Health Service Focus

The Mandate to the NHS Commissioning Board

The NHS Commissioning Board received its mandate from health secretary Jeremy Hunt in November, setting out exactly what it must achieve from April 2013 with the majority of the NHS budget at its disposal. NHE spoke to Claire Mundle of the policy team at the King’s Fund about the NHS Mandate and what it means for the Commissioning Board and individual clinical commissioning groups (CCGs).

The NHS Mandate, covering the next two years, outlines what patients in England can expect from GPs, hospitals and the wider NHS.

It focuses on helping people live longer, managing ongoing physical and mental health conditions, helping patients recover from periods of injury or ill-health, making sure people experience better care, and providing safe care. Improving early diagnosis will be prioritised, as will reducing premature death from the biggest killers, improving care for new mothers and better help for patients with dementia (see box out).

Mental and physical health should be treated as equal priorities, and local NHS organisations should publish results for all their major services by 2015.

Also under the Mandate, the Friends and Family patient feedback test will be rolled out from April, and by 2015 everyone will be able to book GP appointments, order repeat prescriptions and talk to their practice online.

The NHS Commissioning Board will be given a budget of £95bn for 2013/14 to deliver these objectives, and, importantly, “to allow space for local innovation at the front line, both the Government and the NHS Commissioning Board will seek to ensure that local NHS organisations are held to account through outcome rather than process objectives,” as the Mandate document puts it.

Health secretary Jeremy Hunt said: “By focusing on what matters to patients, and giving doctors and other health professionals the freedom to deliver, we will make sure the NHS stays relevant to our needs and ensure this country’s proudest creation remains its finest.”

A sound approach

The King’s Fund’s Claire Mundle told NHE that the overall approach represented by the Mandate, handing over the budget and power to the NCB to achieve aims prescribed by the health secretary, with accountability based on outcomes rather than processes, was “sound… given that the whole system has shifted towards measurement of success and performance through outcomes”.

She continued: “The Mandate is well aligned with the NHS Outcomes Framework, so in the sense of having an overall document that links in with the other ‘measurement architecture’, it seems sensible.

“It’s set alongside a number of other documents that will also be used to hold the Commissioning Board to account, such as the memorandum of understanding that there will be between the DH and NCB, and the NCB business plan which will set out the more operational details of how they conduct their business.

“At the local level, CCGs will be reporting on what they’re achieving and then the Commissioning Board will be assessing them on their achievements and taking an aggregate view, having that information from all of the CCGs and then extrapolating that and measuring against these key outcomes set at the national level.

“That will be the Commissioning Board’s job, to then report at the high level, overall, is there improvement in x area.”

Clearly the fact the Mandate exists, alongside the Outcomes Frameworks, does not mean that other key documents and guidelines just disappear – although some are being slowly retired.

COF, the Commissioning Outcomes Framework – now the CCG Outcomes Indicator Set – will be the NCB’s own way of holding CCGs to account and for them to provide information to the public on the services they commission and health outcomes, and the CQUIN payment frameworks will stay in the system.

But Mundle said: “Things like the National Service Frameworks are slowly becoming redundant (some have already); once their lifespans are over, I think the idea is that they don’t then get replaced or reiterated again.”

Integrated care – the biggest challenge?

The King’s Fund is basically happy with the fi ve priorities set out in the Mandate, and welcomed the engagement shown by the Department of Health in listening to the responses to the consultation on the draft version.

A particularly welcome change, she said, was the contextualisation of mental health problems and the specifi c link made with physical health problems, and the strengthened requirements about integrated care.

Asked for her view on how well-suited the new NHS structure is to actually delivering something resembling integrated care, Mundle told us: “I think there is potential there for them to be able to deliver, but it will depend on how the CCGs engage with their local partners and the hospitals – how they’re able to mediate those relationships – but also how they work alongside other CCGs.

“Looking at monitoring, pricing and – with the NCB – how the payment system will work, there’s potential for CCGs to group together and to act in ‘federation-style’ bodies to commission across larger areas, to commission at scale. That would be a move in the right direction towards a more integrated system.

“But a lot is unclear. We’ve been focusing a lot on economic regulation at the moment, and it’s not yet clear to us the relationship that Monitor will have with commissioners and how clear commissioners are on the exact rules about how competition applies, and how they need to take account of expectations over choice and how to apply competition.

