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We turn now to the mandate and I am going to advice Bill McCarthy to introduce the paper
being built. Introduction
Thank, Chairman. A very important piece for the Board and it is a discussion that we have
been progressing over the past months and we have discussed it here before. The mandate
to remind us is the agreement between the Department of Health and the NHS Commissioning
Board which will set out the government's objectives for the NHS in England. Getting
it right and getting it set with the right tone, the right framework will be very important
not just for us but the whole NHS. Focus
The lens through which we have been looking at the mandate consistently as a Board is,
first of all, this needs to be about our patients. This needs to be about the ambitions that
patients have to prove their outcomes and it needs to be about the NHS's commitment
to the NHS constitution standards which give the reassurance to patients about the services
that they receive. That is, I think, our preeminent perspective on the mandate and it has been
throughout. Secondly, I think picking up on the item that Barbara has just let us through,
is the importance of making sure there is enough headroom in the way the mandate sets
out our objectives to ensure that that real clinical leadership, the innovation, the creativity,
the capability that we are investing so much time in supporting has got the headroom to
make the right decisions with the right relationships locally to bring about the understanding services
that we all want. The right focus on outcomes to patients and
the right degree of freedom for clinical leadership locally is the perspective we have taken so
far and I suggest the Board the perspective that you want us to use when we are commenting
on the mandate over the next period. Emphasis
It is an important point now because the department have just put out draft mandate for consultation.
Now, we are being formally consulted. The period of consultation goes on until the end
of September. I would have thought we all want to express a view well before the end
of that period and here is a chance today for the Board to give us an initial steer
on the work you would like us to progress over the next month in putting together a
really clear and robust response to the consultation period which has those principles around the
patient and clinical leadership at its heart. I will stop for a discussion, Chairman.
Malcolm Grant: Thank you, Bill. I think it is impossible to underestimate the sheer importance
of this as a document. We are entering into an era which is unique not only in terms of
the development of the NHS in England but internationally. It is a new model of healthcare.
We are moving into an era in which an independent Board has been established and its competencies
have actually been defined in statute. That is the first.
Secondly, the relationship between the political accountability to the parliament for the NHS
and its day-to-day operation is quite clearly separated in the statute. The Secretary of
State retains overall accountability to parliament for the performance of a healthcare system
in England, but we, the Board have concurrent responsibility with the health secretary for
the promotion of a comprehensive healthcare system in England. To have that responsibility
in turn necessitates the measure of autonomy that will make it work effectively. That autonomy
is established first of all by the terms of the legislation itself and the regulations
that we made under the regulation, secondly, and absolutely critically, by the NHS constitution.
We, I think, are the operational guardians of the NHS constitution. I do not think I
can possibly put it higher than that. That is where the responsibility lies.
Then, thirdly, the mandate, the Secretary of State loses the power to give directions
in respect of the day-to-day operation of the National Health Service in England. Our
responsibility is for that operational command. However, the Secretary of State is entitled
and indeed obliged by the legislation to set the high-level objectives, the outcomes. The
essence of the approach to this is to try to balance how we can in this country maintain
a political responsibility for an excellent healthcare system through the mandate specifying
for us what our outcomes must be and at the same time empowering us to take a process
choices that may not be any longer prescribed centrally which allow us to veer between different
ways of doing things. However, not just us, we of course have direct responsibility for
direct commissioning for primary care and for specialist care but the bulk of commissioning
is through the CCGs. Through the CCGs whom we in that last session have undertaken to
develop a partnership with and enabling a relationship with require as we do as much
autonomy as is consistent with proper conduct but with the delivery of the highest possible
outcomes for the benefit of patients and carers and other stakeholders in the health service.
The role of the mandate, to my mind, is one of being very tight on outcomes but being
relatively loose on process to allow those choices to be made which involve inevitably
trial and error, the taking of risk, the making of mistakes. It is impossible, I think, under
a liberated NHS where resources are aligned with clinical judgment through CCGs to have
a tight central national top-down prescription of process. So those I would commend to the
Board are the principles which we should be thinking our way through as we consider the
appropriate response to the draft mandate that we have have. I would say to the Board
that there are areas of this which I think completely fit with the government's objective
of liberating the NHS on being clear about the outcomes in the five key domains.
There are other parts of it where we might find that the mandate goes further than we
would have wished and I would hope that we will over the coming weeks have an opportunity
to review those parts and to have constructive discussions with government and with other
stakeholders as to how we can ensure that we do deliver the government’s overriding
objective for the mandate which is a liberated NHS and greater clinical leadership aligned
with resources that can advance the health outcomes for the people of England. Let me
take observations on the paper and then on the draft mandate that our colleagues have
seen. Ciarán? Ciarán Devane: Two things which pleasantly
surprised me. One was the mental health side of this. I think the recognition that people
with mental health difficulty also have poorer physical health and people with physical health
issues can have their mental health impacted. I think that was good.
The other one which I think is important is maintaining this line around not putting all
our favourite hobby horses in, speaking of somebody who has favourite hobby horses, and
I think if we are going to achieve some of the things we have to achieve, what we want
to do in cancer or diabetes or Alzheimer's or anything else gets implemented really needs
to happen through the relationship between the commissioning Board and the CCG. I think
it is very encouraging not to see that in and I think part of our response back needs
to be to support that line because if we do all put our hobby horses in we will only get
some of them in anyway. Then we will all have to go delivering this particular thing on
cancer and that particular thing on Alzheimer’s is one also. I think whatever we need to do
in our response to get that across, the importance of that and the risks it creates to the whole
system if actually we have a secondary outcome framework lying on top of an existing outcome
framework; I think that would be very, very difficult.
