The government has rejected the use of fixed national targets in its mandate to the NHS Commissioning Board in favour of seeking continuous improvement against the NHS outcomes framework.
The draft version of the mandate, put out for consultation over the summer, proposed setting targets in five areas, including improved overall life expectancy and an increase in the number of quality adjusted life years enjoyed by people with long term conditions.
However, the final version of the mandate, published on Tuesday, says success will be measured by the “average level of improvement”, alongside progress in reducing health inequalities and unjustified variation. This is a departure from what then health secretary Andrew Lansley told HSJ in June.
Launching the mandate, health secretary Jeremy Hunt said that if he had given commissioning board chief executive Sir David Nicholson a target of increasing life expectancy by 0.7 years within two years, it could mean a “return to the old NHS”. This would see Sir David “under pressure to micro manage all the clinical commissioning groups, because I will be so determined I can stand up at the dispatch box and be accountable for a specific target,” Mr Hunt said.
He said the aim was to give “operational freedom” and the chosen approach was “more ambitious” as it would allow the government to measure progress towards becoming the “best in Europe”.
HSJ understands the Department of Health hopes this approach will prevent perverse incentives arising where organisations already hitting a target feel no pressure to improve.
Sir David said the mandate will lead to local improvements through a “conversation” that will start “tomorrow” with local NHS organisations. Sir David said it would lead to CCGs producing a “prospectus” for improvement in their local areas.
Under the Health Act the mandate is the main means by which the government can influence the priorities of the NHS.
Despite not setting specific targets around waiting times for acute treatment, the mandate is clear progress should not be lost and draws particular attention to the need to improve services at evenings and weekends.
Process targets which were in the July draft, such as the requirement to increase health visitor numbers, have been lost. However, the mandate warns its list of requirements is “not exhaustive” and the “the board has agreed to play its full part in fulfilling pre-existing government commitments not specifically mentioned”.
The mandate also identifies the five top priorities on which “the government expects to see the greatest rate of progress”. They reflect the priorities identified by health secretary Jeremy Hunt.
The priorities are: improving quality of care, not just treatment; dementia services; support for people with multiple long-term conditions; preventing premature deaths from the biggest killer conditions; and furthering economic growth, including by supporting people with health conditions to remain in or find work.
All of the indicators the NHS will be judged against are included in the revised 2013-14 NHS outcomes framework.
The mandate includes 13 patient experience measures, including two new indicators under development on experience of young people and experience of integrated care, and measures on access to GP services and dental services.
The mandate also commits the commissioning board to ensuring that speciality level mortality rate data is published for all “major services by 2015” at CCG level, as well as the level of “teams and organisations providing care”.
The mandate on workforce
NHS managers, doctors and nurses can expect to be put under greater scrutiny over the next two years to ensure better and safer care.
The mandate has a large focus on culture, values and tackling variation in service quality.
It says NHS managers will be “better held to account” when failures occur. At health secretary Jeremy Hunt’s request, the Care Quality Commission is already investigating how to achieve this and the Professional Standards Authority published its own set of standards for NHS boards earlier this month.
The NHS Commissioning Board will encourage the “systematic development of clinical audit and patient-reported outcome and experience measures”. It also backed the development of the same levels of hospital staff cover seven days a week.
The mandate suggests staff could be asked for their opinions about their organisation and care standards more frequently than occurs under the annual staff survey.
British Medical Association council chair Mark Porter said: “There needs to be greater clarity on how the commissioning board is to be held to account and a clear plan to communicate the cultural change the mandate seeks to achieve to NHS staff and patients… Ministers must ensure there is genuine clinical involvement.”
The mandate on mental health
Providers of NHS mental health services could be expected to meet new waiting time standards to drive improvements in access, according to the mandate.
Mental health will be given “parity of esteem” with physical health services by March 2015, with the NHS Commissioning Board required to measure levels of access and waiting times.
Clinical commissioning groups will be expected to address “unacceptable” delays and make significant improvements in access.
The mandate says the government will work with the board to “consider” new access standards, including waiting times for mental health services. It will also examine the “financial implications” of their introduction.
Rachel Newson, chief executive of Coventry and Warwickshire Partnership Trust, said: “With the reality of shrinking funds in health and social care, it is hard to see how this will all pan out. We already see some shifts in referral behaviour due to the local authorities needing to reduce services to deal with budgetary challenges.”
According to the mandate, the Improving Access to Psychological Therapies programme will be extended. By 2015, patients will be also offered the choice of any qualified provider in community and mental health services, the mandate says.
The mandate on friends and family
Hospitals with good scores in the friends and family test “will be financially rewarded”, the mandate said.
It is not clear if the financial “reward” will be under the existing commissioning for quality and innovation (CQUIN) payments system or a different arrangement in the NHS standard contract between trusts and commissioners.
There are two versions of the test, one asking staff in the annual staff survey whether they would recommend the trust to a friend or family member, and one asking the same question of patients.
The latter system has already been trialled in the NHS Midlands and East strategic health authority cluster.
The mandate confirmed the friends and family test would be rolled out to all acute hospital inpatients and accident and emergency patients from April 2013 and, from October 2013, to “women who have used maternity services”.
It said it must then be introduced “as rapidly as possible” for all NHS services - although it is not clear if this will include NHS-funded care in the private and charitable sectors.
A Department of Health spokeswoman said it would be for the NHS Commissioning Board to decide exactly how the financial reward would be allocated.
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