Hunt loosens the reins of power

The caveats first. Much will depend on how the relationship between the Department of Health and the commissioning board develops – the NHS mandate creates wriggle room for government by stating it is “not exhaustive”. As ever, there is also likely to be some devil in the details which accompany the mandate, or are added over time into the Outcomes Framework’s already bloated “technical index”.

‘The impact of the mandate will largely be felt through its interpretation by the commissioning board’

Finally, of course, the impact of the mandate will largely be felt through its interpretation by the commissioning board. The board’s guidance to CCGs based on the mandate objectives will be a second hurdle that devolution of power has to jump.

It is also significant that while the mandate makes specific reference to the commissioning board not being the “manager” of NHS health economies, it does refer to it as the “convener”, responsible for bringing “NHS organisations together across larger geographical areas.”

But, broadly, the mandate is a “lighter” document that some in the NHS feared. It is, in one of Andrew Lansley’s favourite terms, fairly “permissive”. It also sets out the government’s aspirations until the end of this parliament – the maximum timescale possible – giving the board some scope for longer term planning.

Change of emphasis

There are some subtle changes of emphasis. In June, Andrew Lansley told HSJ that the final mandate “will have some specific ambitions where there is some trend data and a clear trajectory that we want to meet.” Now, no exact “levels of ambition” will be set, but instead “measurable improvement” tracked, sometimes against international comparators. 

The government argue this is just as demanding and the change has been made in the name of giving more freedom to clinical commissioning groups, but there is no doubt it also provides fewer hostages to fortune for the government.

In contrast there is more noise on the quality of care (as opposed to treatment) - an issue that Mr Hunt has already said he wants greater focus on. As expected the friends and family test is to the fore, complete with likely added financial incentives, and the government’s ambition for it to become a proxy for overall NHS performance is clear. The ambitious expectation that patients will be able to access GP records and book appointments online by 2015 shows a government determined to transform the “experience” of healthcare.

This thread is picked in the board’s responsibility to support the creation of a “fair playing field” for “the best providers whether from the public, private, independent or voluntary sectors”. But integration and joint working gets an even stronger backing. The mandate declares that working together with public sector partners is “a core part of what the NHS does and not an optional extra” and confirms an integration measure is under development.

Theme of transparency

Perhaps the most interesting theme running through the mandate is “transparency”. Ministers are required to be “transparent about their objectives”; a “revolution in transparency” will ensure “the NHS leads the world in the availability of information about the quality of services”; the board must have a “transparent system” for intervening in the affairs of clinical commissioning groups; “transparency” will enable “competition between peers for better quality”; while both the NHS payment system and the CCG allocation process must be “transparent” to ensure the right behaviours and financial stability.

Should the government and board prove serious about transparency – and there are signs that their various promises are more than lip service – then this strand may prove to be the most challenging of all contained within the NHS mandate.