Malcolm Grant: Okay. Victor? Victor Adebowale: I think the key thing for
me is the inequalities because that drives a whole lot of measures and outcomes that
can be literally very visible to those patients receiving health and social care. I welcome
it and looking at it what worries me a little bit is there is an awful lot in these documents
that really are not about the mandate, like choice for instance. I mean, there is a lot
of stuff in there and I think we should welcome the one big thing that is in there which is
the thing about inequalities, reversing the inverse care law. I think we should question
some of the stuff about choice. The mandate and the choice document are all lumped in
the same thing and I think that is a bit confusing. I know there has been discussion about this
but I wonder how it can coordinate or find out how the CCGs are going to respond to this
because if they come out with a different response to us or a vastly different response
to us, then I think that it causes problems. David Nicholson: I thought we started off
with a really good position which is, we want to steadily improve or in some places significantly
improve outcomes for all of our patients, not just some of them. You want to continue
to develop and improve the relationship between the NHS and the NHS constitution and how it
impacts all these patients and you want to do that at the same time as providing universal
healthcare for free at the point of use, tax-funded. You start with that and then you add to that
the philosophy of liberation of taking decisions very close to patients and patients themselves
taking more decisions about themselves. You want all of that to go and that takes about
four minutes to say. However, when people try and write it down, it is something that
becomes quite difficult and I think that is where we need to help the department think
this through. It seems to be potentially this is an enormously powerful communication document
for both the government and ourselves to set out to people in a way that they can understand
what they can expect from all the hard-earned taxes that they pay for the NHS. I think there
is something here that we could work on but I think it is somewhere away from where we
needed it to be. The second thing I would say about it is that
where you have what in old terms might be described as a process-driven targets, we
need to be really clear about why and how and what for and what the benefit of all of
that is. Just listing things down with no justification is quite a difficult thing to
communicate and work with people from. I think we can work on this document. Work with the
department and get it into a much better place for patients and of course for the system
that we want to run. Malcolm Grant: Thank you. Naguib?
Naguib Kheraj: I am glad to hear your view on that, David, because I think that was my
reaction in reading it is as a non-NHS expert person, you get lost in the document because
it has become quite dense and complex and I think if it is a document that should be
capable of being read by members of the public who are interested to understand the mandate,
it needs to be shorter and more simple and more to the point. I think what you just described
is exactly the direction I think you should go in.
Malcolm Grant: Moira? Moira Gibb: Yes. I could not agree more really.
It seemed to me that we have heard about the stresses and strains that people are undergoing
to change the structure to allow this liberation to deliver better for patients. However, this
needs to signal that they believe in that culture change and that opportunity whereas
actually the message it is saying is, ‘Do everything that you have done before in the
same way and here are more things that we want you to do’. So I think it has to signal
a change. We all do have our particular pet subjects that we want to see there. However,
I think we do, as Ciarán says have to restrain that desire in the interest of that overall
message that somehow rather the public will get finally what this is actually intended
to achieve. Malcolm Grant: Jim?
Jim Easton: A slightly presentational point which is the danger when you read it that
it feels like a list of important incremental objectives one of which by the way is continuing
to deliver efficiency savings for the coming period. The sum total of all of those is a
transformational change in care. So, it is a document that will signal for us and the
wider service significant process of I think positive, a quite profound change in implementing
these things. It will not come about simply by incrementally addressing each of those
into it. David Nicholson: I am just thinking of the
word. We keep on hearing this word change. I really just want to echo Jim's point: if
this document does not effectively provide the manifesto for a very, very positive but
real disruption in a service to patients then we have just lost a massive historic opportunity.
I mean, what this should be is underpinning a programme that will deliver vast and real
transformation, is the word, in customer services for patients. I absolutely agree, this just
does not capture that at the moment and I think we can, as David was saying, I really
hope we can help the department express this in a much more accessible and real way for
people who are engaged in the NHS and indeed for the staff of the NHS as well.
Malcolm Grant: Can I say I am mentally heartened by the comments we have had around the table
because I think there is a great seriousness of purpose here. However, just to emphasise
again, it is unique. Not only in healthcare systems I think it is unique in terms of being
the first time in 64 years that the British government have been required to spell out
or impose upon themselves the requirement of spelling out what their expectations are
of the NHS and not just for one year, but five years and for 10 years. Given that it
is so unique an opportunity, it would be immensely powerful as a document were it to seize the
transformational agenda and to understand that the whole point of these quite difficult
reforms has been to transform the quality of healthcare for patients in England.
To include patients as part of this, I think, is immensely important. In other words, a
document that is immediately accessible; a document that sets up quite simply what the
high-level objectives are. I think we could work very closely with the department to assist
them in coming up with something which could be not more of the same but something, dare
I say, quite inspirational and transformational. May we work with your approval on a response
in close working with the department to see where I have to say I think there was quite
a close convergence of view and what we are thinking about I think is the approach and
the means of expression, given that this is not just a slight turning of course but a
quite radical change in direction. Thank you very much for that response.
We turn now to item six which is the progress report on partnership arrangements.