Thursday, 15 November 2012

NHS mandate dumps the targets to focus on improvements

NHS mandate dumps the targets to focus on improvements: Final document sets clear objectives, which reflect priorities managers are already pursuing, but fails on one crucial test
The first NHS mandate, which sets out the government's expectations of the health service to the NHS Commissioning Board, hardly represents freedom for managers and clinicians but it at least has the feel of moving to an open prison.

After several months of consultation, the final document identifying the priorities for 2013-15 wisely dumps the targets proposed by Andrew Lansley in favour of a focus on improvement. This is more than mere semantics.
The health secretary, Jeremy Hunt, realised that piling more targets on to the NHS would have all but compelled the commissioning board to micromanage the clinical commissioning groups, crushing one of the central objectives of the government's reforms. This way there is at least the hope of more local autonomy.
Yet there is a weary familiarity in the commitment to end the "culture of command and control", and the promise of "a new style of leadership from ministers and from the board which is about empowering individuals and organisations at the front line". The board chair, Malcolm Grant, must be unsparing in his insistence that the chief executive, Sir David Nicholson, and his team make this happen.
The mandate fails on one key test – robust support for the need to reconfigure some services to raise quality. It sets out four obvious criteria for service changes, such as public engagement and a clear clinical evidence base, but does not spell out the importance of focusing some services on centres of excellence to raise quality and reduce avoidable deaths – one of the mandate's principle objectives. Yet again a health secretary has not had the courage to provide leadership on this crucial issue, making the work of local commissioners tougher.
Strong themes in the document include better integration of care, improving the quality of life of patients with long term conditions and caring for those with dementia. Improving the patient experience is a prominent aim, articulated in the government's obsession with the "friends and family" test: asking patients and staff whether they would recommend the service to others. It is a poor performance measure, and is particularly prone to under-reporting issues such as lack of dignity in the care of older people or the extent to which patients are engaged in decisions about their treatment.
Beyond one fleeting reference there is not a single use in the 28-page document of the word "competition". But it is there of course, dressed in the clothing of patient choice. The mandate instructs the board to lead "major improvements in how the NHS undertakes procurement, so that it is more open and fair, and allows providers of all sizes and from all sectors to contribute, supporting innovation and the interests of patients".
There are no qualifying clauses about using competition where it is clinically appropriate, or the need to balance the use of competition with judgments about the role of a particular service in the wider health economy. The board's interpretation of this bald instruction will have major consequences for how the NHS develops in the next few years, and whether competition is deployed as a useful lever for improvement or becomes an ideological objective for its own sake.
The mandate expresses a determination to drag GP services into the 21st century. It wants everyone to be able to book a GP appointment, get a repeat prescription and talk to their GP online. Having recently been delayed at my GP for want of a sheet of carbon paper it is reasonable to speculate that many surgeries won't be providing this sort of convenient and responsive service by 2015.
Overall the mandate sets clear objectives, which broadly reflect the priorities that managers and clinicians are already pursuing in the interests of patients. It avoids the error of imposing new targets (although those for A&E waits and referral-to-treatment times remain) and gives local commissioners and providers some space to shape their services. Now the commissioning board has to explain how it is going to fulfil the promise of "a new style of leadership". Guardian Professional. 

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