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  • BIOETHICS FORUM ESSAY

A New Era of Responsibility: For the U.S., England’s Health Service Constitution, and the Broccoli Police

The headline on the BBC News web site immediately after Barack Obama’s historic inauguration speech read: “Obama calls for new era of responsibility.” And indeed President Obama called for such an era, urging “recognition, on the part of every American, that we have duties to ourselves, our nation, and the world, duties that we do not grudgingly accept but rather seize gladly…This is the price and the promise of citizenship.”

Coincidentally, on the following day, the U.K.’s Department of Health published the National Health Service Constitution for England, setting out, for the first time, rights and responsibilities of NHS users. In a significant sense, the NHS constitution also heralds a new era of responsibility, although the language may be unsatisfying to people on both sides of the divisive debate over how much responsibility citizens are obliged to take for their health.

Work on the Constitution began in early 2008, and its first draft was published alongside a comprehensive review of the NHS carried out by Health Minister Lord Darzi. The introduction to the Constitution notes that its purpose is to establish “the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledgeswhich the NHS is committed to achieve, together with responsibilities which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively.”

The section on values is presented under the six headings of: respect and dignity; commitment to quality of care; compassion; improving lives; working together for patients; everyone counts. Seven overarching NHS principles are set out, the first two of which specify that comprehensive services are provided to all, and that access is based on clinical need and not ability to pay (although some user-charges may be sanctioned by Parliament). Other principles relate to professional standards; the need to reflect patient preferences in NHS services; and the importance of providing cost-effective services. The largest part of the Constitution is dedicated to setting out rights of NHS users, and twenty-five individual legal entitlements are described. These rights are not new, but rather have been brought together from other pieces of legislation.

By contrast, the brand new section on responsibilities of NHS users goes as follows:

The NHS belongs to all of us. There are things that we can all do for ourselves and for one another to help it work effectively, and to ensure resources are used responsibly:

You should recognise that you can make a significant contribution to your own, and your family’s, good health and well-being, and take some personal responsibility for it.

You should register with a GP practice–the main point of access to NHS care.

You should treat NHS staff and other patients with respect and recognise that causing a nuisance or disturbance on NHS premises could result in prosecution.

You should provide accurate information about your health, condition and status.

You should keep appointments, or cancel within reasonable time. Receiving treatment within the maximum waiting times may be compromised unless you do.

You should follow the course of treatment which you have agreed, and talk to your clinician if you find this difficult.

You should participate in important public health programmes such as vaccination.

You should ensure that those closest to you are aware of your wishes about organ donation.

 You should give feedback–both positive and negative – about the treatment and care you have received, including any adverse reactions you may have had.

It is interesting to note that the responsibilities differ significantly in their level of detail. The first item is of a very general nature, although (or because?) it concerns one of the most controversial parts of the health responsibility debate: obligations that may conflict with the way one chooses to lead ones life, however constrained these choices may be. The remaining items are very specific. Some relate to actions that are supposed to have good consequences for the person concerned, whereas others are benefits for other people, including those to whom one is in a caring relationship, other NHS users, health care professionals, or the health care system as a whole, which might be run more efficiently if all complied with the responsibilities.

So in what sense could this mix of perhaps overly vague motherhood-and-apple-pie obligations and detailed instructions for responsible behaviour within the NHS be seen as heralding a new era or responsibility? Because, as Health Secretary Alan Johnson put it, the broccoli police are not involved. Responding to concerns that the new responsibilities might lead to people being denied treatment he said, “We never intended this to change the way the NHS works, which is, if you have a health problem we will deal with it… We have got a section in there on personal responsibilities, but it’s not something that’s backed up by law and [therefore] you’ll not have the broccoli police come round if you are having a fry-up…  ”

Perhaps Johnson would not even have had to explain this point if the final Constitution had clarified it explicitly–and appropriate suggestions have been made in some of the responses to the consultation. In any case, the new era of responsibility that the NHS Constitution is introducing is this, I suggest: to argue the case of responsibilities without penalizing sanctions. Clearly, for many in conservative quarters, the Constitution’s approach will be seen as selling out, if not failing to understand a fundamental aspect in the concept of responsibilities, which is that the “stick” option may simply be required, where people do not comply with obligations. Equally, some in liberal quarters may emphasize the overriding importance of the social determinants of health, demonstrated most recently in the final report of the WHO’s Commission on Social Determinant of Health–they may, hence, question more fundamentally the need to talk about personal responsibility in health care. Or they may simply not trust the project on strategic grounds and suspect that this is the thin end of a wedge that, ultimately, will lead to the introduction of financial or other penalties, once people have got used to the idea of responsibilities.

Arguably, much, then, depends on how the responsibilities set out in the Constitution will be implemented in practice. But for now, the approach taken should be lauded, for establishing the principle of disconnecting responsibilities from penalties can help make important progress in a debate that is often stuck unhelpfully between dogmatic left-right positions. In a very simple functional sense, personal responsibility will always play a role in health promotion: for even the most favorable environments will not make people healthy, and often there is considerable scope for action in environments that impose some, or perhaps even considerable, constraints. Belittling the potential of individual action and responsibility can lead people to become unnecessarily fatalistic, and add to their sense of being overburdened and powerless.

By contrast, a reasonable concept of responsibility can help people realize their powers, and encourage them to complain in a constructive way about external obstacles that prevent them from taking more control of their health and contributing to an efficient health care system. This action can help improve environments in a focused and people-driven way. Introducing personal responsibilities without penalties in the new NHS Constitution should therefore be welcomed–and explored as an idea in the urgently needed comprehensive U.S. health care reforms, which Tom Daschle’s team is about to embark on, in this new era of responsibility.

Harald Schmidt is Research Associate at LSE Health, and Assistant Director of the Nuffield Council on Bioethics, London. The views expressed here are his own and may not be attributed to the Council or LSE Health.

Published on: January 23, 2009
Published in: Health Care Reform & Policy

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