“That could, in reality, play a big part in how the provider landscape starts to get shaped up, based on how commissioners interpret the various guidance they’ve been given.

“As much as there can be informational integration, there is also all this information coming out about Any Qualifi ed Provider in a more competitive market – the requirements on licensed providers to provide information to Monitor.

“All of that alongside each other does present quite a complex picture.”

The NHS and economic recovery

The Coalition Government’s own wider economic and employment strategy also features in the Mandate, receiving a number of mentions, such as: “These priorities refl ect the Government’s absolute commitment to high quality healthcare for all, while highlighting the important additional role the NHS can play in supporting economic recovery.”

It adds: “[The NHS] contributes to the growth of the economy…by addressing the health needs of the population, thereby enabling more people to be economically active.”

The section on boosting research funded by both commercial and non-commercial organisations mentions both improved patient outcomes but also economic growth as key drivers, while one of the fi ve areas in which the Government is “expecting particular progress to be made” is in “furthering economic growth, including supporting people with health conditions to remain in or find work.”

This is a tricky area, Mundle suggested, and pulls in some of the wider determinants of health. “There is a big role there, obviously, for local authorities and public health teams who are at the moment a step behind the NHS in establishing themselves, and are sorting out their relationships to CCGs as well.

“The fact that there were three outcomes frameworks, suggests the Government was trying to say, ‘this is NHS territory’, but it is difficult to decide what is an NHS-determined outcome and what isn’t, and where those barriers could really lie.”

Mundle concluded: “Obviously we put a lot of energy into infl uencing the way the reforms have been shaped and the final content of the Act, so it’s in our interests to keep an eye on the new system and commissioning structure.” 

Objectives in the NHS Mandate

• Preventing ill-health, and providing better early diagnosis and treatment of conditions such as cancer and heart disease, so that more of us can enjoy the prospect of a long and healthy old age;
• Managing ongoing physical and mental health conditions such as dementia, diabetes and depression – so that we, our families and Objectives in the NHS Mandate
• Preventing ill-health, and providing better
early diagnosis and treatment of conditions
such as cancer and heart disease, so that
more of us can enjoy the prospect of a long
and healthy old age;
• Managing ongoing physical and mental
health conditions such as dementia,
diabetes and depression – so that we, our
families and our carers can experience a
better quality of life; and so that care feels
much more joined up, right across GP
surgeries, district nurses and midwives,
care homes and hospitals;
• Helping us recover from episodes of ill
health such as stroke or following injury;
• Making sure we experience better care,
not just better treatment, so that we can
expect to be treated with compassion,
dignity and respect;
• Providing safe care – so that we are
treated in a clean and safe environment
and have a lower risk of the NHS giving us
infections, blood clots or bed sores.

These areas correspond to the five parts of
the NHS Outcomes Framework, which are
listed in this document and will be used to
measure progress.

Five areas where ‘particular progress’ is to
be made:

(i) improving standards of care and not just
treatment, especially for older people and at
the end of people’s lives;
(ii) the diagnosis, treatment and care of
people with dementia;
(iii) supporting people with multiple longterm
physical and mental health conditions,
particularly by embracing opportunities
created by technology, and delivering a
service that values mental and physical
health equally;
(iv) preventing premature deaths from the
biggest killers;
(v) furthering economic growth, including
supporting people with health conditions to
remain in or find work.

(Source: ‘The Mandate: A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015’. Contains public sector information licensed under the Open Government Licence v1.0.)

Translating decentralisation into practice

Responding to the publication of the NHS Commissioning Board Mandate, Anna Dixon, Director of Policy at The King’s Fund, said: “Getting the Mandate right is important to ensure that the NHS Commissioning Board is effectively accountable for its work. Ministers have listened to the concerns that we and others raised about the need for a clearer and more focused set of objectives - today’s document is much better than the one originally consulted on.”

She added: “The Mandate includes a strong focus on decentralisation and freeing up local organisations to innovate. The real test will be how this translates into practice, especially given the tight fi nancial climate and need to maintain fi nancial control.”

NHS Confederation chief executive Mike Farrar said: “It was really important that the Government avoided stuffi ng the mandate to the gunnels with detailed targets for every condition under the sun. While that might have looked superfi cially attractive, it would have meant more top-down prescription and less innovation and responsiveness to local needs.

“The real challenge for the Government now is to stay true to its word and use the mandate to give the NHS stability, rather than use it as a tool to reset priorities on a regular basis."