The NHS Mandate: Deal or no Deal?


The arrival of Jeremy Hunt as the new Secretary of State for Health has had an important role in shaping the final NHS mandate, the draft version of which was published in July under his predecessor Andrew Lansley.  This mandate is more patient friendly, shorter (though only by six pages) and looks to set broader ambitions for service improvement rather than tight formulaic goals.  It focuses on particular priority areas for the new Secretary of State (and the Prime Minister): long term physical and mental health conditions, dementia, elderly care, mortality from major diseases such as cancer, heart, liver and respiratory disease as well as the overall financial stability of the system. 

The deal

The mandate’s construction and content showcase Hunt’s ability both to listen and cut a deal with those in the new system.

As both myself and my colleague Mike Birtwistle have previously commented, there was a tension in what the mandate needed to deliver.  Members of the Commissioning Board were keen to avoid the document becoming too prescriptive and being set up to fail.  Those on the political side of the system wanted it to help demonstrate the benefits the reforms have brought in advance of the next general election (the mandate runs for two years and expires in March 2015, just two months before polling day).

The change in Secretary of State during the consultation process has certainly assisted the powers in the Commissioning Board in their efforts to see specific targets and goals for delivering achievements watered down.  The ambitions for quantified targets of ambition to be set across the domains of the NHS Outcomes Framework defined in life years or quality of life years (QALYs), central to the Lansley mandate, have been removed as they were ‘too complex.’  These have been replaced with what could generously be classified as broader objectives based around the indicators in the NHS Outcomes Framework.  In conceding this (and it was debatable whether such proposed measures were indeed workable in practice) Hunt has ensured that the Commissioning Board will prioritise his areas of focus above any others. 

This shift is undoubtedly a huge relief for the Commissioning Board (who very quickly and unsurprisingly welcomed yesterday’s announcement) which will now be able to focus on their day job of delivering improvements in outcomes in the Outcomes Framework knowing that this will in turn help them show the politicians how they are delivering on the mandate.

Which came first the Outcomes Framework or the Mandate?

Given that the NHS Outcomes Framework has already been running in shadow form for two years, and it is this which will be used to hold the Commissioning Board to account on the outcomes it delivers, and in turn it is these outcomes which will be used to judge the success and or failure of the new system, then what can the mandate add?  This makes one think back to the dilemma of which came first, the chicken or the egg.

There are signs that some of the priorities announced in the mandate are reflected in the updated outcomes framework, published alongside, showing the mandate’s role as a lever in the new system.  For example the mandate includes an objective to better diagnose, treat and care for people with dementia, whilst the outcomes framework includes plans to expand the current outcome indicator for dementia to measure the effectiveness of post diagnosis care in sustaining independence and improving quality of life.

In addition the mandate goes beyond the Outcomes Framework in its scope.  There are objectives relating to the good financial management of the NHS, the production of measurable and comparable data on the quality and value of services, working with other agencies involved in the delivery of health and care services, innovation, and creating a fair playing field between providers, none of which is adequately captured in the Outcomes Framework.

Finally (and given the supposedly independent operation of the NHS Commissioning Board) the mandate is an important opportunity for the Secretary of State to set out the political priorities for the NHS and for Parliament to debate them.  The mandate was laid before Parliament and is subject to parliamentary debate and scrutiny upon publication. It will be an important political reference point as the new system emerges.

Delivering the mandate

The mandate fires the gun for the battle for health at the next general election.  The priorities have been set, the new system is soon to be operational and the Government – which has spent significant political capital in getting this far– will have everything crossed that it delivers.  For the NHS that process of delivery starts now.