You probably won’t have noticed, but you’ve got just ten days to comment on the only bit of democracy left in the NHS. It’s the NHS mandate – ie, what the government tells the NHS to do for the next 5 years.
Pretty important, huh?
As the introduction to the mandate consultation explains:
“The mandate to NHS England sets the Government’s objectives for NHS England, as well as its budget. In doing so, the mandate sets direction for the NHS, and helps ensure the NHS is accountable to Parliament and the public… This consultation document sets out, at a high level, how the Government proposes to set the mandate to NHS England for this Parliament.”
The mandate is what Jeremy Hunt talks about whenever he’s accused of no longer having any proper responsibility or political accountability for securing a comprehensive NHS service, since the 2012 Act.
At the end of October, the Department of Health quietly put the mandate aims and objectives out to consultation for 4 weeks, with a deadline of 23 November. Local HealthWatch organisations have stated that they only became aware of the consultation on 11 November, although since this article was first published, HealthWatch England (the national body that is supposed to give patients a voice in the NHS) have asked OurNHS to point out that they did take some steps to publicise it to those groups prior to that date (see editors note below).
Here’s what OurNHS has just submitted. I’ve written a fair few consultation responses in my life, and this is probably the grumpiest I’ve ever done. So do feel free to use any of this – but you may wish to tone down the grumpiness and make your response more formal!
Bear in mind, ‘high level’, in this context, means the government's document contains lots of vague, aspirational sounding stuff – so you have to read through it carefully for clues about what kind of policies it might open the door to…
OurNHS’s response to the NHS mandate consultation
1. It is very worrying that the word 'comprehensive' doesn't appear in the document once, which seems a pretty major omission given this document is supposed to summarise what our NHS will do in future...
2. It is worrying – particularly given the current fraught relationship between government and NHS staff, and the exodus of the skilled staff that are the backbone of the NHS - that the document mentions 'staff' only once (in the context of a commitment to continue the flawed friends and family test) - and doesn't mention doctors or nurses once.
3. It is worrying that the document does not say anything that would rule out an increase in health co-payments (ie patient charges), given that voices within government such as health minister Lord Prior have been floating the consideration of such charges. It does state that the mandate will focus on "the changes needed to ensure that free healthcare is always there whenever people need it most." But hang on - why do we need that last word, 'most'? Are we creating a mandate for unelected people to decide when people need free healthcare 'most' - and when we may be charged for previously free healthcare?
4. It is worrying the document does not say anything that would rule out large groups of people being prevented from accessing NHS services on account of (clinically unrelated) lifestyle choices/diseases, as Devon attempted to do last year. Government ministers criticised Devon – Eric Pickles said the plan was "not the kind of Britain I recognise" - but if these are not to be crocodile tears, government needs to make sure no other cash-strapped local health bosses try the same plan.
5. It is worrying that the document commits the NHS to ‘maximise income’, without saying how, exactly. NHS hospitals are already increasing their private patients, meaning fewer beds and longer waits for people without means to pay. The mandate should not be encouraging this practice – the supposed safeguards we were promised in 2012 are clearly insufficient.
6. As for setting the NHS an objective to ‘minimise costs’ – well, there isn’t an NHS hospital in the land that is not already desperately trying to do that! Indeed, as hospitals' duties to provide mandatory services are whittled away, and again in the absence of an overarching duty to provide comprehensive health services across England, we are told by governors that many hospitals are discussing how they can shed unprofitable procedures and patients. This must be stopped – not encouraged.
7. It is worrying that there is no commitment to sufficient funding through the fairest and most efficient system (which the evidence shows, is public funding through progressive taxation).
Of course, we recognise that this gaping hole is inherent in the 'mandate' system set out in the 2012 Act, with its greatly narrowed political accountability. We want to put on record how unsatisfactory it is, to be 'consulted' on a document that is separated from the political and financial settlement in this way, and which blithely states we have to wait for the Spending Review to see if any of the commitments are actually deliverable.
8. We also feel concerned about the heavy emphasis on self-care/self-management of patients own care. Given the lack of commitment to proper funding and a comprehensive system, we fear this opens the door to excusing reductions in the amount of care patients are entitled to receive on the NHS.
