It's said to 'liberate' the NHS from top-down interference, but can the mandate avoid conflict between local and national desires?
The publication of the government's draft mandate for the NHS is big news for managers and clinicians. It sets out the priorities for the NHS Commissioning Board for the next two years and beyond. What is in the final version and how the board delivers it will have a profound impact on the culture and practice of the new NHS.
Until now the key NHS document has been the annual operating framework, the embodiment of the command and control culture which spells out the targets, priorities and rules NHS bodies must follow. The mandate is intended to be more long-term than the operating framework has been, promising stability rather than lurching from priority to priority as the political winds change.
The first mandate, to be published following the end of consultations in September, will run from 2013 to 2015, while setting "ambitions" for improving outcomes over five to 10 years. It will, however, be revised annually. Will ministers resist the temptation to squeeze in one more target?
The mandate is intended to reflect the NHS outcomes framework, first published in 2010 to set indicators for healthcare performance. The board will be expected to demonstrate progress against each of the framework's dozens of indicators.
In inviting responses to the draft mandate, the first question being asked is the right one: will the mandate drive a culture which puts patients at the heart of everything the NHS does? That mirror must be constantly held up to the mandate itself, and the way the commissioning board implements it. Managers and commissioners should resist anything violating that principle.
The mandate claims "the NHS is being liberated from day-to-day top-down interference in its operational management". Commissioners might want to pin this "free at last" commitment to their wall, and point it out to visitors from the board's local and regional outposts whenever they stray over the line.
But there is one area where the presumption of autonomy does not apply – service reconfigurations. The board is to take a leading role in "supporting" clusters of clinical commissioning groups in handling major changes. While this is against the spirit of local control, the alternative is paralysis. The demise of strategic health authorities means that unless the board intervenes there is no organisation with the big picture view and organisational clout to make change happen. Yet the opportunities for conflict between local desires and national and regional imperatives will be considerable.
This issue is further complicated by local government's role. The speech by commissioning board chief executive Sir David Nicholson to last month's Local Government Association annual conference was poorly received; the board clearly has some distance to go in understanding the role of local politics in the new NHS.
The health secretary, Andrew Lansley, should be applauded for stressing, in the heart of the mandate, the importance of improving the health and healthcare of NHS staff. Stressed, unsupported staff will not deliver high quality care. As Elisabeth Buggins, chair of Birmingham Women's Foundation Trust, has argued: if we demand that staff expend emotional energy in providing patient-centred care, the staff themselves need support.
Plaudits are also due for the prominence given to mental health, which continues its journey towards the centre of the healthcare system. The draft mandate points out it is the single largest cause of disability, and declares it to be as important as physical health.
But the mandate risks setting some precise yet difficult to measure targets. Objective 5 is: "Improve patient safety, reducing Quality Adjusted Life Years lost to NHS patients … through avoidable harm by X% by 2015; X% by 2018; and X% by 2023."
While the intention is laudable, it could generate industrial scale monitoring to secure data of questionable robustness. Managers need to work through what each of the objectives would mean for their clinicians and managers. If there are unintended consequences, now is the time to point them out. Guardian Professional.