New blueprint puts dementia and better care at heart of NHS

BMJ 2012; 345 doi: (Published 14 November 2012) Cite this as: BMJ 2012;345:e7747
  1. Nigel Hawkes
  1. 1London

The government has set out the course it expects England’s NHS Commissioning Board to follow for the next two years. Better care rather than simply better treatments, a focus on mental health and dementia, preventing premature death from the biggest killers, and ushering general practice into the online era are the highlights of the first NHS mandate, published on 13 November.

Under the government’s changes to the NHS in England, the board has been given responsibility to deliver care, together with a budget of £95.6bn (€120bn; $152bn) for 2013-14 with which to pay for it. The mandate is the government’s set of requirements against which the board’s performance will be judged. The first mandate will run until April 2014, covering the first full year of the board’s operation; thereafter it will be renewed annually.

The final version of the mandate is shorter and focuses on fewer objectives than the draft that was circulated for discussion in July, which included 60 outcome measures, some very precisely defined.1 The board showed scant enthusiasm for such a detailed list of instructions—its chairman, Malcolm Grant, saying that he would prefer a document simply setting out what the high level objectives are.

He seems to have got his way. The final result is a mixture of general principles and detailed instructions, but the requirement of the board in every case is that it should make “measurable progress” towards achieving the objectives.

While the draft sought, for example, an additional XX life years through the reduction of mortality from the biggest killers (with XX yet to be defined) by 2015, the final version contains no numbers. It simply says, “Our ambition is for England to become one of the most successful countries in Europe at preventing premature deaths, and our objective for the NHS Commissioning Board is to make measurable progress towards that outcome by 2016.”

And while the draft suggested that it should be possible to halve the gap between cancer survival rates in England and those in the best performing countries by 2014-15, the final version simply calls for England to become “one of the most successful countries in Europe at preventing premature deaths.”

Jeremy Hunt, the health secretary, defended the changes at a press conference in London also attended by David Nicholson, chief executive of the board. “We thought about it very hard,” Hunt said. “If I say to David, ‘I want you to increase life expectancy by X years,’ we could return to the old NHS.

“He would have to micromanage to achieve it, and I don’t want it to work that way. Making ‘measurable progress’ is actually more ambitious, because it aims towards being the best in Europe.”

Nicholson agreed that this was “a much better way” forward.

The first key objective listed—“improving standards of care and not just treatment, especially for the elderly”—falls into the category of a general principle. But the requirement that by 2015 everyone will be able to book GP appointments online, order a repeat prescription online, and exchange emails with their general practice is far more prescriptive.

The other key objectives listed are better diagnosis, treatment, and care of people with dementia; a named midwife for every woman during pregnancy, childbirth, and the postnatal period; availability to all patients of the “friends and family” test (whether patients would recommend a service to their family and friends) to judge the quality of care from next April; a greater focus on mental health; prevention of premature deaths from the biggest killers; and the publication by 2015 of the outcomes achieved by all major NHS services. Some of these are already NHS policy.

The list includes a commitment to narrow health inequalities between rich and poor people, though this occupies a single paragraph rather than five in the draft. Hunt denied that this represented any reduction in ambition. “Most sections of the mandate have got shorter,” he said. “The board has a legal obligation to narrow health inequalities, and it won’t meet any of the other objectives in the mandate unless it does so.”

Waiting times are to be kept low and to be improved where possible, particularly in access to mental health services. The NHS, the mandate says, should be there for people when they need it: “this means providing good care seven days of the week, not just Monday to Friday.”

The mandate sets demanding standards for access to information, saying that every patient should be able to see their medical records online by March 2015, with clear plans in place to enable these records to be linked to provide a complete record. This would not involve reinventing the failed IT system attempted by the Labour government, Hunt said, but by a bottom-up process of linking existing GP held records. “We can’t use the failure of that IT system to bury our heads in the sand,” he said.

Hunt said that the publication of the mandate was “a very historic moment for the NHS” and represented the removal of the ability of ministers to run the system from Whitehall. Nicholson said that it was “the most ambitious and radical document I’ve seen, more radical than the structural changes in the NHS.”

Seeking to dispel any notion that the NHS Commissioning Board had managed to water down the mandate so as to provide it room for manoeuvre, he added that this would be “by no stretch of the imagination easy to do.”


Cite this as: BMJ 2012;345:e7747