9. We also feel particularly concerned about the related heavy emphasis on so called 'person-centred' care without any proper explanation of what this nice sounding buzzword means, beyond patients being “empowered” to "make meaningful choices". We fear that - given Simon Stevens commitment to rolling out personal health budgets to millions - 'person-centred' may be interpreted as treating patients as consumers, shopping around with their personal health budgets. Such a system we see as little different to the Thatcherite voucher schemes of old, and similarly likely to lead to cost caps for patients and devastated budgets/planning for NHS providers. There is a paucity of independent evidence for the benefits of personal health budgets, per se - and some evidence that they are dangerous even at an individual, short-term sweetened level.
10. It is also worrying that the proposed mandate green-lights the continued merging of NHS and local authority spend. The impacts of expenditure through this route to date have not been sufficiently assessed, and the Public Accounts Committee found much money had been wasted. We also have serious concerns about the pace of, and lack of accountability of, the delivery of some of this merging of expenditure, through devolution, vanguards, 'success regimes', and personal budget roll-out. The mandate is worryingly silent on the implications of all of these - despite the fact the Kings Fund has just raised serious concerns that the NHS cannot cope with devolution on top of its other challenges.
11. It is very worrying that there is a green light given to a vague commitment to 'harness digital and online technology'. This is misleadingly implied to be mostly about patient access to records online. In fact there is a mushrooming of initiatives (and expenditure) where not just admin, but patient care is increasingly delivered through digital means. Once again, there is a paucity of evidence for the benefits of much of this ‘digital health’ and a surplus of magical thinking about its benefits.
For example, NHS England's recent submission to the Department of Health for the spending review (as reported in Digital Health) was full of claims that remote monitoring equipment “has the potential” to reduce length of stay, and that in primary care tele/web consultation “may lead to substantial benefits” (my emphasis). The summary of the Department of Health’s submission (in a heavily McKinsey influenced presentation) also states that “While it is envisaged that data transparency may (my emphasis) have benefits for patient care direct evidence for economic impact has not been found.” And in primary prevention it admits that there is “relative scarcity of longitudinal studies linking digital programmes to encourage healthy living to long term impact”. In integrated care and screening it admitted the evidence for telehealth was “mixed”.
12. Indeed it is very worrying indeed that the word 'evidence' doesn't appear in this document about what should drive the NHS - not once.
The Kings Fund have raised similar concerns, particularly in relation to mental health, where they said this week that 'trusts have embarked on large-scale transformation programmes aimed at shifting demand away from acute services towards recovery-based care and self-management. This has seen a move away from evidence-based services in favour of care pathways and models of care for which the evidence is often limited. There has also been little formal evaluation of the impact of these changes.' The Kings Fund characterised this as a 'leap in the dark' approach with highly deleterious consequences for the quality of patient care.
We need a mandate that stops the toys for boys / creative destruction / disruptors and heretics / leap in the dark approach, and returns to a proper, evidence-based approach to health care improvements.
Lastly, we have an allergic reaction to phrases like this:
"We propose to set an objective for NHS England to support the transformation of out-of-hospital care using whole system approaches to ensure people get the right care in the right place at the right time."
Banalities do not improve un-evidenced policies.
In summary, our view is that the mandate's aims and objectives need to be driven by the NHS values the public understand (and hold dear).
These are not buzzwords like 'transformation', but values that actually mean something to patients - a service that is comprehensive, universal, staffed with sufficient skilled and properly rewarded staff, run ethically, and underpinned by proper evidence.
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Editors note: HealthWatch England have asked us to clarify that they "contacted local HealthWatch groups to let them know that the consultation was coming" on 14 October, adding "though we had not ourselves been informed of a specific date at that time". OurNHS understands this took the form of a brief mention in a newsletter. HealthWatch England also advise that "when the consultation was launched on 29 October we retweeted it and this was retweeted by a number of local HealthWatch" and that they also sent a tweet and a message on their internal "Yammer" network "to provide some advice on how local HealthWatch could promote this Department of Health consultation".
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