1 What is the idea behind the NHS Mandate?
The rationale behind the mandate is that it will take politics out of the NHS. The secretary of state for health will describe in it their expectations and set specific objectives that the NHS Commissioning Board must deliver. The health secretary remains accountable for ensuring a comprehensive health service for everyone.
The mandate may only be changed during the year in certain circumstances: by agreement with the board, if there is a general election, or in ‘exceptional circumstances'. Any changes would have to be reported and explained to Parliament.
Dr Richard Vautrey, GPC deputy chair and a GP in Leeds, is not convinced politicians could keep out of the NHS for a whole year.
‘How truly independent CCGs will be is the million-dollar question – and a real concern for the GPC,' he says. ‘Whatever they say now, politicians may have to step in and alter things when the Francis report into the Mid Staffs scandal comes out [on 15 October]. And will they step in and alter things if the quality premium widens health inequalities and interferes with the doctor-patient relationship, as we fear it will?'
Ruth Thorlby, senior research fellow at the Nuffield Trust, also believes it's ‘inevitable' politicians will still want to stay ‘in' the NHS: ‘If the public wants something sorted out, will the politicians really say: "That's for the NHS to solve"?'
Ms Thorlby also has questions around how exactly the board will be held to account by the mandate: ‘We have questions around what trickles down. We've seen under Labour that if the NHS wants, for example, to change the direction of waiting times, this takes single-minded action. It's all very well having a lot of targets, but what really matters is the top five.'
2 Where does the mandate ‘sit' with other NHS documents and policies?
Ms Thorlby warns there is potential confusion on how the mandate conflicts or ties in with other NHS documents and policies: ‘What is the weight of the mandate relative to that of the NHS Constitution? And then there are questions about where the public health outcomes framework fits with this. Public health efforts to reduce obesity, for example, could have a massive effect on the outcomes in the mandate. Where's the balance of energy going to be in achieving these?'
Elizabeth Wade, head of commissioning policy at the NHS Confederation, welcomes the mandate's multi-year time frame – but questions how it will work with annual budgets: ‘We're supportive of the mandate having a multi-year time frame to give continuity and stability. This is a clear statement of intent in that direction, which is good. But it's not at all clear how that will play out when spending and funding in other areas is annual. It's clear that this is a mandate for the NHS Commissioning Board, not the NHS. But it raises the question of whether there will be alignment with other mandates and outcome measures such as those for Monitor and the Care Quality Commission.'
3 Does it move us into an outcomes era?
The mandate contains a series of outcomes drawn from the NHS Outcomes Framework, grouped in five domains ‘that people care about most':
- preventing people from dying prematurely
- enhancing quality of life for people with long-term conditions
- helping people to recover from episodes of ill health or following injury
- ensuring people have a positive experience of care
- treating and caring for people in a safe environment and protecting them from avoidable harm.
For Don Redding, director of policy at National Voices, this is most welcome: ‘I think this document throws the reforms into stark relief. It's clear now that commissioners are being held responsible for some big health outcomes. And that's very different from providers being responsible for these in the past, where they were able to manipulate things to meet targets.'
But a concern is how far CCGs can control such outcomes. How much can they actually do – at this early stage – to reduce the number of people dying prematurely?
Mr Redding says: ‘It's so profound, it's almost a philosophical question. CCGs don't control people's housing or their health awareness. Everyone agrees the outcome-based system is the way to go. But can commissioners really achieve these things or is there a fundamental flaw in the thinking?'
Commissioning consultant Scott McKenzie warns the outcomes focus could become an industry in its own right – compromising other commissioning objectives: ‘If that industry of meeting these goals has to take place in CCGs or they have to pay for it, then I don't think there's the money for it.'
4 Why are there so many blanks to fill in regarding outcomes?
The mandate does not single out particular clinical conditions or patient groups. Rather, it provides ‘domain-level' objectives to allow CCGs flexibility on where local focus should be. There are a number of blanks to be filled in on the five main objectives the mandate sets out for the NHS Commissioning Board – for example, secure an additional X life-years for the people of England through the reduction of avoidable mortality by 2015; X life-years by 2018 and X life-years by 2023.
Elizabeth Wade says the blanks can be interpreted several ways: ‘You could either see this as "We've put blanks in because we are not there yet" or "It's extremely hard to put figures on this" or "We've put blanks in because we genuinely want to consult".
I think this is going to be the really tricky bit – how to hold the line between giving the system flexibility while providing some sense of ambition and stretch, and a clear idea of what's expected from the NHS Commissioning Board.'
For Don Redding, giving space and time to the blank spaces is important: ‘These need to be thrashed out fully in consultation. It's good that they have kept it relatively short and comprehensible for the public and left plenty of room for input.'
5 How will outcomes be measured?
For many, this is vital information that the mandate is lacking.
