Commissioning board mandate must set out a clear vision

The mandate received little attention during the parliamentary furore over the act, but it is an essential part of the new system. It is designed to be the main mechanism through which the government expresses its will - and in theory therefore the will of the people - on what the NHS should prioritise. The commissioning board will translate the mandate’s priorities into guidance for clinical commissioning groups.

Although the government has the right to issue a new mandate every year, the intention is for it to cover the three-year public spending cycle with annual refreshes produced if necessary. The first mandate will be something of a halfway house, arriving one year into the current cycle. Having published the mandate, the government is meant to back off and let the new NHS run itself.

National Voices, the umbrella body for health and social care charities, argues the mandate should echo the BBC charter in highlighting clear “purposes”. It rejects the “alienating” idea of making indicators related to the NHS outcomes framework its “centrepiece”. However, a “citizens’ jury” put together by consultants PWC seemed to indicate a degree of public comfort with the use of framework indicators.

HSJ would encourage the government to avoid attempting to please every interest group by producing a “long tail” of aspirations alongside the big themes, which should dominate. It should also avoid being prescriptive in what models of care should be adopted - that is a matter for the board, CCGs and their partners.

With the consultation not yet under way, it is impossible to determine exactly what those big themes might be. But HSJ would suggest that issues likely to be highlighted in the impending Francis report on failings at Mid Staffordshire Foundation Trust, such as dignity in care, are likely to be to the fore. The prime minister’s recent push on dementia suggests the mandate will also set out aspirations in that area too. Cancer tsar Sir Mike Richards has already indicated he expects the mandate to embrace his ambition of reducing annual deaths from the disease by 5,000.

We can also expect the mandate to gel with wider government objectives - for example, increasing the transparency of public service performance.

However, uppermost in the minds of many CCG leaders will be how the ambitions of the mandate are balanced with the need to make commissioning groups effective public bodies.

The vast majority of CCGs look likely to be told in the autumn they will be authorised to take over budgets from next year. However, they should be wary about what comes next. Even before their statutory birth in April 2013, they will have to sign “development agreements” with the commissioning board, in which the board will not be shy about setting priorities for local services - no doubt, heavily influenced by the contents of the mandate.

Detail is thin about how the authorisation framework will evolve into an assurance system for CCGs covering performance, finance and quality. But the new regime may prove just as tough and directive as the now defunct operating framework. As one experienced NHS observer commented: “Authorisation’s the easy bit. It’s the years of agonising scrutiny thereafter that count.”

So creating and translating the first mandate will be a tricky balancing act between setting out a bold vision for improvements in care quality, while recognising the system put in place to realise that vision is still - in large parts - being constructed, tested and, inevitably, reconfigured.