Is the NHS England Mandate an agenda for privatisation?

Philippa Brice

21 December 2015

The UK government has released an official response to the recent consultation on the Mandate to NHS England (NHSE) for 2016-17.

The original consultation set out the priorities for NHSE: preventing ill health and supporting healthier living; creating safe, high-quality health and care services including 7-day hospital care; improving performance while achieving financial balance; transforming out-of-hospital care by making services more integrated and accessible; driving improvements in efficiency and productivity; and supporting research, innovation and growth. It also sought to endorse the NHS’s own plan for change, the Five Year Forward View, and set a long-term strategic mandate that was accessible to the public.

Responses and rebuttals

Responses were received from over 140 organisations, over 12,000 unique individuals, and over 100,000 individuals via campaigns organised by 38 Degrees and Our NHS. Rather than addressing these questions directly, most responses are said to have largely raised general issues; plans to improve mental health services and focus on prevention of ill-health were widely supported amid concerns over finances would permit them.

Other widespread concerns included worries about seven-day services, safe staffing levels, pay and conditions; the risks of exacerbating existing inequalities; the lack of accountability of Clinical Commissioning Groups to NHSE; and significant opposition to ‘further private sector involvement in the NHS’, with many noting the lack of a formal commitment to maintain the NHS as a service free at the point of care.

This last point drew an emphatic denial in the government response and a firm commitment to maintain a health service free at the point of care, which many respondents will no doubt be pleased by - although the intention to retain as much privatisation as deemed necessary was also clearly stated:

‘The Government remains committed to the founding principles of the NHS and the Secretary of State retains a duty to promote a comprehensive health service free at the point of use. To sustain this now and in the future means that we must change the way that health services are provided. This is not an agenda for privatisation. The NHS will continue to harness the capacity of the private and third sectors where they are best placed to deliver high quality services for NHS patients’.

A question of cash

Insufficient funding to achieve the aims of the mandate was a common concern for public health, health and social care. Addressing this, government acknowledged that concerns were valid but underlined the plans for increased health funding under the recent Spending Review, starting with £3.8 billion for 2016 and rising to be ‘£10bn higher in real terms by 2020-21 than 2014-15’.

The response points out that social care and most public health falls outside the scope of the NHSE mandate, but nevertheless emphasises the provision of ‘£3.5 billion of new support for social care by 2019-20’ and the new capacity for councils to raise revenue for social care via council tax increases. A total of £16 billion will go to councils for public health spending over the next five years.

Funding allocations are certainly increasing – a mighty total of £560 billion has been earmarked to deliver the Five Year Forward View - but many fear that the rise could be swallowed up just in tackling current service shortfalls arising from the increasing demands placed on the NHS.  

It is therefore somewhat surprising that the consultation response did not also emphasise the intention to create cost-efficiencies via more integrated and innovative ways of working, such as implementing comprehensive electronic health records and other digital health applications. Whilst some attention was paid to the current Accelerated Access Review with a view to speeding up access to innovative treatments and diagnostics (see below), the potential of innovations to offer cost-neutral or even cost-reducing improvements in care was not mentioned.

Commissioning concerns

NHSE is said to have ‘strengthened how it holds CCGs to account’ to ensure that they are well-led and financially sustainable, and there is a new requirement to ‘develop a new CCG assessment framework to show clearly how well CCGs are performing compared to one another’.

Some charities and patient groups were said to have said that there was a lack of clarity on the role of NHSE in commissioning specialised services, including for rare and long-term conditions, and to have called for more support, including faster diagnosis and treatment. The response said that NHSE was committed to applying ‘the same level of scrutiny to its own direct commissioning responsibilities’ as to CCG commissioning via a similar assurance framework and have national quality standards of specialised services, although it may delegate responsibility for commissioning to CCGs and local authorities provided that this is ‘in the best interests of patients’.

Exactly who decides what is the patients’ best interests is open to question, and the point about lack of clarity well made, since the whole point of specialised services is in the same response noted to be that they are ‘expensive, complicated or for rare conditions where it is better for NHS England to commission them for the whole country instead of CCGs doing so locally’. How does this sit with delegating responsibility to local CCGs? Whilst in practice specialised services do tend to be built around local centres of clinical expertise, this expertise does not typically sit with the corresponding local CCG, and so there must be a fair risk that they might lack sufficient understanding to commission a suitable national programme.