality of the care they receive. He loves to combine deep qualitative insights with quantitative data to challenge traditional thinking on how to tackle policy challenges. Prior to working for National Voices, Jacob spent almost 10 years helping to build the Healthwatch network. In this time, he led successful nationwide policy influencing campaigns on a huge variety of topics, from maternal mental health services to access to NHS dentistry. He has also worked in local Government and for the British Library.