The new NHS Commissioning Board will oversee the way that over £80 billion of taxpayers’ money is spent to secure NHS services for the people of England.
Under the Health and Social Care Act 2012, the Government must set objectives for the Board in a “mandate”, which must be updated every year, following consultation. In order to provide stability for the NHS, the mandate can only be changed mid-year in limited circumstances.
The mandate is one of the most important ways for the Government to set objectives for the Board, but it is just one part of a broader relationship through which the Secretary of State will hold the Board to account for its performance. Ministers will continue to be accountable overall for the health service as a whole.
Comments on
Department of Health
Developing our NHS care objectives:
A consultation on the draft mandate to the NHS Commissioning Board
The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the Department of Health’s consultation on the draft mandate to the NHS Commissioning Board.
The College has the following comments on specific consultation questions:
1. Will the mandate drive a culture which puts patients at the heart of everything the NHS does?
The College has mixed views on this question. The mandate certainly makes an attempt to put the patient at the centre. However, there are competing demands within the mandate in the finance and effective commissioning sections which may give rise to conflict.
There is a need to ensure consistency, and assuming this document is read by patients and compared with the NHS constitution, which is the dominant document? It would be helpful if this could be clarified.
In general this will increase the burden of reporting for organisations and while there is discussion about outcomes in the document, many of the measures mentioned involve process and this is not particularly transparent for patients or others attempting to analyse performance.
Whether a patient-driven culture will emerge partially depends on the regulatory framework set but, crucially, a step change in culture which requires training and education, and engagement in a health care institution of all levels of staff will be required.
2. Do you agree with the overall approach to the draft mandate and the way the mandate is structured?
Generally, yes. However, the mandate is a broad brush approach to a complex and diverse service.
There is also no mention of some issues which warrant attention: for example, the ability to provide education and experience to trainee doctors, nurses and other health professionals as well as on-going training is vital in maintaining a high quality service.
There is little mention of non-nursing and non-medical staff, who should also be included in the mandate.
3. Are the objectives right? Could they be simplified and/or reduced in number; are there objectives missing? Do they reflect the over-arching goals of NHS commissioning?
Possibly. The objectives are clear but are overly simplistic. The setting of such high level standards means that it will feel difficult relating these to healthcare on the ground, and difficult showing real progress.
There is also a rather incongruent mix of the subjective and objective outcomes and some could be subsumed into other objectives – for example, objective 11 is overarching and could be part of many other objectives.
4. What is the best way of assessing progress against the mandate, and how can other people or organisations best contribute to this?
The mandate is attempting to measure a number of changes in a complex system, and therefore assessment against recognised markers and benchmarking regionally and nationally will be important.
Many of the objectives set out target (or potential target) percentage improvements in different domains. However, many clinicians have major concerns over the current quality of information and data collected which will be used to measure the NHS against these targets. For example, clinical coding in NHS Trusts is highly variable and currently it is common to get an enquiry from Dr Foster registering an outlier set of data which is due to coding issues -which takes much time and manpower to discover and put right. Additionally, for example, many Trusts have been tasked with a 50% reduction in MRSA bacteraemia rate – which is laudable – however, what happens if the Trust has only had two cases in 6 months? Many will feel that this mandate will over-complicate the situation, particularly when even more bodies are involved in ensuring an improvement in outcomes.
It is also important to recognise that the collection of data will fall onto frontline staff and their time for clinical matters will be reduced, which the College feels should be examined further.
5. Do you have views now about how the mandate should develop in future years?
Development of the mandate should be focussed on its effectiveness for patients.
The system needs to be responsive to change after trial periods (of which there appear to have been too few) and real life experience. This would enable maximisation of what works successfully and a re-think when necessary - for example, if there are problems with data collection.
Professional societies and bodies such as the medical Royal Colleges could be usefully engaged in this process, as many have a good understanding of current deficiencies and where there should be targets for improvement.
6. Do you agree that the mandate should be based around the NHS Outcomes Framework, and therefore avoid setting separate objectives for individual clinical conditions?
Generally, yes. However, there is a danger that generic comments are simply too vague to be of value.
7. Is this the right way to set objectives for improving outcomes and tackling inequalities?
Yes. While it is right to improve outcomes, it has to be recognised that in some conditions there is no reliable outcome data available. For example, the document outlines the possible use of the modified Rankin Scale for stroke outcomes which is a fairly crude outcome measure and does not factor into it the psychological consequences of the disease. Other examples quoted in the document talk about recovery from fragility fractures and helping older people recover their independence. While both objectives again are laudable, older people who fall and sustain a fracture often have multiple co-morbid conditions and require a holistic assessment to improve outcomes. This may require time in a hospital setting which may conflict with another indicator which states “emergency admissions for acute conditions that should not usually require hospital admission”.
8. How could this approach develop in future mandates?
The process is likely to become more sophisticated as data improves and useful indicators are developed. Additionally, professional societies and the medical Royal Colleges are in a position to provide assistance in developing the approach taken in future mandates.
While the mandate will be developed every year to reflect the changing scenario, the College is concerned that NHS services may be disrupted in the future if there is a change in approach to the mandate as a result of a change in government.
9. Is this the right way for the mandate to support shared decision-making, integrated care and support for carers?
Yes. The mandate is right to ensure that services become more joined up. Carers play an important part in the NHS, and they are not often recognised for their vital contribution. Therefore the mandate goes some way to readdressing their role. However, again this is tackled at a very high level and success will only come if the changes are embedded locally.
10. Do you support the idea of publishing a “choice framework” for patients alongside the mandate?
The College has mixed views on a “choice framework” and concerns that it could be undeliverable.
Choice depends upon accurate information and access to this information. Older people, for example, often have fewer IT skills than younger patients, which may result in them not having all the information they need to make a decision. If a hospital provides a service, patients have a choice of which consultant they see for that condition. This may lead to an imbalance in referrals, as one consultant may get disproportionately higher referrals compared to his or her colleagues.
A "choice framework" needs to be relevant to all parts of the country and it should be recognised that a high level of patient choice may only be relevant and available to areas of high density population.
11. Does the draft mandate properly reflect the role of the NHS in supporting broader social and economic objectives?
This is again a high level position statement. The challenge will be in the ability to translate this concept into practice.
The College does not feel that inclusion of crime prevention strategies in the mandate is helpful. The majority of social and other problems which lead to crime are not health care matters and would be an additional burden on the NHS.
12. Should the mandate include objectives about how the Board implements reforms and establishes the new commissioning system?
The College has mixed views on the practicalities of this question; however there is a strong opinion that the system used must be clear, transparent and accountable.