The annual NHS mandate is being published months later than usual, following disagreement between the government and NHS England over the service’s progress and accountability.

The document is the mechanism for the government to set annual objectives and requirements for NHS England, and to hold it to account for performance.



The Treasury is concerned about financial delivery and holding the NHS to account

This is the fifth annual iteration of the mandate, which will cover 2017-18. The document has never previously been published later than Christmas.

HSJ understands one reason it is late is lengthy exchanges and negotiations between the government and NHS England. Several sources said the Treasury, Number 10 and the Department of Health have all raised issues about “delivery” by the NHS and its “accountability”.

The Treasury has been particularly concerned about financial performance - with the trust sector having recorded a large deficit for several years - and its ability to hold the NHS to account for this. Other concerns have included poor progress of sustainability and transformation plans and emergency care – both waiting times performance and the continued rapid growth in emergency admissions.

Sources said the prospect had been raised of moves to tighten accountability, and of taking a sharper tone in the mandate document than in the past, such as expressing the view given by the prime minister and chancellor in recent months that “we’ve given [the NHS] £10bn extra” and it must now deliver.

However, while the discussions have delayed the mandate, it is thought the final document is now unlikely to take this tone or reflect the significant tensions. It is likely to be similar to previous mandates, though there may be a shift in emphasis on particular objectives – for example, NHS England and NHS Improvement recently said the service must achieve the four hour emergency department waiting target in 2017-18 and shifted incentives from elective and cancer treatment.

NHS England chief executive Simon Stevens is known to have a less close relationship with Theresa May and Philip Hammond than their predecessors, who oversaw his appointment, and in January The Times reported that ”key members of the prime minister’s team accused [Mr Stevens] of being insufficiently enthusiastic and responsive”. However, the government’s budget this month showed “signs the May/Hammond government have reached an accommodation with the service’s leadership”, including an unexpected commitment to additional capital funding. 

Other reasons for the delay to the mandate include the new leadership in Number 10 and the Treasury who have not previously dealt with the mandate process, while government business is dominated by Brexit.

It will only be the second time that there has been no public consultation on the mandate. The consultation for the 2016-17 version received 127,00 responses – with 114,000 linked to a campaign by 38 Degrees about “greater public awareness of, and involvement in the mandate, and… private sector involvement in NHS services”. The likely reason which will be given is that no major changes are being made to the document, although this has also been the case in the past.

The DH has been approached for comment. It is expected to publish the final mandate imminently.