Ruth Thorlby says while it's good to set objectives, defining what will actually be measured is ‘critical': ‘It's easy to set your target with trends – mortality is likely to carry on going down whatever they do – but the real technical challenge now is to set these so they're not too easy or too hard.'
Scott McKenzie agrees: ‘Three or four times, reading through, I've been asking myself: "How do they intend to measure these things?" I haven't found the answers.'
6 How will the NHS Commissioning Board pass on its remit to CCGs?
For some, the mandate is missing an accountability framework for CCGs.
Ruth Thorlby says a cascade of mini-mandates from the board to CCGs could be the result: ‘We'll watch this with interest to know how the mini-mandates will play down from the NHS Commissioning Board and how independent the CCGs will be in practice. If panic emerges about one indicator at board level, you can imagine that being passed down.'
She adds: ‘We think some sort of clarity around how the board will act if targets aren't being met is missing. There's nothing speaking to the quality of primary care, and high-quality primary care is very important. There's definitely a question mark around how the board is going to be held to account for the quality of primary care.'
Elizabeth Wade says CCGs need to be clear what the bottom line is: ‘There has to be an accountability framework for commissioners, and I would very much like to see that. You can only operate for so long without knowing the bottom line.'
7 Choice will be extended ‘at every stage of patients' care'. Does this mean increased fragmentation?
One of the document's four annexes contains a draft choice framework that greatly extends patient choice.
The mandate says: ‘As one key way of ensuring patients are more involved in their care, the Government has committed to extending the range of choices available at every stage of patients' care: with more choices in primary care, before a diagnosis is made, when they are referred for specialist care and after a diagnosis.'
Elizabeth Wade says that increasing choice has ‘been part of Government policy from the outset': ‘I don't think it necessarily results in fragmentation. I don't think choice and cohesion of services are mutually exclusive.'
Scott McKenzie, however, is unsure choice can be extended without fragmentation: ‘The question I had here, was would every CCG have to have a separate policy for extending patient choice? I can't see how you could do this without fragmenting services.'
But Don Redding says the Government has been committed to patient choice from the start: ‘At this point we're watching to see what comes next. In social care there seems to have been a bit of a retrenchment going on, the menu of choices has tended to reduce over time, the suggestion being that the professionals are clawing back a bit of power. We've never been in doubt that extending choice is the right thing to do, but it's going to take a lot of extra thought.
8 The mandate says every patient with a long-term condition should have a care plan. Is this possible?
The mandate reveals much about the Government's aspirations for its reforms – including ambitious use of care plans.
It says: ‘Care plans – encompassing healthcare, social care and preventive care – should be available to all with long-term health needs. They should be developed and agreed with a named professional, to ensure people feel in control of their own care, know how to manage their condition and who they can go to when they need support.
Elizabeth Wade says there is a lot of work to do on this: ‘A lot of very detailed work still remains to be done, including working out how to achieve this. I wouldn't want to see that detail in the mandate, necessarily.'
Don Redding adds: ‘This aspiration goes back to New Labour days. All our member charities think care plans are essential. It's closely related for us to the objective of integrated care, so we welcome that – very much so. A consensus has been forming.'
9 Can CCGs deliver on the mandate's pledge to greatly extend personal health budgets?
This is another high-level aspiration enshrined in the mandate.
The mandate says the Government wants commissioners across the country to offer personal health budgets ‘wherever appropriate', including the option of direct payments, and joint budgets across healthcare, social care and other services.
It adds that ‘over time' anyone asking for a personal health budget would benefit from one. And from April 2014, people receiving NHS Continuing Healthcare or parents of children with special educational needs or disabilities will be able to ask for a personal budget based on a single assessment across healthcare, social care and education.
Elizabeth Wade says: ‘Moving towards personal budgets may not increase the amount you're spending.
I don't think this inflates the costs.'
In London alone, continuing care costs the NHS £310m a year, making this an ambitious part of the mandate. Personal budgets have generated headlines, with reports of the cash being spent on theatre tickets, manicures and complementary therapies.
And GP commissioners have already raised concerns that adoption of personal health budgets is happening while pilots are ongoing.
10 Does the mandate water down the role of clinical senates?
The mandate adds a little clarity to the role of the controversial clinical senates, and says: ‘The [NHS Commissioning Board] will host "clinical senates" and "clinical networks" as sources of advice, but CCGs should be free to make their own arrangements collectively or individually.'
Dr Richard Vautrey says: ‘It sounds as if CCGs will have the degree of flexibility and power they wanted to make the decisions. There had been worries that the Department of Health would be more specific and bow to pressure on this. On senates, the wording certainly suggests those worries were unfounded.'
And with CCGs having to help fund the running costs of clinical senates, there is the possibility some will choose to enhance their own decision-making forums rather than engage with a new external body.
Our NHS care objectives – a draft mandate to the NHS Commissioning Board was published by the Department of Health last month for consultation. Comments and views are invited by 26 September 2012. Click here to read the full draft mandate.
Alisdair Stirling is a freelance journalist
