Following the passage of the Health and Social Care Act, the NHS Commissioning Board has been steadily putting flesh on the bones of how it will actually operate. As I have written before, the relationships the Board will forge will be as important as the rules under which it was established. The cast of senior-level individuals tasked with establishing these relationships is nearly complete, albeit with one major gap: the domain leads who will be tasked with delivering the improvements in outcomes which will be the ultimate test of the new NHS.
The mechanism which binds together the rules and relationships will be the Mandate – the framework which will hold the individuals (and organisation) accountable. This will be a product of discussion, negotiation and agreement between the Secretary of State and the NHS Commissioning Board. There have already been mutterings about the content of the Mandate, with those on the Board side making clear their intention of avoiding a prescriptive document intended to maintain political grip on the NHS by another means. Yet, for those on the political side of the building, there is an equal determination to prove that reform has led to demonstrable improvements in outcomes. They will not be content to let the Board batten down the hatches and seek to ride out the storm of transition and a slowdown in spending. Instead, they will require something to show that the NHS is on track to deliver outcomes which are comparable with the best in Europe.
This is relatively straightforward in theory. After all, the NHS Outcomes Framework is meant “to provide an accountability mechanism between the Secretary of State for Health and the proposed NHS Commissioning Board.” Set across five domains, the Framework provides an extensive range of indicators against which to assess performance. However, for it to be useful in this respect, levels of ambition need to established for each indicator and this will not be simple, requiring an assessment of trajectory in outcomes, international comparisons, cost effectiveness, impact of inequalities and the time lag between intervention and change in outcome.
At this stage, not every indicator even has a finalised definition or method of measurement and two areas – dementia and learning difficulties – only have ‘placeholders’ (code for no workable indicator in existence). It is therefore hardly surprising that work on levels of ambition is further behind. This is not a criticism: measuring outcomes in a way which is meaningful for performance management is not an easy task (there was a reason for all those process measures), but it does flag up how agreeing the first Mandate may be more challenging than first envisaged. It also identifies that determining the level of progress against each domain will not be simple.
Health outcomes are also influenced by factors beyond the NHS’ control. Even setting aside socioeconomic factors (which are challenging at a time of double-dip recession), the impact of public health (for example, if you prevent people developing heart disease, they are less likely to die from it, have their quality of life constrained by it or be exposed to the risk of avoidable harm as a result of treatment for it) and social care (for example, good care for older people will expand their life expectancy at 75) can be significant. Conversely, failures in public health or social care (not unlikely given the pressures on both services) will make the NHS’ task that much harder.
The NHS Future Forum, as part of its efforts to encourage greater integration, recommended that shared indicators should be established across public health, the NHS and social care. As a result, there are shared indicators between the NHS and public health (mortality) and between the NHS and social care (health-related quality of life and rehabilitation following discharge from hospital).
However, it is easy to see how this could descend into a blame game between different services, or at least a mechanism for excuses. For example, on liver disease the Framework states: “it is not possible to define an indicator that focuses precisely on the NHS contribution to increasing survival of those with the disease. It is therefore important to note the external factors determining incidence, and to take those into account when assessing the trend in liver disease mortality, hoping to encourage the NHS to do what it can to mitigate the burden of this disease.” This could easily become an abdication of responsibility.
Given these technical challenges, it would be easy for the NHS Commissioning Board to argue for a Mandate against which it is difficult to measure progress, and which prevents proper accountability. Such a scenario would alarm those who warned of a diminution in political responsibility as a result of the creation of the Board. Equally, it is easy to see how – in an effort to avoid this – politicians would instead seek to fill the Mandate with a series of prescriptive measures which may further alienate those running clinical commissioning groups, who are already complaining of the heavy hand of the centre.
If these two extremes are to be avoided, then the role of the domain leads will be critical. The appointment of these figures is meant to be imminent, although this has been the case for some time.
The domain leads will need to identify a middle way between vacuity and prescriptiveness – and they will need to take those who may be inclined to one or the other with them. In order to do this, they will have to challenge the NHS (and themselves) by arguing for stretching goals, perhaps in the absence of validated indicators or levels of ambition, whilst at the same time tempering the instincts of politicians to push for a headline grabbing ambition which may not be achievable. This will require a detailed level of understanding of the outcomes which matter in their domain; the ability to command clinical, political and managerial confidence; a knowledge of how the system works (and doesn’t work); as well as a level of diplomacy which would not go amiss in the Middle East. These will not be easy jobs.
To date, much of the focus has been on which big beast will take which big job within the Board. Yet perhaps the most challenging roles have yet to be filled. It is in the interests of both the Board and the Department of Health to get these appointments right and to make them relatively rapidly. The Mandate should not be agreed without them.