Health Matters | Paul Corrigan's blog

This is an exciting week for me! (I know, it’s sad but I live in a small world).  My first three posts this week will reflect on different aspects of the draft mandate for the NHS that the Secretary of State launched last Wednesday, and on Thursday I will review Nick Timmins’ publication on the NHS reform programme Never Again.

The unifying theme for the week is a growing set of insights into the way in which the current Secretary of State thinks about the way in which change in the NHS happens. Nick’s pamphlet gives us a whole range of insights into the world according to Andrew. But so does the way in which he is introducing the mandate to the NHS.

Within the new architecture of the NHS the mandate between the Secretary of State and the National Commissioning Board is, and will be, the key document that starts the planning year for the NHS.

As I understand it the architecture works something like this.

The Secretary of State issues a draft mandate which when completed acts as the main set of instructions to the NCB over the coming period. He says something to the effect of “Here is £110 billion. Go and buy me some health care which will achieve the themes in this mandate”. This mandate will be to be completed and published by around the first week in October.

The NCB, in accepting the money and the mandate, then uses its powers to commission the care that will meet the themes of the mandate. In accepting the mandate they then look around at the powers they have and use them to drive towards those objectives.

They do this in two ways. Firstly they buy health care themselves – specialist hospital care and GP services. So they look at the objectives in the mandate and think how they can use the direct commissioning of which they are in charge to achieve them. If they take this seriously they will bend all of this spend toward achieving the objectives that they are meant to meet.

Secondly the NCB themselves create a series of contracts with the 220 Clinical Commissioning Groups – where they say to each of them, “Our national mandate is to achieve a b c d e f and g e. We will give you £*** million in your location and in return we will expect you to achieve a b c d and g in your locality.” A wise NCB will ensure that they when they add up all of the potential achievements in all the CCGs and combine these with those to be made under the NCB’s own commissioning power the result comes to roughly that the Secretary of State has told them to achieve in the national mandate.

Of course this is never as simple as it sounds, but this looks to me like a clear chain of accountability which I think is what Andrew Lansley has been searching for with his reform programme.

It is, as it is in most of the ways in which Andrew Lansley sees the world, clear straightforward and linear.

But as he has found out in the last 2 years the real world just isn’t like this.

Tomorrow I will explore how the Secretary of State, in developing a brand new outcomes based framework, will in reality also be holding the NHS to account for most of the inputs and outputs that were in last year’s operational framework. So whilst the mandate will not say how many health visitors there should be – which is after all an input – the Secretary of State will still be very interested in performance managing the NHS to reach the health visitor target set by the Prime Minister.

But here I want to explore the mandate in its own right and try and understand the theory and practice of change that lurks within the current Secretary of State.

Two years ago when the White Paper ‘Liberating the NHS’ was published there was much talk of the government reforms being ‘revolutionary’. Over the ensuing 20 months of struggle this shifted next to ‘evolution’ and finally to promises of the NHS remaining much the same as it was before the reforms started..

The revolutionaries amongst you will be really pleased to read the draft mandate. You will recognise that it sees Andrew returning to his revolutionary Maoist phase.

It is an amazing document which seriously believes that from April 2013 all of the NHS can be driven towards outcomes and not inputs.

The mandate contains 22 objectives. This is a reasonable number for the NHS to concentrate upon and, as I will discuss tomorrow, if this were all the NHS had to do it would be about the right number.

Crucially each of the outcome domains in the NHS outcome framework has a target in the mandate. The exact number to be achieved in that target will, quite correctly, come about as a result of the consultation. As an example let’s take domain number 2, ‘Enhancing the quality of life for people with long term conditions’. Draft Objective 2 is to ‘increase the number of Quality Adjusted Life Years for people in England with long term condition to X by 2015 x by 2018 and x by 2023’.

As I say, the numbers will be determined over the next three months, but let’s pretend they are small numbers – 2%, 4% and 8%.

That would mean that by accepting the mandate one of the outcomes, that the NCB will be using the £110 billion to drive towards, would be a 2% increase in the number of Quality Adjusted Life Years (QALYs) for people with long term conditions (LTCs) by 2015..

Then let’s pretend (as Andrew Lansley undoubtedly does) that the NCB take this seriously. They would then look to their own commissioning and to the contracts they commission with the CCGs to drive towards this increase in QALYs.

The CCGs would then, in accepting the contract from the NCB, take on board the proportion of the national increase of QALYs for people with LTCs in their locality. In some places it may be an increase of 3%, in others 2%.

Then let’s pretend (as Andrew Lansley undoubtedly does) that each CCG uses its local commissioning power to buy health care that does that. They approach the providers of health care in November 2012 and say, “we, from April 2013, want to commission health care that increases QALYs by 2%. Over the next two years.”

And this is where the Maoist intent hits reality. Mandate to NCB, NCB to CCG, so much is good planning. But NCB to health care provider and CCG to health care provider, that is beyond planning – to reality.

From the year beginning April 2013 the aim of commissioning spend will be to improve QALYs. Up until the end of March it will have been a series of input and occasional outputs.

How might this change look?

From next April the NCB will hold the GP’s contracts and they could meet the mandate by changing those contracts so that GPs are paid when they can prove they have improved the QALYs of their patients.

From next April CCGs will hold the contracts with their local hospitals. The CCG could meet the mandate by changing these contracts so that hospitals are paid when they prove that they have improved the QALYs of their patients.

Are there real plans at the moment to radically transform GP contracts to drive GPs toward those outcomes by improving QALYs?

Is the NCB radically changing the standard hospital contract for CCGs so that the CCGs will hold the hospitals to account through outcomes?

And even more importantly if, between 2013-2015, I am to increase the QALYs of people with LTCs in my locality by 2%, what is the baseline for QALYs at the moment? Does the Secretary of State really believe that there is reliable data in every locality in the country to tells us what the current QALY is for people with long term conditions?

If we don’t know the baseline in 2013 – how will we know we are 2% better or worse off in 2015?

I think Andrew Lansley believes this will happen. He has made up his mind that it will happen and he will issue his mandate to make it happen. And as far as he is concerned that will make it happen

From 9 months from now.

People who saw him introduce this draft mandate in the House of Commons said he seemed a bit euphoric. I can imagine why.  It would be a lovely world if it could be made like this.

In 9 months time, in the new world, NHS organisations will be agreeing to the mandate that the Secretary of State wants and they will be pretending that the system is driving towards outcomes.

But in the real world the mechanics that will be provided by the NCB will mainly continue to focus on inputs.