Almost two years to the day since the launch of the White Paper Equity and excellence: liberating the NHS, the Secretary of State for Health Andrew Lansley has published his first draft mandate to the NHS Commissioning Board. The Secretary of State chose American independence day, a date marking freedom from distant control – surely a coincidence – to set out his vision for the improvements he expects the health service to deliver in the coming two years.
The mandate is a crucial part of the new NHS infrastructure and is designed to hold the NHS Commissioning Board to account for the quality of healthcare services it delivers. As my colleague Mike Birtwistle has previously pointed out its content has been the source of much wrangling and debate in recent months. The main source of contention being between a Board keen to avoid a prescriptive approach and politicians keen to include measures that will enable them to show to the electorate that the reforms are working and delivering improvements in care. A further relevant dynamic has been the desire of several campaigning organisations to ensure that the importance of “their” condition is acknowledged in the mandate.
Today’s draft mandate – which is a draft and will be consulted on over the next twelve weeks – reflects this tension. In some respects the draft mandate goes further than some would have previously thought, setting out 22 care objectives for the NHS over the next two year period (this mandate, when implemented, will run from April 2013 to April 2015, although it will be updated annually). However, a closer inspection reveals that the scope and breadth of these objectives varies greatly.
As previously set out on this blog, the NHS Outcomes Framework which is designed “to provide an accountability mechanism between the Secretary of State for Health and the proposed NHS Commissioning Board” takes a leading role in the objectives and the construction of the draft mandate. Indeed just under a third (32%) of the objectives in the draft mandate clearly relate to delivering measures within or in the context of the NHS Outcomes Framework. These include objectives in each of the five domain areas of the framework to set clear ambitions (not targets) on the improvements that should be delivered in each. At this stage, the numerical and percentage reductions have not been included for these objectives, although assurances are given that these will be included once the final mandate has been published. Delivering these ambitions will be a key priority for the Board when it becomes fully operational and will cascade down across the health system. Clinical commissioning group leads, who saw the reforms as an opportunity to be liberated from central control may well not appreciate being assessed and scrutinised against such tight measures.
Of the remaining care objectives, many relate to familiar key reform areas including choice, incentives, localism, efficiency, patient engagement, integration, information, support for carers, mental health and NHS staff development. However, these are far broader in their ambitions and scope. For example, in implementing the amendment to the Health and Social Care Act 2012 placing mental health on a par with physical health, the draft mandate merely says it will “develop a collaborative programme of action.” How such a plan will be implemented is not expanded upon. On extending choice, the draft mandate reiterates an existing right in the NHS Constitution that patients who wait longer than 18 weeks for treatment should be able to choose from a range of different providers much trailed in this morning’s papers, although again the enforcement mechanism for this is not clearly set out. The draft mandate also reiterates the pledge in the NHS Innovation Review to improve access to NICE-approved drugs, but again no additional funding or measures are included that clearly set out how this ambition will be realised. There is little doubt that such measures are the less prescriptive side of the mandate and present the greatest opportunities for local interpretation, innovations and solutions.
Whilst some of the objectives are broad in their scope, the challenge in implementing the mandate is immense in a new system containing a variety of new bodies at a local and national level all of whom will have to work together to ensure the objectives are realised. Indeed integration and integrated working between these bodies will be key to the mandate’s overall success or failure. A significant part of the responsibility for ensuring the mandate succeeds will fall on the five domain leads of the NHS Outcomes Framework, who will be announced imminently. If they were under any illusions as to the scale of their task, their job description to liberate whilst mandating has just been published.