Intended for healthcare professionals


Setting objectives for the NHS Commissioning Board

BMJ 2012; 345 doi: (Published 06 September 2012) Cite this as: BMJ 2012;345:e5893
  1. Anna Dixon, director of policy,
  2. Chris Ham, chief executive
  1. 1King’s Fund, London W1G 0AN, UK
  1. cham{at}

The draft mandate must be rewritten if it is to be fit for purpose

One of the principal aims of England’s Health and Social Care Act 2012 is to distance politicians from the day to day management of the NHS. This aim is being pursued by the creation of the NHS Commissioning Board, which will take responsibility for allocating resources to clinical commissioning groups and commissioning some services directly. Government critics have described the board as “the greatest quango in the sky” because of its major role in the new system, overseeing how £80bn (€100bn; $126bn) of public money is spent and employing 3500 staff drawn mainly from the Department of Health and the NHS.1 The board will work under a mandate from the secretary of state for health, setting out his objectives and priorities for the NHS. The government published the draft mandate in July 2012 and is now consulting on it and seeking views on how it can be strengthened.2

The government intends that the mandate should establish clear and transparent expectations of the NHS and form the basis on which the commissioning board is held to account. It will be a document that sets ambitions for improving outcomes over a period of years. To ensure that it has impact in the long term, ministers have made it clear that the mandate should rarely be changed between annual reviews and that most objectives should roll forward until they have been achieved.2 It is, therefore, particularly important that the first mandate is well designed because the framework that it establishes will probably be in place for some time.

The draft mandate focuses initially on outcomes contained in the NHS Outcomes Framework, which identified 60 indicators across five domains.3 In addition, it proposes several other objectives that encompass putting patients first, the broader role of the NHS, effective commissioning, and financing the NHS. A supporting technical annex describes the data sources that will be used to assess progress in delivering the objectives.

If the mandate is to serve a useful purpose, then the lessons of previous attempts to strengthen the accountability and performance of public services should be heeded.4 The most important are the need to identify a small number of objectives and priorities, express these clearly and in a way that can be measured, and ensure that the goals are both stretching and realistic within a specified timescale. The objectives and priorities that are chosen must also reflect the main areas of health and care that ministers are trying to improve and that resonate with the views of patients, the public, and staff.

On most of these counts the draft mandate falls far short of what is needed. Its main weaknesses are the large number of objectives it contains—22 in total—and the general and vague language in which many of these objectives are expressed. For example, the stated aim of objective 11 is to “develop a collaborative programme of action . . . to further the ambition that healthcare professionals throughout the NHS should take all appropriate opportunities to support people to improve their health.” It will be well nigh impossible to measure the achievement of an objective phrased in such vague terms.

Some objectives, mainly those that relate to outcomes, are set out in a way that can be measured, but progress will be assessed using one aggregate indicator for each of the five domains. Although this may seem to be sensible and simple, in reality it requires a complex series of calculations that are incomprehensible to most people working in or served by the NHS, as illustrated by the lengthy and detailed technical papers that describe how this will be done.5 As a consequence, it will be near impossible for the board and NHS commissioners to determine what they can do to support the achievement of these objectives.

Other objectives bear all the hallmarks of priorities identified by policy leads in the Department of Health and other government departments who are anxious to ensure that their areas of responsibility are not left out. For example, objective 16 effectively amounts to a shopping list of high level aspirations in relation to other public services, whose provenance can be clearly traced to various parts of Whitehall. The mandate risks becoming devalued both in concept and in practice before it has got off the ground because when everything is a priority then nothing really is.

Another weakness is the transactional rather than transformative tone of the draft mandate. If the mandate is to live up to the ambitions of its architects, not only must it be capable of holding the commissioning board to account for its performance but it must also inspire NHS leaders and staff to redouble their efforts to bring about improvements in health and care. The current draft fails to do this by being entirely focused on listing specific and general objectives and omitting to convey any sense of how the experience of patients and those caring for them will be changed for the better as a result.

In our view, government ministers and officials should go back to the drawing board and heed the old adage that less is often more. The number of objectives in the mandate should be cut drastically and objectives should be included only if they fulfil the SMART criteria (specific, measurable, achievable, realistic, and time limited) often used in the setting of key performance indicators. More emphasis should be placed on situating the final list of objectives in the context of a clear and compelling vision for the future of health and social care that demonstrates the link between delivery of objectives and the transformational changes in models of care that are urgently needed.6


Cite this as: BMJ 2012;345:e5893


  • Competing interests: Both authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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